Colorado Health Institute1576 Sherman Street, Suite 300Denver, Colorado 80203-1728www.coloradohealthinstitute.org

Data Chartpack

Recruitment and retention of Colorado’s primary care workforce: Rural/urban

differences

October 22, 2009

2nd Colorado Health Professions Workforce Summit

Overview of CHI study

Five areas of inquiry -- Workforce diversity Educational pipelines Aging of the workforce Career ladders Scopes of practice and collaborative models of care

Three primary care health professionals reviewed -- Physicians Nurses Oral health providers (dentists and dental

hygienists)

2

Study methods

• Synthesis of peer-reviewed literature and available Colorado data

• Literature review included abstract reviews and analyses of evidence-based studies

• Analysis of CHI health professions’ workforce surveys by age, geography, race/ethnicity and other relevant variables (2005-09 surveys)

3

PHYSICIANS

4

Physician diversity: What the literature says…

Effects on access to care• Minority physicians are providing a disproportionate

share of care to the underserved1

– Minority status is a stronger predictor of service to the underserved than National Health Service Corp participation, socioeconomic background or growing up in underserved area2

• Lack of cultural sensitivity by health professionals is associated with reduced care-seeking by parents for their children3

• Diversity among medical school students is associated with higher levels of cultural sensitivity of all students and greater willingness to serve diverse populations4

5

Physician diversity: What the literature says…

Effect on health outcomes• Language barriers between physicians and

patients increase costs and potential for medical errors5

• Cultural competency/racial concordance are associated with higher patient satisfaction and levels of patient participation in their care6

• Lack of cultural understanding and awareness can lead to withholding information, noncompliance, delays in care and incorrect diagnoses7

6

Physician diversity: What the literature says…

Effects on patient satisfactionRacial/ethnic identification with physician is

associated with:– Improved satisfaction among minority patients8

– Higher perceived quality of care9, 10

– Higher levels of patient participation in their care11

7

Physician diversity: A Colorado perspective

8

Race/ethnic background of licensed, active Colorado physicians

SOURCE: United States Census: 2008 Population Estimates, Colorado Health Institute 2005 Physician Workforce Survey (Q2), 2009 Rural Physician Survey (Q10)

Physician diversity: A Colorado perspective

9

Payer mix by physician race/ethnicity, rural practice, 2009

SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q10, Q27)

Physician diversity: A Colorado perspective

10

SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q10, Q29)

Perc

ent

Resp

ond

ing “

Inte

rest

ed”

(4 o

r 5

)

Physician pipeline: What the literature says…

KEY FINDINGS• The success of particular pipeline interventions

such as pairing middle and high school students with mentors to increase students’ interest in the health professions varies depending on age of student12

• Pipeline programs and interventions can have an effect on physician supply13

• Selective admissions, institutional commitment, debt forgiveness and other efforts are effective in promoting rural practice and primary care specialties14

11

Physician pipeline: What the literature says…

Factors associated with choosing a rural practice• Growing up rural15

• Selective admissions by medical school16

• Medical school focus on primary care and rural medicine17

• Financial incentives, such as NHSC funding18

• Medical school experiences, such as rural clinical rotations19

12

Physician pipeline: What the literature says…

FACTORS ASSOCIATED WITH CHOICE OF PRIMARY CARE PRACTICE• Interest at time of admission to medical

school20

• Selective admissions policies of medical school21

• Growing up rural22

• Having less medical school debt23

• School’s commitment to primary care practice24

• Being female25

13

Physician pipeline: A Colorado perspective

14

Where physicians practicing in rural Colorado grew up and state

conferring medical degree, 2009

Place where grew up

Percent of rural

physicians

Urban 18.0%

Suburban 42.4%

Rural 39.6%

SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q32, Q9)

Physician pipeline: A Colorado perspective

• Two medical schools in Colorado (DO and MD)

• 132 MD graduates in 2008—UC Denver only; no graduates from Rocky Vista (DO) until 2012

• Colorado family medicine residency graduates:– Of 172 family medicine residents in 2007-09, 114

remained in Colorado to practice– Approximately 87% of Colorado’s family

medicine residents are from out of state15

SOURCE : American Association of Medical Colleges Graduation Data, 2009, Correspondence – TonyPrado-Gutierrez, University of Colorado at Denver

Aging of the physician workforce: What the literature says…

Key findingMany retired physicians are interested in volunteering after retirement, but barriers include malpractice concerns, paperwork and bureaucracy26

16

Aging of the physician workforce: A Colorado perspective

17

Percent age 55 and older

Colorado’s workforce

17.3%

Non-rural physicians

28.7%

Rural physicians 33.6%

Proportion of physician workforce and overall Colorado workforce, age 55 and older, 2009

Proportion of rural Colorado primary care physicians by age group, 2009Age 44 and

younger 45-54 yrs 55-64 yrs 65+ yrs

Primary care*

57.0% 42.1% 45.8% 31.1%

* Primary care includes family medicine, general pediatrics and internal medicineSOURCE : U.S. Census Bureau 2008 Workforce Estimates, Colorado Health Institute 2009 Rural Physician Survey (Q8, Q4), Peregrine Database April 2009

Aging of the physician workforce: A Colorado perspective

18

Physician practiceAges 44

and younger

45-54 yrs

55-64 yrs 65+ yrs

Proportion working part time 12.8% 15.0% 24.5% 51.4%

Proportion volunteering, not billing

0.4% 0.0% 1.4% 7.5%

Volunteerism and part-time practice among Colorado’s rural practicing physicians by age, 2009

SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q2, Q8)

Collaborative care models: A Colorado perspective

19

% reporting staffing model that includes MLPs

All rural practicing physicians 35.6%

Primary care rural practicing physicians

45.8%

Specialist rural practicing physicians

26.0%

Percent of rural physicians reporting mid-level providers (MLPs)

in their practice, 2009

SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q17)

Registered Nurses (RNs) and Licensed practical nurses (LPNs)

20

Diversity in the nursing workforce: What the literature says…

• Literature does not include evidence-based studies on nursing diversity/cultural competence relative to patient outcomes and satisfaction

• Further research warranted to assess these relationships in the practice of nursing

21

Diversity in the nursing workforce: A Colorado perspective

22

Nurse by practice area% fluent in another

language

Non-rural practicing RNs 12.3%

Rural practicing RNs 11.9%

Non-rural practicing LPNs 8.8%

Rural practicing LPNs 4.4%

Fluency in language other than English used to communicate with patients, RNs (2008) and LPNs (2007)

SOURCE: Colorado Health Institute 2008 Registered Nurse Survey (Q38), 2007 Licensed Practical Nurse Survey (Q34, Q34b)

Nursing pipeline: What the literature says…

• Non-competitive faculty salaries contribute to faculty shortages27

• A variety of approaches around the country have successfully improved nursing student enrollment:– Changing to year-round academic schedule

and year-long faculty appointments at University of Nevada Las Vegas28

– In Colorado, partnership between Poudre Valley Hospital and University of Northern Colorado29

23

Nurse pipeline: A Colorado perspective

• 24 accredited 2-year associate degree in nursing (ADN) degree programs

• 11 accredited 4-year bachelor of science in nursing (BSN) degree programs

• 10 accredited licensed practical nurse (LPN) programs

• 15 accredited 2-year and one 4-year nursing programs with LPN exit option

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SOURCE: Colorado State Board of Nursing

Nurse pipeline: A Colorado perspective

Colorado nursing program graduates, 2007

25

ProgramApproximate total

graduates Graduates licensed

LPN 615 544

ADN 879 717

BSN 941 847Area where nurse grew up and was educated, active RNs (2008) and LPNs (2007) Percent trained in

ColoradoPercent from rural

area

RNs – Non-rural 46.1% 31.9%

RNs – Rural 47.0% 60.7%

LPNs – Non-rural 58.0% 43.5%

LPNs – Rural 78.7% 69.8%SOURCE: Colorado State Board of Nursing, Colorado Health Institute 2008 RN Survey (Q4, Q34), 2007 LPN Survey (Q1a, Q30)

Nursing pipeline: A Colorado perspective

PIPELINE CAPACITY ISSUES• Wait lists—3,579 qualified applicants not admitted due to

lack of slots (2008-09)• Faculty vacancies (2008)

– 15% of associate degree in nursing (ADN) faculty positions

– 8% of bachelor of science in nursing (BSN) faculty positions

– 15% of licensed practical nurse (LPN) faculty positions– 11% of master of science in nursing (MSN) faculty

positions– 17% of doctor of nursing practice (DNP) faculty positions– 76 FTE vacancies for clinical nurse instructors

• Reported barriers to program expansion include faculty shortages, securing clinical placements, lack of funds, noncompetitive salaries for faculty

26SOURCE: Colorado Health Institute 2008/2009 Nursing Faculty Studies

Aging of the nurse workforce: What the literature says…

• Incentives such as improved benefits, flexible schedules, ergonomic improvements in the work environment and institutional support/recognition can influence older nurses to delay retirement30

• Turnover highly expensive both monetarily and in terms of loss of expertise31

• No single retention strategy works across all settings, multiple factors involved32

27

Aging of the nursing workforce: A Colorado perspective

28

% 55 and older

RNs in a non-rural practice 27.4%

RNs in a rural practice 31.9%

LPNs in a non-rural practice 20.4%

LPNs in a rural practice 32.1%

Proportion of RN (2008) and LPN (2007) workforce age 55 and older

SOURCE: Colorado Health Institute 2008 RN Survey (Q36, Q17), 2007 LPN Survey (Q19, Q31)

Aging of the nursing workforce: A Colorado perspective

OF NURSES PLANNING TO LEAVE THE WORKFORCE: • 14% of non-rural and 10% of rural RNs ages 55

and older reported planning to leave their primary nursing position in next 12 months (2008) – Highest reported reasons included insufficient

wages, too much stress, insufficient benefits, lack of respect and retirement

• 15% of non-rural and 25% of rural LPNs ages 55 and older planned to leave their primary nursing position in next 12 months (2007)– Highest reported reasons included too much

stress, insufficient wages, retirement, workplace safety issues, and not feeling respected

29

SOURCE: Colorado Health Institute 2008 RN Survey (Q29, Q30, Q36), 2007 LPN Survey (Q25, Q36, Q31)

Nurse scope of practice/models of care: What the literature says…

• Nurse practitioners (NPs) deliver comparable quality of care to physicians within the scope of their practice

• Patients report greater satisfaction with NPs and certified nurse midwives (CNMs) than with physicians in specific care settings

• NPs and CNMs are more likely to work in an underserved area and/or with an underserved population

30SOURCE: Colorado Health Institute, Collaborative Scopes of Care Study, 2009

Nurse scope of practice/collaborative models of care: A Colorado perspective

• More than 80% of RNs agreed that their relationship with physicians was good (2008)

• Most nurses (74% non-rural and 77% rural) agreed that they participated in decisions related to their patients’ care

• Approximately 2,322 practicing nurse practitioners in Colorado*

31SOURCE: Colorado Health Institute 2008 RN Survey (Q23), Colorado Department of Regulatory Agencies

* The American Academy of Nurse Practitioners estimates that 90% of registered NPs are practicing in the field; Colorado had 2,580 actively licensed nurse practitioners as of January 5, 2009.

Career ladders in nursing: What the literature says…

• Robust career ladder opportunities are associated with increased productivity and satisfaction among nurses33

• Two general types of career ladders34

– Clinical ladder achieved through on-the-job performance and clinical evaluation

– Educational ladder based on obtaining higher degrees

32

Career ladders in nursing: A Colorado perspective

33

Highest degree Non-rural RNs Rural RNs

Associate degree in nursing

24.5% 37.1%

Bachelor of science in nursing

46.9% 35.4%

Master of nursing degree 13.8% 11.0%

Non-nursing doctorate 0.3% 1.4%

Nursing-related doctorate

1.5% 0.7%

Highest degree earned by practice location, active RNs, 2008

SOURCE: Colorado Health Institute 2008 RN Survey (Q1, Q2, Q7)

Career ladders in nursing: A Colorado perspective

• Pursuit of additional education:– More non-rural than rural nurses reported

having returned to school for an additional degree

– Greater proportion of nurses with bachelor’s degrees in nursing (BSNs) returned to school for additional nursing degrees

• RNs whose first degree was an associate degree in nursing (ADN) began and ended their education later than BSN graduates

34

SOURCE: Colorado Health Institute 2008 RN Survey (Q2, Q7)

Career ladders in nursing: A Colorado perspective

• Type of facility where first employed– More older, non-rural LPNs began work in

hospitals– More younger, non-rural LPNs began work in

nursing homes, clinics or physician offices

• Pursuit of additional education– 15% of non-rural and 18% of rural LPNs

reported currently being enrolled in an RN program

– 36% of non-rural and 43% of rural LPNs reported plans to pursue an RN education

35

SOURCE: Colorado Health Institute 2007 LPN Survey (Q7, Q7a, Q10, Q11, Q31)

Dentists and Dental Hygienists

36

Diversity among oral health professionals: What the literature says…

37

• Racial/ethnic minority dentists more likely to care for underserved patients35

• Lack of cultural understanding by dentists associated with barriers to care-seeking for Medicaid-enrolled children36

• Available literature did not address diversity in the dental hygiene workforce

Oral health professionals and diversity: A Colorado perspective

38SOURCE: U.S. Census Bureau 2008 population estimates, Colorado Health Institute 2008 Rural Dentist Survey, 2006 Dental Hygienist Survey

Diversity among oral health professionals: A Colorado perspective

39

Language other than English

Rural dentists 27.5%

Dental hygienists (urban/suburban)

6.4%

Dental hygienists (rural) 5.9%

Language proficiency among dental hygienists (2006) and rural dentists (2008)

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

Diversity among oral health professionals: A Colorado perspective

• 27.5% of rural dentists indicate they speak a language other than English to communicate with some or all patients

• 6.4% of urban/suburban and 5.9% of rural dental hygienists report being fluent in a language other than English

40

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

Diversity among rural oral health professionals: A Colorado perspective

• Minority rural dentists report spending greater proportion of time in direct patient care with children and older adults

• Payment sources– More minority rural dentists offer a sliding-fee schedule

than White rural dentists – More minority rural dentists report accepting Medicaid

payment, new Medicaid patients, Child Health Plan Plus (CHP+) payment and new CHP+ patients

• Non-White dental hygienists report twice as many volunteer hours as White dental hygienists

• More non-White dental hygienists report that their primary worksite provides care to Medicaid patients, accepts new Medicaid patients and provides care on a sliding-fee schedule

41

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q3, Q20, Q22), 2006 Dental Hygienist Survey (QB3b, QC5, QB16, QB16a)

Dentist pipeline: What the literature says…

• Perceived barriers to dental students’ practicing in underserved areas/populations include lack of information about practice opportunities, student debt and lack of access to patient populations in dental school37

• Untested effectiveness of dental pipeline interventions to promote service to underserved populations38

• Secondary school interventions and select characteristics of dental school admissions and curriculum known to promote dental graduates practice with underserved populations39

42

Dentist pipeline: A Colorado perspective

43SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q24, Q32)

Dentist pipeline: A Colorado perspective

44

Factor % indicating “Yes”Quality of life 95.1%

Good place to raise children 90.0%

Recreational/leisure activities 87.2%

Slower pace of life 86.2%

Personal/family reasons 57.9%

Opportunity to be involved in community

57.5%

Good schools 51.9%

Smaller practice 48.8%

Grew up in a rural area 43.1%

Took over established practice 42.5%

Other reason 32.5%

Factors important in the decision to practice in a rural community, 2008

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q12)

Dental hygienist pipeline: A Colorado perspective

45

Trained in CO

Grew up in CO

Grew up in rural area

Non-rural dental hygienists 44.9% 38.2% 30.3%

Rural dental hygienists 47.6% 36.8% 48.4%

Dental hygienist background by work location, 2006

Associate degree in dental hygiene

Bachelor’s degree in dental hygiene

Non-rural dental hygienists 61.3% 34.7%

Rural dental hygienists 73.8% 20.7%

Type of dental hygiene degree of dental hygienists by work location, 2006

SOURCE: Colorado Health Institute 2007 Dental Hygienist Survey (QA1, QC1, QC2, QB5, QA2)

Aging of the oral health workforce: A Colorado perspective

• 41% of rural dentists are age 55 and older• Greater proportion of older rural dentists

support the independent dental hygienist practice

• 13% of rural dental hygienists are age 55 and older

46

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q1, Q34), 2007 Dental Hygienist Survey (QC7, QC1)

Oral health scopes of practice: What the literature says…

• Peer-reviewed studies indicate that dental hygienists provide equal or better quality of care within scope of practice

• Vast majority of dental hygienist patients are satisfied with care

47

SOURCE: Colorado Health Institute, Collaborative Scopes of Care Report, 2009

Oral health scopes of practice/collaborative models of care: A Colorado perspective

• 51% of rural dentists indicate they collaborate with physicians/nurses in the community

• 72.8% work with at least one dental hygienist• 25% indicate support for expanding the role

of dental hygienists as independent practitioners

• 3% of dental hygienists statewide report working in independent practice

48

SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q17, Q33, Q34), 2007 Dental Hygienist Survey (QB6)

Dental hygienist career ladders: What the literature says…

A 2008 study found that a greater proportion of dental hygienists who begin their dental hygiene career with a bachelor’s degree– Have or are seeking a master’s degree– Are in faculty positions or other teaching

positions– Are involved in research40

49

Dental hygienist career ladders: A Colorado perspective

50

Degree Highest

degree

Percent Non-rural highest

degreePercent Rural

highest degree

Associate 53.8% 52.5% 62.0%

Bachelor’s 39.4% 40.8% 30.9%

Master’s 3.8% 4.0% 2.8%

Doctorate 0.2% 0.2% 0.5%

Highest degree (dental hygiene or other) obtained by working dental hygienists, 2006

Percent indicating “Yes”

Non-rural dental hygienists

18.7%

Rural dental hygienists 28.5%

Dental hygienists intending to pursue another degree/certification, 2006

SOURCE: Colorado Health Institute 2008 Dental Hygienist Survey (QB5, QA2, QA4)

References

Slide 51. Komaromy, et al. (1996); Institute of Medicine; Rabinowitz, Diamond, Veloski and Gayle (2000);

Edmunds (2006); Brotherton, Stoddard and Tang (2000); Davidson and Montoya (1987); Saha and Shipman (2008); Cohen, Gabriel and Terrell. (2002); Smith, Ester and Inglehart (2006).

2. Saha and Shipman (2008); Rabinowitz, Diamond, Veloski and Gayle (2000).3. Lassetter and Baldwin (2004); Kelly, Binkley, Neace and Gale (2005).4. Institute of Medicine (2004); Saha, Guiton, Wimmers and Wilkerson (2008).

Slide 65. Brotanek, Seeley and Flores (2008); Lassetter and Baldwin (2004).6. Lieu, et al. (2004); Cooper-Patrick, et al. (1999); Berger (2008); Institute of Medicine (2003).7. Institute of Medicine (2003); Berger (2008); Lassetter and Baldwin (2004). Slide 78. Cooper-Patrick, et al. (1999).9. Institute of Medicine (2003).10. Berger (2008); Institute of Medicine (2003).11. Halbert, Armstrong, Gandy and Shaker (2006); Cooper-Patrick, et al. (1999).

Slide 1112. Cooney, Kosoko-Lasaki, Slattery and Wilson (2006).13. Hsueh, Wilkinson and Bills. (2004); Ko, et al. (2005).14. Hsueh, Wilkinson and Bills. (2004); Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice

(1996); Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997).

51

References (cont.)

Slide 1215. Ward, Kamien and Lopez (2004); Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Hsueh,

Wilkinson and Bills (2004); Easterbrook, et al. (1999); Curran and Rourke (2004); Henry, Edwards and Crotty (2009).

16. Hsueh, Wilkinson and Bills (2004).17. Hsueh, Wilkinson and Bills (2004); Curran and Rourke (2004).18. Bärnighausen and Bloom (2009).19. Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Curran and Rourke (2004); Henry, Edwards and

Crotty (2009). Slide 1320. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Owen, Hayden and Connors (2002);

Kassebaum, Szenas and Schuchert (1996); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997).21. Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997).22. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Kassebaum, Szenas and Schuchert

(1996). 23. Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice (1996).24. Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997).25. Owen, Hayden and Connors (2002); Kassebaum, Szenas and Schuchert (1996); Ward, Kamien and

Lopez (2004); Rosenblatt and Andrilla (2005); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997); Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997).

Slide 1626. Sloane, Cohen, Konrad, Williams, Schumacher and Zimmerman (2008).

Slide 2327. Allan and Aldebron (2008); Yucha and Witt (2009).28. Yucha and Witt (2009).29. DeYoung, Bliss and Tracy (2002).

52

References (cont.)

Slide 2730. Robert Wood Johnson Foundation (2006); Cyr (2005); Blakeley and Ribeiro (2008).31. Robert Wood Johnson Foundation (2006).32. Robert Wood Johnson Foundation (2006). Slide 3233. Nelson and Cook (2008); Goodrich and Ward (2004).34. Nelson & Cook (2008). Slide 3735. Butters and Winter (2002); Mofidi, Konrad, Porterfield, Niska and Wells (2002); Okunseri,

Bajorunaite, Abena, Self, Iacopino and Flores (2008).36. Kelly, Binkley, Neace and Gale (2005). Slide 4137. Davidson, Nakazono, Carreon, Bai and Afifi (2009).38. Davidson, Nakazono, Carreon, Bai and Afifi (2009).39. Davidson, Nakazono, Carreon, Bai and Afifi (2009). Slide 4840. Rowe, Massoumi, Hyde and Weintraub (2008).

53

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55

Works cited (cont.)Kelly, SE, CJ Binkley, WP Neace, and BS Gale. "Barriers to Care-Seeking for Children's Oral Health Among Low-

Incom Caregivers." American Journal of Public Health 95, no. 8 (2005): 1345-1351.Ko, M, et al. "Impact of the University of California, Los Angeles/Charles R. Drew Medical Education Program on

Medical Students' Intentions to Practice in Underserved Areas." Academic Medicine, 2005: 803-808.Komaromy, M., et al. "The role of black and Hispanic physicians in providing health care for underserved

populations." New England Journal of Medicine, 1996: 1519-1525.Lassetter, JH and JH Baldwin. "Health Care Barriers for Latino Children and the Provision of Culturally

Competent Care." Journal of Pediatric Nursing, 2004: 184-192. Lieu, TA., et al. "Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-

Insured Children." Pediatrics, 2004: e102-e110.Mofidi, M., TR Konrad, DS Porterfield, R Niska and B Wells. "Provision of care to the underserved populations

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Economics, 2008: 353-360.Okunseri, CR Bajorunaite, A Abena, K Self, AM. Iacopino and G Flores. "Racial/Ethnic Disparities in the

Acceptance of Medicaid Patients in Dental Practices." Journal of Public Health Dentistry, 2008: 149-153.Owen, JA., GF Hayden and AF Connors. "Can Medical School Admission Committee Members Predict Which

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56

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