Establishing voluntary certification of community health workers in Arizona: a policy case study of building a unified workforce.

BACKGROUND: Community health workers (CHWs) are widely recognized as essential to addressing disparities in health care delivery and outcomes in US vulnerable populations. In the state of Arizona, the sustainability of the workforce is threatened by low wages, poor job security, and limited opportunities for training and advancement within the profession. CHW voluntary certification offers an avenue to increase the recognition, compensation, training, and standardization of the workforce. However, passing voluntary certification legislation in an anti-regulatory state such as Arizona posed a major challenge that required a robust advocacy effort. CASE PRESENTATION: In this article, we describe the process of unifying the two major CHW workforces in Arizona, promotoras de salud in US-Mexico border communities and community health representatives (CHRs) serving American Indian communities. Differences in the origins, financing, and even language of the population-served contributed to historically divergent interests between CHRs and promotoras. In order to move forward as a collective workforce, it was imperative to integrate the perspectives of CHRs, who have a regular funding stream and work closely through the Indian Health Services, with those of promotoras, who are more likely to be grant-funded in community-based efforts. As a unified workforce, CHWs were better positioned to gain advocacy support from key health care providers and health insurance companies with policy influence. We seek to elucidate the lessons learned in our process that may be relevant to CHWs representing diverse communities across the US and internationally. CONCLUSIONS: Legislated voluntary certification provides a pathway for further professionalization of the CHW workforce by establishing a standard definition and set of core competencies. Voluntary certification also provides guidance to organizations in developing appropriate training and job activities, as well as ongoing professional development opportunities. In developing certification with CHWs representing different populations, and in particular Tribal Nations, it is essential to assure that the CHW definition is in alignment with all groups and that the scope of practice reflects CHW roles in both clinic and community-based settings. The Arizona experience underscores the benefits of a flexible approach that leverages existing strengths in organizations and the population served.

Registered Nurses: The Curious Case of a Persistent Shortage.

PURPOSE: To better understand the apparent persistent shortage of registered nurses (RNs), including both aggregate trends and cyclical responses. DESIGN: We examine the employment of RNs over variations in economic activity, employing national aggregate and unique micro-population data on nurses in Arizona. METHODS: These data, including our unique, ongoing survey of nurses in Arizona, enable a systematic examination of the cyclical demand for hospital care and institutional responses to that demand in the nursing market by employing multivariate regressions. FINDINGS: Demand for hospital nursing care increases rapidly during the early years of recessions, moderating as the economy improves. Hospitals initially employ more temporary nurses, then reduce temporary hires by shifting employed RNs from part time to full time while also adding RNs not previously employed in hospitals. The substitution of regularly employed RNs for temporary nurses reflects the need to reduce staffing costs to offset increases in uncompensated care. CONCLUSIONS: The increased supply of nurses came from delayed retirements, higher relative hospital wages (inducing nurses in other sectors to return to hospitals), and added-worker effects. Additional nursing hours were drawn from a pool of RNs who were not employed in health care. CLINICAL RELEVANCE: These results strongly suggest that correctly aligned incentives could reduce RN shortages without waiting for another recession.

Modifying State Laws for Nurse Practitioners and Physician Assistants Can Reduce Cost Of Medical Services.

"Bending the cost curve" for health care services in the United States challenges policymakers. A cost analysis was undertaken based on what would occur if more physician assistants (PAs) and nurse practitioners (NPs) per capita were deployed over a 10-year period. The State of Alabama was used as a case study because it is one of a handful of U.S. states with restrictive legislation impacting the scope of practice of PAs and NPs. Changing PA and NP scope of practice legislation in Alabama to match states in the upper quartile of collaborative legislation such as Washington and Arizona would increase the employment and distribution of PAs and NPs. Even modest changes in legislation will result in a net savings of $729 million over the 10-year period. Underutilization of PAs and NPs by restrictive licensure inhibits the cost benefits of increasing the supply of PAs and NPs and reducing the reliance on a stagnant supply of primary care physicians in meeting the needs of its citizens.

Mexican American elders' use of home care services.

Mexican American (MA) elders are more functionally impaired at younger ages than other elders yet use home care services (HCS) less. To determine the possible reasons, nine questionnaires were completed in Spanish or English by MA elders and caregivers living in southern Arizona (N = 280). Contextual, personal, and attitudinal factors were significantly associated with the use of HCS, and cultural/ethnic factors were significantly associated with confidence in HCS. Interventions should be designed and tested to increase the use of HCS by MA elders by increasing service awareness and confidence in HCS while preserving the expectations of familism and reducing caregiving burden.

Assessment of musculoskeletal knowledge in primary care residents.

We assessed musculoskeletal training in primary care residency programs at the University of Arizona to determine whether formal orthopedic instruction increased musculoskeletal knowledge. The University of Pennsylvania Basic Competency Examination in Musculoskeletal Medicine was administered to 38 of 52 primary care resident volunteers. The established "passing" score to demonstrate basic competency on this test is 73.1%. The overall score of the residents tested was 56.3% (range, 21%-88%). Eight of 38 residents had a score of 73.1% or higher. The mean scores were 61.5% with orthopedic rotation and 47.3% without orthopedic rotation. The difference was statistically significant (P=.05). Pediatric residents had the least exposure to musculoskeletal training, and none of them "passed" the competency examination. Primary care providers have a larger role in managing musculoskeletal problems with current managed health care systems in the United States. Many primary care residency programs do not provide adequate training in musculoskeletal medicine. The majority of exiting primary care residents do not have basic competency in managing musculoskeletal problems. Our study results show that residents who take an orthopedic rotation have a larger knowledge base. It seems reasonable to increase primary care residents' formal education regarding musculoskeletal problems.

Student and resident education and rural practice in the Southwest Indian Health Service: a physician survey.

BACKGROUND AND OBJECTIVES: The Indian Health Service (IHS) is an educational rotation site for numerous medical students and residents. These IHS rotations may be an important factor in recruitment and retention of physicians to the IHS. We describe the combined number of student/resident rotations in the Southwest IHS and their influence on recruitment and retention. We also analyze factors related to choice of rural practice in the IHS. METHODS: We conducted a survey of clinical directors and IHS physicians in Arizona and New Mexico. RESULTS: Twenty (87%) clinical director surveys and 289 (66%) physician surveys were returned. More than 400 students/residents participate in rotations annually in the IHS in Arizona and New Mexico. Eighty-four percent of clinical directors feel that educational programs are important to recruitment. Forty-five percent of current IHS physicians participated in IHS rotations as students or residents, and 87% feel that rotating influenced their decision to join the IHS. Eighty percent of IHS physicians who teach feel that working with students and residents improves their job satisfaction. Seventy-five percent of respondents practice in rural areas. Rural medical student and resident rotations are associated with subsequent rural practice. CONCLUSIONS: Many medical students and residents rotate in the Southwest IHS. Clinical directors state that these rotations are helpful to recruitment, and IHS physicians who rotated feel it was important in their decision to join the IHS. IHS clinicians feel that teaching improves job satisfaction.

Physician price fixing under the Sherman Act. An indirect test of the Maricopa issues.

The expression 'price fixing' usually indicates an attempt by competitors to put a floor under the minimum price they will charge. But a recent decision of the Supreme Court, Arizona v. Maricopa County, suggests that attempts to fix maximum prices are equally economically objectionable. In this paper I propose an explanation of simultaneous minimum and maximum price fixing. I also investigate empirically the distribution of physicians' fees in a closely related instance of alleged physician price fixing. The data reject any inference of successful price fixing, and instead conform to the usual predictions of the economics of costly market information.

Cost-effective school nurse practitioner services.

Creative utilization of school nurse practitioners by school districts throughout the country represents a cost-effective approach in meeting educational goals for the educationally high-risk student. Services provided by these practitioners complement the expertise of every member of the educational team while upgrading the comprehensive quality of benefits received by students. From all indications, school nurse practitioners are not recognized nor utilized to the full extent of their potential by educators who are accountable to develop and implement a curriculum for students that allows for individual differences and ensures the acquisition of knowledge. Funding available through state child health legislation and national grants can reimburse school districts using school nurse practitioner services, although these services in and of themselves can represent substantial cost savings.

Threats on campus. Need for faculty response.

Be calm and decisive in all your actions. Threats are meant to intimidate and instill fear. Do not assume someone else will handle the situation. Report the threat immediately to your supervisors. Make a crime report to campus public safety officers and law enforcement officials in the appropriate jurisdiction. Follow up to determine the status of the investigation. Refer the student to campus and/or community mental health services. Document the student's behavior and threats. Don't spend time alone with students who exhibit warning signs that could result in violence. Arrange your office so you have easy access to an exit. Be sure that the desk and chair are not between you and the door. Save all written and electronic threats and provide them to law enforcement officials. There is a mechanism for determining the origin of e-mail threats. Obtain a restraining order if necessary.

The Phoenix fanny pack. An infection protection accessory for all occasions.

Arrangement of Fanny Pack Contents Back zippered compartment Sanitary wipes, Paper sleeves, N-95 mask, Front zippered compartment: Plastic eyewear, Latex gloves, Velcro flap compartment: Scissors, Penlight, glasses and tape. And because providers must document everything, many also carry a pen, pencil and notepad in the pack. The fanny pack for infectious control items has been a big hit for the Phoenix Fire Department and many others throughout the country. The pack removes several bulky items from medical boxes and vehicles, leaving them less cluttered and better organized. The pack also helps departments avoid the costly loss of staff hours due to illness. But most importantly, the packs put essential protective items within quick and easy reach of responders, so they can protect themselves and patients from unnecessary exposure to infectious diseases.

Medical marijuana: legal issues for physicians, others.

AIDS: California's and Arizona's pro marijuana for medical use initiatives possess practical problems, particularly those regarding possible dangers to physicians who recommend use of cannabis. Doctors, regardless of safeguards placed in the State initiatives, may still face Federal charges and criminal liability according to the California Medical Association (CMA). The CMA believes the safest course for doctors to take is to not recommend marijuana at all, and health care providers are being cautious. No one knows whether Federal authorities will aggressively enforce the law against doctors or others, however, the government appears to be proceeding from the notion that such initiatives are a national strategy to legalize drugs. It appears that, for public relations reasons, prosecution efforts may be limited to distributors that may include buyers' clubs. Congress may also draft a Federal bill aimed at effectively nullifying the two initiatives. Californians for Medical Rights, the organization that sponsored Proposition 215, is working on strategies to protect doctors.^ieng

Employers return to wellness to stem rising health care costs.

While many payers have yet to embrace the concept of DM, there are also those on the other end of the spectrum ready to try interventions aimed at preventing or at least delaying the development of chronic disease. And vendors are emerging to answer this demand. Consider the solution offered by one Phoenix-based organization that has been specifically designed for implementation at the workplace.

A day in the life of a rural community health nurse. Tales from the trenches.

The rural nurse is a community nurse--an integral part of her neighbors' lives, with too few hours in the day to meet their specialized needs.

The role of crime prevention education in healthcare security.

The author describes the crime prevention education program developed at his medical center. This program, which he has coordinated, has increased staff awareness and inspired community involvement. As a result, he says, the facility is safer--with fewer staff injuries from assaults.

Multiple shifts as a solution to limited resources.

How a security manager, faced with a limited budget, was able to find a flexible and cost-effective way to provide security coverage for a large medical campus that includes a trauma center.