Drivers of hospital nurse practitioner turnover: A national sample survey analysis.

BACKGROUND: Hospital nurse practitioner (NP) turnover is costly and complex. PURPOSE: Provide a pre-COVID-19 pandemic baseline of hospital NP turnover. METHODS: A secondary analysis of NSSRN18 data on 6,558 (67,863 weighted) NPs employed in hospitals on 12/31/2017. We describe rates of turnover, intention to leave, and reasons for leaving or staying. Using multivariate logistic regression, we examine the association between individual and organizational characteristics and turnover. Survey weights and jackknife standard errors were applied to analyses. DISCUSSION: Approximately 10% of NPs left their job the following year, and 53% of NPs that remained considered leaving at some point. The top reasons cited for leaving or staying were largely organizational factors. Regression analysis revealed not practicing to one's fullest scope, lower income, lack team-based care, and non-white race were associated with an increased likelihood to leave. CONCLUSION: We find several modifiable factors associated with hospital NP turnover that can be used to tailor recruitment and retention strategies.

Lessons Learned From State-Based Efforts to Leverage Medicaid Funds for Graduate Medical Education.

PURPOSE: Total Medicaid funds invested in graduate medical education (GME) increased from $3.78 billion in 2009 to $7.39 billion in 2022. States have flexibility in designing Medicaid GME payments to address population health needs. This study assessed states' impetus for using Medicaid funds for GME, structure of state Medicaid payments, composition and charge of advisory bodies that guide these investments, and degree of transparency and accountability to track whether Medicaid GME investments achieved desired workforce outcomes. METHOD: Structured interviews were conducted in 2015 to 2016 and 2020 to 2021 with subject matter experts representing 10 states. Interview transcripts were analyzed and coded in 6 thematic areas: impetus for using Medicaid funds, the structure of state Medicaid payments, the composition of advisory bodies, the degree of transparency of Medicaid investments, accountability of Medicaid investments, and challenges and changes. RESULTS: States used Medicaid GME funding to address maldistribution of physicians by geography, setting, and specialty, respond to population growth and undergraduate medical education expansion, offset potential loss of teaching health center program funds, and launch new programs and sustain existing ones. States leveraged Medicaid funding by modifying state plan amendments and redesigning funding formulas to meet specific health workforce needs. Many states had advisory bodies to educate legislators, reach consensus on workforce needs, recommend how to disburse funds, and navigate competing stakeholder interests. States identified a need for improved data and analytic systems to understand workforce needs and monitor the outcomes of GME investments. Determining which accountability measures to use and implementing metrics were challenges. CONCLUSIONS: States have much to learn from each other about strategies to best leverage Medicaid funds to develop and sustain residency programs to meet population health needs. Learning collaboratives should be developed to provide a forum for states to share best practices and strategies for overcoming challenges.

Where are the critical care nurses? A statewide analysis of actively practicing nurses' transitions out of the clinical area.

BACKGROUND: Critical care nurse shortages and burnout have spurred interest in the adequacy of nursing supply in the United States. Nurses can move between clinical areas without  additional education or licensure. PURPOSE: To identify transitions that critical care nurses make into non-critical care areas, and examine the prevalence and characteristics associated with those transitions. METHODS: Secondary analysis of state licensure data from 2001-2013. DISCUSSION: More than 75% of nurses (n = 8,408) left critical care in the state, with 44% making clinical area transitions within 5 years. Critical care nurses transitioned into emergency, peri-operative, and cardiology areas. Those observed in recession years were less likely to make transitions; female and nurses with masters/doctorate degrees were more likely. CONCLUSION: This study used state workforce data to examine transitions out of critical care nursing. Findings can inform policies to retain and recruit nurses back into critical care, especially during public health crises.

Improving the Health of Rural Communities Through Academic-Community Partnerships and Interprofessional Health Care and Training Models.

Health disparities between rural and urban areas are widening at a time when urban health care systems are increasingly buying rural hospitals to gain market share. New payment models, shifting from fee-for-service to value-based care, are gaining traction, creating incentives for health care systems to manage the social risk factors that increase health care utilization and costs. Health system consolidation and value-based care are increasingly linking the success of urban health care systems to rural communities. Yet, despite the natural ecosystem rural communities provide for interprofessional learning and collaborative practice, many academic health centers (AHCs) have not invested in building team-based models of practice in rural areas. With responsibility for training the future health workforce and major investments in research infrastructure and educational capacity, AHCs are uniquely positioned to develop interprofessional practice and training opportunities in rural areas and evaluate the cost savings and quality outcomes associated with team-based care models. To accomplish this work, AHCs will need to develop academic-community partnerships that include networks of providers and practices, non-AHC educational organizations, and community-based agencies. In this commentary, the authors highlight 3 examples of academic-community partnerships that developed and implemented interprofessional practice and education models and were designed around specific patient populations with measurable outcomes: North Carolina's Asheville Project, the Boise Interprofessional Academic Patient Aligned Care model, and the Interprofessional Care Access Network framework. These innovative models demonstrate the importance of academic-community partnerships to build teams that address social needs, improve health outcomes, and lower costs. They also highlight the need for more rigorous reporting on the components of the academic-community partnerships involved, the different types of health workers deployed, and the design of the interprofessional training and practice models implemented.

New Opportunities for Expanding Rural Graduate Medical Education to Improve Rural Health Outcomes: Implications of the Consolidated Appropriations Act of 2021.

Evidence shows that those living in rural communities experience consistently worse health outcomes than their urban and suburban counterparts. One proven strategy to address this disparity is to increase the physician supply in rural areas through graduate medical education (GME) training. However, rural hospitals have faced challenges developing training programs in these underserved areas, largely due to inadequate federal funding for rural GME. The Consolidated Appropriations Act of 2021 (CAA) contains multiple provisions that seek to address disparities in Medicare funding for rural GME, including funding for an increase in rural GME positions or "slots" (Section 126), expansion of rural training opportunities (Section 127), and relief for hospitals that have very low resident payments and/or caps (Section 131). In this Invited Commentary, the authors describe historical factors that have impeded the growth of training programs in rural areas, summarize the implications of each CAA provision for rural GME, and provide guidance for institutions seeking to avail themselves of the opportunities presented by the CAA. These policy changes create new opportunities for rural hospitals and partnering urban medical centers to bolster rural GME training, and consequently the physician workforce in underserved communities.

Primary Care Clinicians in Low-Access Counties.

Advanced practice providers comprise an increasing percentage of the health care and primary care workforce. This paper evaluates the weighted contribution of advanced practice providers to the primary care workforce in well-served and underserved counties across North Carolina using age- and sex-adjusted population measures of access.

Efforts to Recruit Medical Students From Rural Counties: A Model to Evaluate Recruitment Efforts.

Background Over the past 40 years, the physician supply of North Carolina (NC) grew faster than the total population. However, the distribution of physicians between urban and rural areas increased, with many more physicians in urban areas. In rural counties, access to care and health disparities remain concerning. As a result, the medical school implemented pipeline programs to recruit more rural students. This study investigates the results of these recruitment efforts. Methodology Descriptive analyses were conducted to compare the number and percentage of rural and urban students from NC who applied, interviewed, and were accepted to the University of North Carolina's School of Medicine (UNC SOM). The likely pool of rural applicants was based on the number of college-educated 18-34-year-olds by county. Results Roughly 10.9% of NC's population of college-educated 18-34-year-olds live in rural counties. Between 2017 and 2019, 9.3% (n = 225) of UNC SOM applicants were from a rural county. An increase of just 14 additional rural applicants annually would bring the proportion of rural UNC SOM applicants in alignment with the potential applicant pool in rural NC counties. Conclusions Our model of analysis successfully calculated the impact of recruitment efforts to achieve proportional parity in the medical school class with the rural population of the state. Addressing rural physician workforce needs will require multiple strategies that affect different parts of the medical education and healthcare systems, including boosting college completion rates in rural areas. This model of analysis can also be applied to other pipeline programs to document the success of the recruitment efforts.

Harnessing the electronic health record to advance integrated care.

INTRODUCTION: Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing. METHOD: Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings. RESULTS: Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate. DISCUSSION: Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The evolving sex, race, and ethnic composition of the surgical workforce: North Carolina is a bellwether of national change.

BACKGROUND: North Carolina, as a state with a significant Black population and fast-growing Hispanic population, serves as bellwether of demographic changes nationally and the challenges facing the nation to recruit and retain a general surgery workforce that mirrors the population. METHODS: Annual licensure data from the North Carolina Medical Board were analyzed between 2004 and 2019. Physicians self-reporting a specialty of abdominal surgery, critical care surgery, colon and rectal surgery, general surgery, trauma surgery, proctology, and surgical oncology were categorized as general surgeons. RESULTS: Female surgeons made the most gains from 2004, at just 8% of the workforce in 2004 to 26% of the workforce in 2019. Over the same period, Black surgeons increased from just 5% to 6% of the workforce, with those gains largely represented by Black female surgeons. Almost half of North Carolina's Black physicians are aged 46 and 55 and will be nearing retirement in the coming decade. Nearly two-thirds (64%) of Hispanic general surgeons were 45 or younger, and one-third of these young surgeons were international medical graduates. CONCLUSION: Although the general surgery workforce in North Carolina is slowly diversifying, growth in the Black surgeon workforce has stagnated in the last 15 years at levels much lower than their representation in the population. More research is needed on the individual and life course phenomena that drive this underrepresentation.

The Supply and Distribution of the Preventive Medicine Physician Workforce.

CONTEXT: Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since. OBJECTIVE: The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce. DESIGN: Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile. SETTING: The 50 US states and District of Columbia. PARTICIPANTS: Board-certified and self-designated preventive medicine physicians in the United States. MAIN OUTCOME MEASURES: Number, demographics, and location of preventive medicine physicians in United States. RESULTS: From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing. CONCLUSIONS: The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Using State Licensure Data to Assess North Carolina's Health Workforce COVID-19 Response Capacity.

BACKGROUND In the early months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages.METHOD Descriptive and cartographic analyses were conducted using licensure data held by the North Carolina Health Professions Data System to assess the supply of respiratory therapists, nurses, and critical care physicians in North Carolina. Licensure data were merged with population data and numbers of intensive care unit (ICU) beds drawn from the Centers for Medicare and Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).RESULTS The pandemic highlighted how critical data infrastructure is to public health infrastructure. Respiratory therapists and acute care, emergency, and critical care nurses were diffused broadly throughout the state, with higher concentrations in urban areas. Critical care physicians were primarily based in areas with academic health centers.LIMITATIONS Data were unavailable to capture the rapid changes in supply due to clinicians reentering or exiting the workforce. County-level analyses did not reflect individual, facility-level supply, which was needed to plan organizational responses.CONCLUSIONS Health care decision-makers in North Carolina were able to access information about the supply of clinicians critical to caring for COVID-19 patients due to the state's long-standing investments in health workforce data infrastructure. Ability to respond was made easier due to strong working relationships between the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, the North Carolina Area Health Education Centers Program, the health professional licensure boards, and state government health care agencies.

COVID-19 and the Health Workforce.

The health workforce has been greatly affected by COVID-19. In this commentary, we describe the articles included in this health workforce research supplement and how the issues raised by the authors relate to the COVID-19 pandemic and rapidly changing health care environment.

The Evolving Role of Medical Assistants in Primary Care Practice: Divergent and Concordant Perspectives from MAs and Family Physicians.

Medical assistants (MAs) are a flexible and low-cost resource for primary care practices and their roles are swiftly transforming. We surveyed MAs and family physicians in primary care practices in North Carolina to assess concordance in their perspectives about MA roles, training, and confidence in performing activities related to visit planning; direct patient care; documentation; patient education, coaching or counseling; quality improvement; population health and communication. For most activities, we did not find evidence of role confusion between MAs and physicians, physician resistance to delegate tasks to properly trained MAs, or MA reluctance to pursue training to take on new roles. Three areas emerged where the gap between the potential and actual implementation of MA role transformation could be narrowed-population health and panel management; patient education, coaching, and counseling; and scribing. Closing these gaps will become increasingly important as our health care system moves toward value-based models of care.

Primary Care Nurse Practitioner Wage Differences by Employment Setting.

BACKGROUND: Previous studies reported that primary care nurse practitioners working in primary care settings may earn less than those working in specialty care settings. However, few studies have examined why such wage difference exists. PURPOSE: This study used human capital theory to determine the degree to which the wage differences between dingsPCNPs working in primary care versus specialty care settings is driven by the differences in PCNPs' characteristics. Feasible generalized least squares regression was used to examine the wage differences for PCNPs working in primary care and specialty care settings. METHODS: A cross-sectional, secondary data analysis was conducted using the restricted file of 2012 National Sample Survey of Nurse Practitioners. FINDINGS: Oaxaca-Blinder decomposition technique was used to explore the factors contributing to wage differences.The results suggested that hourly wages of PCNPs working in primary care settings were, on average, 7.1% lower than PCNPs working in specialty care settings, holding PCNPs' socio-demographic, human capital, and employment characteristics constant. Approximately 4% of this wage difference was explained by PCNPs' characteristics; but 96% of these differences were due to unexplained factors. DISCUSSION: A large, unexplained wage difference exists between PCNPs working in primary care and specialty care settings.

Social Work Student and Practitioner Roles in Integrated Care Settings.

INTRODUCTION: Social workers are increasingly being deployed in integrated medical and behavioral healthcare settings but information about the roles they fill in these settings is not well understood. This study sought to identify the functions that social workers perform in integrated settings and identify where they acquired the necessary skills to perform them. METHODS: Master of social work students (n=21) and their field supervisors (n=21) who were part of a Health Resources and Services Administration-funded program to train and expand the behavioral health workforce in integrated settings were asked how often they engaged in 28 functions, where they learned to perform those functions, and the degree to which their roles overlapped with others on the healthcare team. RESULTS: The most frequent functions included employing cultural competency, documenting in the electronic health record, addressing patient social determinants of health, and participating in team-based care. Respondents were least likely to engage in case conferences; use Screening, Brief Intervention and Referral to Treatment; use stepped care to determine necessary level of treatment; conduct functional assessments of daily living skills; use behavioral activation; and use problem-solving therapy. A total of 80% of respondents reported that their roles occasionally, often, very often, or always overlapped with others on the healthcare team. Students reported learning the majority of skills (76%) in their Master of Social Work programs. Supervisors attributed the majority (65%) of their skill development to on-the-job training. CONCLUSIONS: Study findings suggest the need to redesign education, regulatory, and payment to better support the deployment of social workers in integrated care settings. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

Community Use of Physical and Occupational Therapy After Stroke and Risk of Hospital Readmission.

OBJECTIVES: To determine whether receipt of therapy and number and timing of therapy visits decreased hospital readmission risk in stroke survivors discharged home. DESIGN: Retrospective cohort analysis of Medicare claims (2010-2013). SETTING: Acute care hospital and community. PARTICIPANTS: Patients hospitalized for stroke who were discharged home and survived the first 30 days (N=23,413; mean age ± SD, 77.6±7.5y). INTERVENTIONS: Physical and occupational therapist use in the home and/or outpatient setting in the first 30 days after discharge (any use, number of visits, and days to first visit). MAIN OUTCOME MEASURES: Hospital readmission 30 to 60 days after discharge. Covariates included demographic characteristics, proxy variables for functional status, hospitalization characteristics, comorbidities, and prior health care use. Multivariate logistic regression analyses were conducted to examine the relation between therapist use and readmission. RESULTS: During the first 30 days after discharge, 31% of patients saw a therapist in the home, 11% saw a therapist in an outpatient setting, and 59% did not see a therapist. Relative to patients who had no therapist contact, those who saw an outpatient therapist were less likely to be readmitted to the hospital (odds ratio, 0.73; 95% confidence interval, 0.59-0.90). Although the point estimates did not reach statistical significance, there was some suggestion that the greater the number of therapist visits in the home and the sooner the visits started, the lower the risk of hospital readmission. CONCLUSIONS: After controlling for observable demographic-, clinical-, and health-related differences, we found that individuals who received outpatient therapy in the first 30 days after discharge home after stroke were less likely to be readmitted to the hospital in the subsequent 30 days, relative to those who received no therapy.

Physical and Occupational Therapy From the Acute to Community Setting After Stroke: Predictors of Use, Continuity of Care, and Timeliness of Care.

OBJECTIVE: To identify predictors of therapist use (any use, continuity of care, timing of care) in the acute care hospital and community (home or outpatient) for patients discharged home after stroke. DESIGN: Retrospective cohort analysis of Medicare claims (2010-2013) linked to hospital-level and county-level data. SETTING: Acute care hospital and community. PARTICIPANTS: Patients (N=23,413) who survived the first 30 days at home after being discharged from an acute care hospital after stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical and occupational therapist use in acute care and community settings; continuity of care across the inpatient and home or the inpatient and outpatient settings; and early therapist use in the home or outpatient setting. Multivariate logistic and multinomial logistic regression analyses were conducted to identify hospital-level, county-level, and sociodemographic characteristics associated with therapist use, continuity, and timing, controlling for clinical characteristics. RESULTS: Seventy-eight percent of patients received therapy in the acute care hospital, but only 40.8% received care in the first 30 days after discharge. Hospital nurse staffing was positively associated with inpatient and outpatient therapist use and continuity of care across settings. Primary care provider supply was associated with inpatient and outpatient therapist use, continuity of care, and early therapist care in the home and outpatient setting. Therapist supply was associated with continuity of care and early therapist use in the community. There was consistent evidence of sociodemographic disparities in therapist use. CONCLUSIONS: Therapist use after stroke varies in the community and for specific sociodemographic subgroups and may be underused. Inpatient nurse staffing levels and primary care provider supply were the most consistent predictors of therapist use, continuity of care, and early therapist use.