Profile of Older Dual-Enrollees Living in Areas with Managed Long-Term Services and Supports.

OBJECTIVES: Nearly half of all state Medicaid agencies in the United States have implemented managed long-term services and supports (MLTSS). Data gaps have inhibited our understanding of MLTSS experiences to date. We draw on a national survey with novel data linkages to develop a profile of older dual-enrollees with significant LTSS needs by MLTSS program presence. DESIGN: Cross-sectional observational study using the 2015 round of the National Health and Aging Trends Study (NHATS), a longitudinal study of a nationally representative sample of Medicare beneficiaries aged 65 years and older. SETTING AND PARTICIPANTS: The sample comprised 275 participants who self-reported Medicaid enrollment and met our definition of significant LTSS need as defined by receiving help with 2 or more self-care or mobility activities (eating, bathing, toileting, dressing, bed transfer, indoor mobility). METHODS: Bivariate analyses were used to comparatively examine differences in demographic, health, and care circumstances by MLTSS, as defined by living in a county with MLTSS program presence. RESULTS: Among approximately 1 million (weighted sample) older dual-enrollees with significant LTSS needs, 56.2% (weighted percentage) lived in counties with MLTSS and 43.7% lived in counties with mandatory MLTSS enrollment in 2015. Those living in areas with MLTSS were much more likely to be of Hispanic or other race and ethnicity (50.5% vs 15.1%, P < .001) yet less likely to live in a rural location (8.7% vs 31.4%, P < .05) or in a residential care facility or nursing home (18.4% vs 34.7%, P < .05). The majority (78.5%) received assistance from 2 or more helpers and received more than 70 hours of care per week. CONCLUSIONS AND IMPLICATIONS: Our findings reinforce the growing reach of MLTSS programs and importance of filling evidence gaps about who these programs are serving.

The Role of Place in Person- and Family-Oriented Long-Term Services and Supports.

Policy Points Little attention to date has been directed at examining how the long-term services and supports (LTSS) environmental context affects the health and well-being of older adults with disabilities. We develop a conceptual framework identifying environmental domains that contribute to LTSS use, care quality, and care experiences. We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain; increased neighborhood social and economic deprivation are highly associated with experiencing adverse consequences due to unmet need, whereas availability and generosity of the health care and social services delivery environment are inversely associated with participation restrictions in valued activities. Policies targeting local and state-level LTSS-relevant environmental characteristics stand to improve the health and well-being of older adults with disabilities, particularly as it relates to adverse consequences due to unmet need and participation restrictions. CONTEXT: Long-term services and supports (LTSS) in the United States are characterized by their patchwork and unequal nature. The lack of generalizable person-reported information on LTSS care experiences connected to place of community residence has obscured our understanding of inequities and factors that may attenuate them. METHODS: We advance a conceptual framework of LTSS-relevant environmental domains, drawing on newly available data linkages from the 2015 National Health and Aging Trends Study to connect person-reported care experiences with public use spatial data. We assess relationships between LTSS-relevant environmental characteristic domains and person-reported care adverse consequences due to unmet need, participation restrictions, and subjective well-being for 2,411 older adults with disabilities and for key population subgroups by race, dementia, and Medicaid enrollment status. FINDINGS: We find the LTSS environment is highly associated with person-reported care experiences, but the direction of the relationship varies by domain. Measures of neighborhood social and economic deprivation (e.g., poverty, public assistance, social cohesion) are highly associated with experiencing adverse consequences due to unmet care needs. Measures of the health care and social services delivery environment (e.g., Medicaid Home and Community-Based Service Generosity, managed LTSS [MLTSS] presence, average direct care worker wage, availability of paid family leave) are inversely associated with experiencing participation restrictions in valued activities. Select measures of the built and natural environment (e.g., housing affordability) are associated with participation restrictions and lower subjective well-being. Observed relationships between measures of LTSS-relevant environmental characteristics and care experiences were generally held in directionality but were attenuated for key subpopulations. CONCLUSIONS: We present a framework and analyses describing the variable relationships between LTSS-relevant environmental factors and person-reported care experiences. LTSS-relevant environmental characteristics are differentially relevant to the care experiences of older adults with disabilities. Greater attention should be devoted to strengthening state- and community-based policies and practices that support aging in place.

Routes to Rural Readiness: Enhancing Clinical Training Experiences for Physician Assistants.

PURPOSE: The purpose of this study was to describe practices and experiences of rurally oriented physician assistant (PA) training programs in providing rural clinical training to PA students. METHODS: A survey of PA program directors (PDs) included questions about program characteristics, student and clinical preceptor (CP) recruitment in rural areas, and barriers to, and facilitators of, rural clinical training. Programs that considered rural training "very important" to their goals were identified. We interviewed PDs from rurally oriented programs about their rural clinical training and rural CPs about their experiences training PA students for rural practice. We identified key themes through content analysis. RESULTS: Of 178 programs surveyed, 113 (63.5%) responded, 61 (54.0%) of which were rurally oriented and more likely than other programs to recruit rural students or those with rural practice interests and to address rural issues in didactic curriculum. The 13 PDs interviewed linked successful rural training to finding and supporting rural preceptors who enjoy teaching and helping students understand rural communities. The 13 rural CPs identified enthusiastic and rurally interested students as key elements to successful rural training. Interviewees identified systemic barriers to rural training, including student housing, decreased productivity, competition for training slots, and administrative burden. CONCLUSIONS: Physician assistant students can be coached to capitalize on their rural clinical experiences. Knowing how to "jump in" to rotations and having genuine interest in the community are particularly important. Student housing, competition for training slots, and lack of financial incentives are major system-level challenges for sustaining and increasing the availability of PA rural clinical training.

Employers' Perspectives on the Use of Medical Assistant Apprenticeships: A Qualitative Study.

Medical assistants (MAs) are among the fastest-growing occupations in the United States, yet health care employers report high turnover rates and difficulty filling MA positions. Employers are increasingly using apprenticeship to meet emerging workforce needs. This qualitative study examined the perspectives of 14 employers using registered MA apprenticeships in 8 states. The findings revealed motivations for using apprenticeship, perceived benefits to the organization, challenges with implementation, and reflections on successful implementation. We detail how MA apprenticeship is successfully meeting recruitment and training needs in a variety of health care organizations, especially where program support resources are available.

Addressing Systemic Racism in Birth Doula Services to Reduce Health Inequities in the United States.

Purpose: Birth doulas support pregnant people during the perinatal period. Evidence of doulas' positive impacts on pregnancy and birth outcomes, particularly among underserved populations, supports expanding access. However, health workforce-related barriers challenge the development of robust doula services in the United States. This study examined the various approaches organizations have taken to train, recruit, and employ doulas as well as their perspectives on what system-level changes are needed to redress health inequities in underserved communities and expand access to birth doula services. Methods: In addition to literature and policy reviews, we conducted 16 semistructured interviews from March to August 2020 with key informants from organizations involved in training, certifying, advocating for, and employing doulas, and informants involved in state policy making. We analyzed data using qualitative analysis software to identify cross-cutting themes. Results: The landscape of organizations involved in doula training and certification is diverse. In discussing their training and curriculum, interviewees from large organizations and community-based organizations (CBOs) stressed the importance of incorporating a focus on structural racism in maternal health into training curricula. CBOs specifically offered three areas of systems-level change that can help equitably grow doula services: the importance of addressing structural racism, changing the balance of power in decision making and policy making, and a cautious approach to Medicaid reimbursement. Conclusion: This study provides evidence of how doula organizations move the field toward better serving the specific needs of underserved populations. It recognizes the expertise of CBOs in developing policy to expand doula services to communities in need. The information from this study highlights the complexities of facilitating consistency across doula training and certification requirements and implementing a sustainable funding mechanism while also meeting communities' unique needs.

Health Workforce Challenges Impact the Development of Robust Doula Services for Underserved and Marginalized Populations in the United States.

Evidence of doulas' positive impacts on maternal health outcomes, particularly among underserved populations, supports expanding access. Health workforce-related barriers challenge the development of robust doula services in the United States. We investigated organizations' barriers regarding training, recruitment, and employment of doulas. We conducted literature and policy reviews and 16 semi-structured interviews with key informants who contribute to state policymaking and from organizations involved in training, certifying, advocating for, and employing doulas. Our study shows barriers to more robust doula services, including varying roles and practices, prohibitive costs of training and certification, and insufficient funding. This study underscores the importance of doulas in providing support to clients from underserved populations. Health workforce-related challenges remain, especially for community-based organizations seeking to serve underserved communities.

Pipelines to Pathways: Medical School Commitment to Producing a Rural Workforce.

PURPOSE: Despite the efforts of numerous medical schools to produce rural physicians, many rural communities in the United States still experience physician shortages. This study describes the current landscape of rural efforts in US undergraduate medical education and catalogs medical school characteristics and activities that evidence has suggested, and that many experts in rural medical education believe, may result in more graduates choosing rural practice. METHODS: This is a descriptive study of publicly available and rurally relevant characteristics of all 182 allopathic and osteopathic medical schools operating in the 50 states and the District of Columbia in 2016, with rural program information for these schools updated in 2019. The authors constructed a "rural program" definition in order to systematically catalog coordinated and strategic medical school efforts to produce a rural physician workforce. FINDINGS: Few (8.2%) medical schools expressed an explicit commitment to producing rural physicians in public mission statements. However, most (64.8%) provided rural clinical experiences and many demonstrated their commitment in other ways. Only 39 (21.4%) did so through a formal rural program. CONCLUSIONS: In establishing an explicit rural program definition and documenting other markers of rural commitment, this paper provides a baseline for future studies of rural workforce production and medical school investment in these programs, activities, and personnel. Demonstrating the effectiveness of schools' rural physician education efforts will require collaboration across institutions and more intensive evaluations of programs involving students who, though relatively few in number, have great potential for contributing to the health of rural communities across the nation.

Targeted Medical School Admissions: A Strategic Process for Meeting Our Social Mission.

BACKGROUND AND OBJECTIVES: Increased medical school class sizes and new medical schools have not addressed the workforce inadequacies in primary care or underserved settings. While there is substantial evidence that student attributes predict practice specialty and location, little is known about how schools use these factors in admissions processes. We sought to describe admissions strategies to recruit students likely to practice in primary care or underserved settings. METHODS: We surveyed admissions personnel at US allopathic and osteopathic medical schools in 2018 about targeted admissions strategies aimed at recruitment and selection of students likely to practice rurally, in urban underserved areas, or in primary care Results: One hundred thirty-three of 185 (71.8%) US medical schools responded. Respondents reported targeted admissions strategies as follows: rural, 69.2%; urban underserved, 67.4%; and primary care, 45.3%. Nearly 90% reported some type of recruitment outreach to 4-year universities, but much less to community colleges. Student characteristics used to identify those likely to practice in targeted areas were largely evidence-based. Strategies to select students varied widely. CONCLUSIONS: Most responding US medical schools reported a targeted process to recruit and select students likely to practice in rural, urban underserved, or primary care settings, indicating widespread awareness of workforce challenges. This study also demonstrates varying approaches to and allocation of resources toward admissions targeting, especially the application and interviewing processes. Understanding how schools identify and admit students likely to practice in these fields is a first step in identifying best practices for selective admissions focused on addressing workforce gaps.

Promoting Health Careers Among Rural K-16 Students: A Mixed-Method Study to Describe Pathway Programs.

Health career pathway programs can promote and prepare rural students in grades kindergarten through college (K-16) for health careers, but little is known about the prevalence and characteristics of these programs in the U.S. This mixed-methods study provides a baseline description of health career pathway programs for rural K-16 students through a scoping review, survey, and semi-structured interviews with program directors. Among 165 programs responding to the survey, motivational or health career awareness (95.1%), health care exposure (92.0%), and mentorship (70.2%) were the most commonly used strategies. About one-third of programs (34.6%) had discontinued at least one strategy in the past three years, often due to loss of funding or a change in priorities. While reported outcomes suggested positive program effects, evaluations lacked rigor to draw definitive conclusions about program success. This study serves to generate hypotheses for further studies examining characteristics of student participants, program strategies and activities, and outcome measurement for health career pathway programs.

Challenges and Best Practices for Implementing Rurally Targeted Admissions in U.S. Medical Schools.

Student attributes can predict future rural practice, but little is known about how medical schools use these factors in admissions. This mixed-methods study examined admissions strategies to recruit and select students likely to practice rurally. Admissions personnel at U.S. allopathic and osteopathic medical schools were surveyed about rurally targeted admissions. Personnel from selected schools were interviewed to understand further targeted admissions practices. Among 185 medical schools, 133 (71.8%) responded. Schools engaged with students from four-year universities through career exploration (89.9%), admissions preparation (57.7%), academic enhancement (47.7%), and articulation agreements (42.9%). Applicant selection practices included preferential scoring in screening (38.2%) and admissions decisions (30.0%), modified MCAT (21.4%) and GPA cutoffs (18.8%), and reserved class slots (20.2%). Personnel from 10 schools identified key themes of motivations, resources, challenges, and recommendations. Understanding how schools identify and admit rurally inclined students is a first step in identifying best practices for addressing rural workforce gaps.