Filling the Need: Mid-Level Health Providers


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Filling the Need: Mid-Level Health Providers

  1. 1. Co-Chairs: Representative Sharon Cissna Senator Donny Olson
  2. 2. Filling the Need: Mid Level Health Providers Wednesday, February 21 st 2007 Noon to 1:00 PM Butrovich Room, State Capitol A light lunch will be served Check out our new website at:
  3. 3. Cathy Giessel, MS, ANP, FAANP <ul><li>Lifelong Alaskan </li></ul><ul><li>BSN - University. of Michigan </li></ul><ul><li>MS - UA Anchorage </li></ul><ul><li>Fellow, American Academy of Nurse Practitioners </li></ul><ul><li>Alaska Board of Nursing, chair </li></ul><ul><li>RN - 32+ years </li></ul><ul><li>ANP - 7 years </li></ul>
  4. 4. Nurse Practitioners Your Choice for Healthcare Accessible Cost-effective Quality Primary Care
  5. 5. <ul><li>“ Advanced nurse practitioner” </li></ul><ul><ul><li>Registered Nurse </li></ul></ul><ul><ul><li>Specialized education and experience </li></ul></ul><ul><ul><li>Certified to perform acts of medical diagnosis </li></ul></ul><ul><ul><li>Prescription and dispensing of medical, therapeutic, or corrective measures </li></ul></ul><ul><ul><li>Regulated by the Board of Nursing. </li></ul></ul><ul><ul><li>Independent practice of healthcare </li></ul></ul>
  6. 6. <ul><li>Anchorage Municipal Health Dept hired the first NP in Alaska in 1970 </li></ul><ul><li>Independent practice since 1984 with full prescriptive authority for all medications. </li></ul><ul><li>NPs make treatment decisions based on clinical judgment and evidence-based research, not standardized protocols. </li></ul>
  7. 7. High quality, acute, chronic and specialty healthcare <ul><li>Order and interpret diagnostic tests </li></ul><ul><li>Diagnose acute and chronic illness </li></ul><ul><li>Prescribe medication or other treatments </li></ul><ul><li>Manage patient’s care </li></ul><ul><li>Refer to specialists as appropriate </li></ul>
  8. 8. Maintain and improve health <ul><li>Individualized comprehensive health education and counseling </li></ul><ul><li>Provide information necessary to make healthy choices and educated healthcare decisions </li></ul><ul><li>On average, NPs spend 31% more time with patients than physicians (2002, BMJ) </li></ul>
  9. 9. Reduce future healthcare costs <ul><li>Focus on promoting health and preventing illness, which reduces healthcare costs for the patient. </li></ul><ul><li>NP patients have fewer emergency room visits and lower average hospital length-of-stay. (2003, Hospitals and Health Networks; 2000 JAMA; 1995 JAANP) </li></ul>
  10. 10. Education <ul><li>Registered Nurse (4 year baccalaureate) </li></ul><ul><li>Experience as Registered Nurse </li></ul><ul><li>Master’s (2-3 years) and/or doctorate (2-3 years) in a specialty </li></ul><ul><li>National board certification exam required by Alaska </li></ul>
  11. 11. Types of NPs <ul><li>Family, adult, pediatrics, geriatrics, women’s health, mental health, certified nurse midwife, emergency, neonatal, adult and family psychiatric/mental health </li></ul><ul><li>Some subspecialty practice settings in allergy/asthma, cardiology, oncology, neurology, pain management </li></ul>
  12. 12. Reimbursement <ul><li>Designated as primary care providers in Alaska </li></ul><ul><li>NPs practice in hospitals, private and public clinics </li></ul><ul><li>Reimbursed by insurance companies </li></ul><ul><li>Reimbursed by Medicaid and Medicare at 85% of physician reimbursement </li></ul>
  13. 13. Alaska NP Education <ul><li>University of Alaska Anchorage </li></ul><ul><ul><li>Program began in 1981, first graduates in 1983. Estimated >160 Family NPs, > 45 Psych Mental Health NPs </li></ul></ul><ul><li>Family </li></ul><ul><ul><li>15-20 applicants for the12 openings/year </li></ul></ul><ul><li>Psychiatric </li></ul><ul><ul><li>8 students admitted every other year </li></ul></ul><ul><li>90% of graduates practice in Alaska after graduation </li></ul><ul><li>HRSA traineeship grants available for full-time students </li></ul>
  14. 14. NPs meet Alaska’s Primary Care needs <ul><li>More than 540 NPs in Alaska in both urban and rural Alaska </li></ul><ul><li>Alaska has one of the highest ratio of nurse practitioners per capita in the nation- 66.9 per 100,000 . (2000 HRSA data) </li></ul><ul><li>Many NPs practice in rural Alaska, often as the only HCP in a community </li></ul><ul><li>Most NPs accept Medicare and Medicaid patients. (Only 10% of physicians accept Medicare.) </li></ul>
  15. 15. Safe, quality care <ul><li>Only 1.4% of NPs in US have been named as primary defendant in malpractice case </li></ul><ul><li>Numerous studies finding NP care comparable to MD care (1991 Annuals of Internal Medicine; 1979 CBO; 2002 BMJ; 2006 Cochrane Database of Systematic Reviews; 2004 Medical Care Research and Review; 2000 JAMA; 2004 Medical Care; 1974 NEJM) </li></ul>
  16. 16. Certified Registered Nurse Anesthetists (CRNA) <ul><li>Another type of advanced practice RN </li></ul><ul><li>Deliver anesthesia in hospitals or outpatient surgery centers </li></ul><ul><li>Independent practice </li></ul><ul><li>More than 100 in Alaska </li></ul><ul><li>Urban and rural practices </li></ul><ul><li>No in-state education programs in Alaska </li></ul>
  17. 17. NPs in Alaska <ul><li>NPs are nurses with advanced training and skills who combine the philosophy of nursing, with the tools of both nursing and medicine, to address healthcare needs of Alaskans. They provide accessible, cost-effective, quality primary healthcare. </li></ul>
  18. 18. WORKFORCE DEVELOPMENT Alaska Mental Health Trust Authority Beneficiaries
  19. 19. ISSUES AND CONCERNS <ul><li>High staff turnover </li></ul><ul><li>Low social status </li></ul><ul><li>Insufficient training </li></ul><ul><li>Limited educational and career opportunities </li></ul><ul><li>Poor wages and benefits </li></ul>
  20. 20. OVERVIEW <ul><li>One of five focus areas for the Alaska Mental Health Trust Authority </li></ul><ul><li>Involves a wide variety of stakeholders </li></ul><ul><li>Looking across the workforce from executive staff to mid-level managers to direct service staff </li></ul><ul><li>Trust funds used as seed money and springboard for long-term programming </li></ul>
  21. 21. GOAL 1: RECRUITMENT <ul><li>Develop Credentialing and Quality Standards Steering Committee </li></ul><ul><li>Develop comprehensive “grow your own” recruitment strategy for youth </li></ul><ul><li>Develop comprehensive in-state and out-of-state marketing strategies </li></ul><ul><li>Develop partnership with the Department of Labor & Workforce Development </li></ul>
  22. 22. GOAL 2: RETENTION <ul><li>Provide loan forgiveness, scholarships and other incentives </li></ul><ul><li>Provide technical assistance to help providers develop agency-specific recruitment and retention plans </li></ul><ul><li>Develop strategies to increase wages and benefits </li></ul>
  23. 23. GOAL 3: TRAINING/EDUCATION <ul><li>Establish three regional training cooperatives </li></ul><ul><li>Provide support for the Geriatric Education and Training Program </li></ul><ul><li>Support and enhance existing education and training programs </li></ul>
  24. 24. Dental Health Hygienists Vickie Hauff, Hygienist
  25. 25. Hygienists could increase cost effectiveness for oral healthcare
  26. 26. Preventing Chronic Health Problems for Alaskans <ul><li>Caries risk in Alaska is 2.5 times greater than the national rate </li></ul><ul><li>Systemic illnesses related to oral health </li></ul><ul><ul><li>Heart Disease </li></ul></ul><ul><ul><li>Diabetes (2.6 times greater than the national rate) </li></ul></ul><ul><ul><li>Pre-term birth </li></ul></ul><ul><li>Millions of dollars are spent trying to fix oral health problems when early intervention is being ignored and could prevent these chronic diseases. </li></ul>
  27. 27. The Problem <ul><li>Many Alaskans cannot afford oral healthcare </li></ul><ul><li>Preventable oral diseases can cause life threatening emergencies </li></ul><ul><li>Many factors exacerbate oral health disparities: </li></ul><ul><ul><li>The current structure of the oral healthcare delivery system </li></ul></ul><ul><ul><li>Maldistribution of providers </li></ul></ul><ul><ul><li>Geographic, educational & cultural barriers </li></ul></ul><ul><ul><li>Cost of care </li></ul></ul>
  28. 28. Hygienists Can Help: We have the education to provide the needed oral health care <ul><li>The registered dental hygienist is a licensed oral health educator and clinical operator who, as part of the dental team, uses preventive, educational, and therapeutic methods which aid individuals and groups to attain and maintain optimum oral health. </li></ul>
  29. 29. Our Limitations <ul><li>Cannot go independently to places that need the care. </li></ul><ul><ul><li>For Example: villages, schools, homebound facilities, etc. </li></ul></ul><ul><ul><li>Unable to see a patient prior to a dentist exam </li></ul></ul><ul><ul><li>Additional current licensing limitations: </li></ul></ul><ul><ul><ul><li>Cannot do anesthesia without a dentist present </li></ul></ul></ul><ul><ul><ul><li>Cannot do restorative procedures </li></ul></ul></ul><ul><li>Current system does not enable us to provide access for preventative services </li></ul>
  30. 30. Hygienists as Mid-Level Providers <ul><li>California, Minnesota, Oregon, Idaho, Ohio, Kentucky & Washington, etc. all have additional expanded functions beyond the procedures allowed by Alaska statutes </li></ul><ul><li>American Dental Hygiene Association </li></ul><ul><ul><li>Proposed ADHP (Advanced Dental Hygiene Practitioner): a cost-effective response to the oral health crisis </li></ul></ul><ul><ul><li>Services provided </li></ul></ul><ul><ul><ul><li>Diagnostic </li></ul></ul></ul><ul><ul><ul><li>Preventative </li></ul></ul></ul><ul><ul><ul><li>Therapeutic </li></ul></ul></ul><ul><ul><ul><li>Minimally invasive restorative </li></ul></ul></ul>
  31. 31. A possible future for Hygienists as the mid-level provider for Alaskans <ul><li>The possibilities: </li></ul><ul><ul><li>Key to cost effectiveness is early intervention </li></ul></ul><ul><ul><li>Education is prevention </li></ul></ul><ul><ul><li>Collaborative Agreements to expand services </li></ul></ul>
  32. 32. Where we need help <ul><li>Expand our scope of practice and geographic range </li></ul><ul><li>We need to improve Alaskan’s access to a full range of dental services </li></ul><ul><li>“Win – Win” solution for all </li></ul>
  33. 33. Nurse Retention: Even More Important than Recruitment A Conversation Prepared by the Alaska Nurses Association 2000, and Revised 2007
  34. 34. <ul><li>In January of 2000, seven months after the Nurses’ Strike of 1999 at Providence Alaska Medical Center, the administration there – noticing a out flux of nursing staff -- requested that the Alaska Nurses Association offer suggestions for the retention of nurses. </li></ul>
  35. 35. <ul><li>What I am offering today is an updated version of the ten suggestions offered at that time with the idea that they can apply to any 24-hour health care facility in Alaska. </li></ul><ul><li>This is not a “scientific” document, but is meant to open a conversation on the topic. </li></ul>
  36. 36. Retention Idea #1 <ul><li>Address staffing/working condition issues immediately. Do not let them molder. Involve Registered Nurses in finding solutions to identified problems. Take their suggestions once in a while. </li></ul>
  37. 37. Retention Idea #2 <ul><li>Recognize that a culture that recruits RNs, also retains RNs. </li></ul><ul><li>Treat RNs as responsible, valuable adults, worthy of respect and occasional accommodation. </li></ul>
  38. 38. Retention idea #3 <ul><li>Provide qualified staffing to cover meals and rest periods on a regular basis, i.e. an uninterrupted meal break of 30 minutes at a reasonable time; and a 15 minute rest period after each four hours worked. </li></ul>
  39. 39. Retention idea #4 <ul><li>Address working conditions that lead to workplace injuries; </li></ul><ul><li>Eliminate risk factors such as mandatory overtime. </li></ul>
  40. 40. Retention idea #5 <ul><li>Provide “recruitment bonuses” for currently employed RNs to encourage them to talk their RN colleagues into applying for and accepting employment at their health care facility. </li></ul>
  41. 41. Retention idea #6 <ul><li>Provide on-campus (or near campus) childcare and “sick child” care at reasonable rates for ALL shifts. </li></ul>
  42. 42. Retention idea #7 <ul><li>Recognize work done “above and beyond” the call of duty: </li></ul><ul><ul><li>Premium pay for part time nurses who work on days off; </li></ul></ul><ul><ul><li>Preceptor pay for helping train new nurses; </li></ul></ul><ul><ul><li>Certification pay for obtaining additional training; </li></ul></ul><ul><ul><li>Provide additional Paid Time Off for long term nurses. </li></ul></ul>
  43. 43. Retention idea #8 <ul><li>Encourage management and nurses to utilize “overstaff” hours to orient to areas/units where there is a shortage of RNs. Provide “scholarships” for nurses obtaining training in needed areas. </li></ul>
  44. 44. Retention idea #9 <ul><li>Improve physical environment, comfortable break areas, for nurses with the same care and concern as provided for the general public physical environment. </li></ul>
  45. 45. Retention idea #10 <ul><li>Provide for health care after retirement for all nurses between retirement age and eligibility for Medicare. </li></ul>
  46. 46. <ul><li>907-274-0827 </li></ul><ul><li>3701 East Tudor Road, Suite 208 </li></ul><ul><li>Anchorage, AK 99507 </li></ul><ul><li>The nurses of Alaska stand ready to discuss these and other ideas for improving the nursing profession in Alaska and retaining qualified, dedicated nurses in that profession. </li></ul>
  47. 47. Filling the Need: Distance Masters of Social Work Education in Alaska Wednesday, February 21, 2007 Elizabeth A. Sirles, Director University of Alaska Anchorage College of Health & Social Welfare School of Social Work
  48. 48. The Demand for Social Workers in Alaska
  49. 49. Locations of MSW Distance Students <ul><li>Anchorage (3) </li></ul><ul><li>Barrow (1) </li></ul><ul><li>Eagle River (1) </li></ul><ul><li>Fairbanks (3) </li></ul><ul><li>Homer (4) </li></ul><ul><li>Juneau (4) </li></ul><ul><li>Kenai / Soldotna (2) </li></ul><ul><li>Sitka (1) </li></ul><ul><li>Wasilla (1) </li></ul><ul><li>Fernie, British Columbia (1) Canada </li></ul><ul><li>Ketchikan (2) </li></ul><ul><li>Kodiak (2) </li></ul><ul><li>North Pole (1) </li></ul><ul><li>Petersburg (1) </li></ul>
  50. 50. Multimodal Approach to Distance Education
  51. 51. Our Distance Students
  52. 52. Field Placements of MSW Distance Students during 2004-05 <ul><li>North Slope Borough Counseling Center, Barrow </li></ul><ul><li>Alaska Psychiatric Institute, Anchorage (Block Placement) </li></ul><ul><li>Office of Children’s Services, Anchorage </li></ul><ul><li>Tanana Chief’s Conference Counseling Center, Fairbanks </li></ul><ul><li>Homer Community Health Center, Homer </li></ul><ul><li>Bartlett Regional Hospital, Juneau </li></ul><ul><li>Kenai Peninsula Community Care Center, Kenai </li></ul><ul><li>Community Connections, Ketchikan </li></ul><ul><li>Ketchikan Pioneer’s Home, Ketchikan </li></ul><ul><li>Providence Kodiak Mental Health Center, Kodiak </li></ul><ul><li>Child, Youth, & Family Services Society of Powell River, British Columbia </li></ul>
  53. 53. Field Placements for Distance Students in 2006-07 <ul><li>Office of Children’s Services, Anchorage </li></ul><ul><li>Providence Alaska Medical Center, Anchorage </li></ul><ul><li>Hospice of the Tanana Valley, Fairbanks </li></ul><ul><li>Tanana Chief’s Conference Counseling Center, Fairbanks </li></ul><ul><li>South Peninsula Haven House, Homer </li></ul><ul><li>South Peninsula Hospital, Homer </li></ul><ul><li>AWARE, Juneau </li></ul><ul><li>Commission on Aging, Juneau </li></ul><ul><li>Kenai Care Center, Kenai </li></ul><ul><li>NAKENU Family Services, Kenai </li></ul><ul><li>Kodiak Area Native Association, Kodiak </li></ul><ul><li>Petersburg Mental Health, Petersburg </li></ul><ul><li>Sitka Counseling and Prevention Services, Sitka </li></ul><ul><li>Behavioral Health Community Mental Health, Wasilla </li></ul><ul><li>Summit Community Services Society, Cranbrook British Columbia </li></ul><ul><li>Hope Cottages, Anchorage along with Waterford University, Ireland </li></ul>
  54. 54. Physician Assistants in Alaska John Riley PA-C, MS Medex Northwest/UAA Physician Assistant Program Coordinator Department of Health Sciences University Of Alaska Anchorage [email_address]
  55. 55. What are Physician Assistants (PAs)? <ul><li>Physician assistants are health care professionals licensed to practice medicine with physician supervision. </li></ul><ul><li>PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, and in virtually all states can write prescriptions. </li></ul><ul><li>Within the physician-PA relationship, physician assistants exercise autonomy in medical decision making and provide a broad range of diagnostic and therapeutic services. </li></ul><ul><li>PA's practice may also include education, research, and administrative services. </li></ul>
  56. 56. Growth of Profession <ul><li>The United States Bureau of Labor Statistics (BLS) projects that the number of PA jobs will increase by 50 percent between 2004 and 2014 </li></ul><ul><li>The BLS predicts the total number of jobs in the country will grow by 13 percent over this 10-year period </li></ul><ul><li>The PA profession was ranked by CNN and Money magazine in May 2006 as one of the top five jobs in the country </li></ul>
  57. 57. PA Training <ul><li>Majority Alaskan PAs trained at Regional PA training center at University of Washington Medex Program </li></ul><ul><li>Second highest percentage Alaska PAs trained at University of Utah PA Program </li></ul>
  58. 58. Medex PA Training <ul><li>6 or more seats at UW Medex reserved for Alaskan applicants </li></ul><ul><li>First year of didactic training in Washington State </li></ul><ul><li>Second year clinical clerkships in training sites across Alaska </li></ul>
  59. 59. PA Program applicants <ul><li>The typical applicant already has a bachelor's degree and approximately four years of health care experience. </li></ul><ul><li>Commonly nurses, EMTs, and paramedics apply to PA programs. </li></ul>
  60. 60. Two generations of previous Alaska CHAs trained at Medex
  61. 61. Distribution PAs <ul><li>Anchorage 29% </li></ul><ul><li>Outside Anchorage 71% </li></ul>
  62. 62. PAs in Primary Care <ul><li>Primary Care 60% </li></ul><ul><li>Specialty Care 40% </li></ul>
  63. 63. What are the future Alaska workforce needs for PAs and other medical providers? <ul><li>The following information is quoted from the Alaska Physician Supply Task Force Report </li></ul>
  64. 64. Report of the Alaska Physician Supply Task Force <ul><li>There will be a shortage of 1100 physicians over the next 20 years due to physician retirement, aging of the Alaska population and decreased production capacity of new physicians </li></ul>
  65. 65. From Report of the Alaska Physician Supply Task Force <ul><li>As of the end of 2005, there were 284 active physician assistants with Alaska addresses and “AA” status; 29 percent were in Anchorage. </li></ul><ul><li>Of 486 advanced nurse practitioners with active licenses and Alaska addresses, 51 percent were in Municipality of Anchorage. </li></ul>
  66. 66. From Report of the Alaska Physician Supply Task Force Finding 5. Alaska has and should maintain a higher ratio of mid-level providers (advanced nurse practitioners and physician assistants) to physicians than the national average, in order to make it feasible to provide high quality and timely care to the population. Without these providers the need for physicians would be even higher.
  67. 67. From Report of the Alaska Physician Supply Task Force <ul><li>Physician assistants and advanced nurse practitioners are critical providers of care in Alaska, complementing and extending physician coverage for primary care, for supervision and training of community health aides and practitioners, and in some settings for serving as specialists in surgery, emergency medicine, and other areas. </li></ul>
  68. 69. <ul><li>The “Graying” of Alaska </li></ul>
  69. 70. Population Projection for Alaskans Over Age 65
  70. 71. <ul><li>The “Graying” of Alaska’s healthcare workforce </li></ul>
  71. 72. Age Distribution of Physicians (MDs and DOs) in Alaska N=1501
  72. 73. Age Distribution of Physician Assistants in Alaska N=294
  73. 74. Age Distribution of Advanced Nurse Practitioners in Alaska N= 424
  74. 75. Strategies <ul><li>Physician workforce projections are based on “trend” models. Trend models project current conditions into the future. As we increase the number of physicians we must also proportionally increase the numbers of midlevel providers to maintain current ratios </li></ul>
  75. 76. Strategies to increase numbers of PAs educated in Alaska <ul><li>Expand UW Medex/ UAA collaboration to provide both years of PA training in Alaska </li></ul><ul><li>Develop bridge program to support professional development of CHAPS to PAs </li></ul><ul><li>Expand support of clinical year training costs </li></ul>
  76. 77. Strategies to increase numbers of PAs educated in Alaska <ul><li>Create loan repayment assistance programs and funding for physician assistants practicing in shortage areas Alaska </li></ul><ul><li>Alaska Participate in the HRSA Bureau of Health Professions State Loan Repayment Program </li></ul><ul><li>Expand and support programs that prepare Alaskans for medical careers </li></ul>
  77. 78. Co-Chairs, Sen. Donny Olson and Rep. Sharon Cissna thank you for participating in the Legislative Health Caucus. A copy of this powerpoint, as well as other up-to-date information, can be found on our website: The audio file of today’s program can be found at: (type in the date of this Caucus). For more information, please call: 1-800-922-3785