Employment Forecast for Minnesota's NP and PA Workforce Continues to Soar

Angie LaFlamme, Program Coordinator II

Minnesota is suffering from a primary health care workforce shortage and the road to improved population health begins with increased access to care. A large portion of the primary care workforce is nearing retirement while fewer medical students are choosing primary care as their specialty. These shortages are particularly significant in the rural parts of Minnesota. Clearly there are benefits of Nurse Practitioners (NPs) and Physician Assistants (PAs) to health care organizations, and the Obama administration has championed NPs and PAs as an important part of the answer to our nations' health care problems.

Growth in the number of PAs has grown substantially in the past several years. In March 2012, Minnesota had over 1,700 licensed PAs, over three times the number from 10 years ago. According to Health Guide USA, PA opportunities are expected to increase 30% from 2010-2020 due to increased need. This should be particularly true for PAs working in rural and medically underserved areas, as well as those working in primary care. With more physicians entering non-primary care areas of medicine, there will be a growing need for primary health care providers, including PAs. Additionally, general population growth and an increase in the number of insured citizens, due to health care reform, will further spur opportunities for PAs as more people seek health care.

Physician Assistants are master's degree prepared health care professions licensed to practice medicine under physician supervision. They are trained to examine patients, diagnose injuries and illness and provide treatment. Until recently, there was only one established PA program in Minnesota, belonging to Augsburg College in Minneapolis. In the summer of 2012, St. Catherine University in St. Paul opened their new PA program. These two programs graduate approximately 55 students each year. Bethel College is scheduled to accept their first PA students in the fall of 2013 and the PA program at The College of St. Scholastica is tentatively scheduled to open in 2015. There is also a strong connection with Mayo Clinic Health System, located in southern MN, and the University of Wisconsin-LaCrosse Gunderson Lutheran PA program.

Minnesota currently reports nearly 3,100 licensed Nurse Practitioners. According to the Bureau of Labor Statistics Occupational Outlook Handbook, 2012-2013 Edition, NPs will enjoy a forecast of increasing job opportunity. All four categories of advanced practice nurses (Nurse Practitioners, Nurse Midwives, Clinical Nurse Specialists and Nurse Anesthetists), as well as Registered Nurses, will be in high demand, particularly in underserved populations like rural and inner-city communities.

Nurse Practitioners programs are now offering a Doctorate degree (DNP). Minnesota currently has 7 NP programs throughout the state: St. Catherine University, The College of St. Scholastica, Metropolitan State University, Minnesota State University Mankato, University of Minnesota, Walden University and Winona State University. These programs graduate approximately 135 students annually.

Nurse Practitioners currently serve patients in a wide variety of settings under varying degrees of physician supervision. They can prescribe medication, often function as primary caregivers in many locations and can choose to specialize in whatever aspects of health care interest them most. The most common specialty for NPs is family medicine, followed by adult, women's health, gerontology and pediatrics.

Primary care providers are often a patient's first point of contact in the health care system and increasing the role of NPs in providing primary care services has the potential to help alleviate the primary care workforce shortage. One option for states is to re-examine the scope of practice laws governing NPs. The American Academy of Nurse Practitioners (AANP) is focusing on: improving Medicare regulations to include NPs' patients as beneficiaries in accountable care organizations (ACOs); the ability of NPs to order/certify home health care services for Medicare patients; Title VIII funding for NP education programs; and traineeships and, funding for nurse-managed centers.

While an increase in education capacity and recruitment of providers is part of the workforce shortage solution, retention is equally as important. There are many elements involved as part of a successful retention plan such as orientation, practice feedback and satisfaction surveys, recognition activities and mentor programs to name a few. Some retention factors that are most important health care providers include: availability to relieve coverage; availability of specialists; income potential; help with retiring education loan; compatibility with others in health care, and quality housing and schools.

The National Rural Health Resource Center and the National Rural Recruitment and Retention Network, under contracts from the Indiana State Department of Health, Minnesota Department of Health Office of Rural Health and Primary Care, and the Wisconsin Department of Health Services Division of Public Health, has created the Midwest Retention Toolkit.

Another great retention tool is loan repayment. Minnesota offers three different federal and state programs to NPs and PAs. The Minnesota Rural Midlevel Practitioner Loan Forgiveness Program is offered to midlevel practitioner students, which includes Nurse Practitioners, Certified Nurse Midwives, Nurse Anesthetists, Advanced Clinical Nurse Specialists and Physician Assistants. Through this program, the above providers can receive $6,750 annually for a minimum of three years and a maximum for four years of service in rural Minnesota. The Federal National Health Service Corp Loan Repayment Program offers full-time providers $30,000 annually for a minimum of two years and a maximum of four years of service in a health professional shortage area (HPSA). The Minnesota State Loan Repayment Program provides recipients with $20,000 annually by completing a two-year service obligation in a nonprofit private or public site that is located in a federally designated HPSA.

With more national focus on prevention rather than just treatment, approximately 35 million newly insured individuals, many practicing physicians expected to retire and an aging population, expanded use of NPs and PAs could be critical to the delivery of primary care and the increasing health care demands in this country.

Rural Quality Programs Living the Triple Aim

Kap Wilkes and Margo Kulseth

"Wow," was my thought after listening to and talking with the Rural Quality grantees at their annual meeting in May. They are doing great work for improving health in their communities. They are living the Triple Aim and having an impact on the health of the people in their communities. I heard this not only from the select panel members but from around the room in the discussions, conversations, and discourse that took place through the entire gathering; improving care, making an impact on better health, and reducing costs leads to a healthier community!  

The discussion and discourse was particularly robust during the last morning when Margo and I suggested and provided a common vocabulary of key sustainability success factors. We didn't stop there, we also provided an opportunity for the rural quality grantees to practice using these words and ideas in a workshop format. In that workshop rural quality grantees talked about key activities that are specific to sustaining a program. This was followed by a deeper discourse on lessons learned. These lessons learned define the path that any program leader can leverage to sustain impact on the health of their communities.

The term “sustainability” is used quite a bit and can mean different things to different people, for example, financial sustainability, operational sustainability, or outcome sustainability. The definition can shift depending on the person, the project, or the circumstance. However, the basic assumption we presented to the rural quality grantees is that all of these perspectives are the right answer if we define sustainability as "continuing to have impact past the life of the grant.” 

Throughout the rural quality grantee meeting and during the beginning of our workshop, Margo and I heard about a lot of different activities within the defined Key Sustainability Success Factors  that the grantees are accomplishing and are engaged in implementing, including: planning, measuring, collaborating, communicating, documenting, and analyzing. The challenge for Margo and I is not only to identify activities or discover lessons learned; the real challenge for us is to illustrate and convince the leaders of these quality programs that the ultimate success factor is to see these activities through the lens of a system. We are ultimately suggesting it is management of the key success factors, components of a performance framework that is key to sustainability.

We recognize and acknowledge that doing this work of improving health and living the Triple Aim is complicated, but we are convinced that a Performance Framework utilized within a systems approach to manage this complexity is the primary key to sustainability. We also believe this sustained effort on improving the health of communities will lead to a tremendous amount of change and transformation in health care. The National Rural Health Resource Center is using and encouraging other health care organizations to use the Baldrige Performance Excellence Framework as a management tool to focus on quality and performance. The most significant benefit of using a framework within a systems approach is that it provides structure and guidance. This is true of the Baldrige Performance Excellence Framework. It can be trusted and relied on because it has been used successfully for amazing gains in performance and sustaining complex organizations over more than 25 years.

The Baldrige Performance Excellence Framework is a management tool to focus on quality and performance. The National Institute of Standards and Technology, Baldrige Performance Excellence Program describes the history and objective of the Baldrige Program in a 2011 report,  Baldrige 20/20, An Executive’s Guide to the Criteria for Performance Excellence, forward by Rosebeth Moss Kanter. The Baldrige Program “was developed in response to a crisis in U.S. competitiveness several decades ago.” “American manufacturing was losing ground to Japanese companies which had adopted quality improvement systems taught to them, ironically, by an American, W. Edwards Deming, as part of the rebuilding effort after World War II.”  Deming is credited for the Plan Do Study Act cycle. “By the mid-1980s, Japan was an economic powerhouse, and sluggish U.S. companies were under pressure to seek performance excellence and innovation.” “The rise of Japanese industry, from automotive manufacturing to electronics, cannot be written off as due to low-cost labor; it is clearly seen as emanating from outstanding management systems.”

In 1987, the U.S. government created the Baldrige Award based on seven specific components and associated performance excellence criteria, “to encourage American companies to examine their practices, benchmark against the best companies, and make necessary changes to become leaner, faster, and more customer-oriented, and responsiveness to multiple stakeholders; all in pursuit of high performance.” Although it started out as a business framework, criteria for health care organizations were added in 2002. The Baldrige criteria are a much used and respected management tool across multiple sectors including manufacturing, business, healthcare and education.

The results from healthcare organizations that have implemented the Baldrige criteria illustrate the impact of utilizing a performance framework within a systems approach. Quality has improved at one hospital with a 57% reduction in mortality resulting from pneumonia over three years. For another hospital there was a 24% increase in net operating margin over two years. Regarding patient satisfaction, in the year before one health care organization as a whole received the Baldrige Award, they were ranked as “the nation’s no. 1 hospital for overall patient satisfaction.”  Another hospital experienced nearly a 50% decrease of registered nurse voluntary turnover rate over two years.

While no management system can predict exactly what challenges will be faced in the future, using the Baldrige criteria as a framework will mean that you are better prepared to meet unexpected challenges, have a focus on results, have systematic processes in place that are effective and regularly evaluated for improvement, have a system that is responsive to customer and stakeholder need, and is integrated into operational areas.  Margo and I can attest that the Rural Quality Programs are indeed living the Triple Aim. They are making a difference and having an impact.  We are suggesting that to sustain those efforts the next step is to manage their work using a performance framework; a systems approach that will sustain the triple aim; improving quality of care, increasing wellness in our communities, and reducing the cost of health care.

RAP Lesson Learned #3: The Power of Team

Rhonda Barcus, Program Specialist

Lately, I have shared a little about two of the lessons I learned from conducting RAP interviews with hospital leaders. We conduct these interviews in order to gather outcome data from hospitals who have participated in an onsite consultation through Rural Hospital Performance Improvement (RHPI) Project. The first lesson was about the “power of a conversation” and the second concerned the power of “meeting people where they are.” The third lesson involves the rich abundance created from Team.

When I contact an administrator to schedule time to talk about the RHPI project, I encourage other leadership members to join the conversation as well. The really wise administrator usually makes sure the leadership team is included in the conversaton! The richness of the RAP interview increases exponentially when the team is present. This isn’t because there are just more people to talk; it’s because each person brings a unique view and experience which more clearly reflects the many facets of the project. One person might be more data-minded while another can speak more easily of the impact of a project on the patient and another might discuss the impact of a project on the employee. The really smart administrator knows there isn’t just one “right” point of view but instead, many pieces reflecting different aspects that give a more complete picture.

In his book, The 7 Habits of Highly Effective People, Stephen Covey describes the importance in Habit 6 for the need to “synergize.” This is defined as “creative cooperation.” I once worked with a manager who was a master at this concept. While many managers tend to hire employees that are similar in style and personality to his or her own, this leader would purposely seek out new employees who brought a different view. He knew that strength was found in a team, and a diverse one at that, and that to try to maintain a narrow way of thinking, where everyone agreed on everything, would only weaken the ability of the team to build this “creative cooperation.” The key wasn’t to develop a team with only one viewpoint but to choose team members with different views AND who also had the ability to cooperate.

This power of team is one of the really important lessons learned from RAP. The first time I called an administrator at the time of our meeting and he had included a number of his leadership team, I was actually taken aback. In the two years of interviews though, I’ve discovered it’s almost predictive. The interview that includes the whole team is usually the one that results in some of the richest outcomes data. It is as if the culture is “we are all in this together” from project beginning (planning) to end (outcomes) and every single person has an important piece to contribute.

RAP Lesson Learned #2: The Power of Meeting People Where They Are

Rhonda Barcus, Program Specialist

Last time, I shared a little about the first lesson I learned from RAP (Recommendation Adoption Process), the process we use to gather outcome data from hospitals who have participated in an onsite project through Rural Hospital Performance Improvement (RHPI) Project. That first lesson was about the power and impact of just having a conversation with someone. The second lesson concerns the power of “meeting people where they are.”

 

RAP involves asking lots of questions about how the hospital implemented the consultant’s recommendations and how that affected measurable outcomes. This is a conversation which could easily put someone “on guard”, feeling like they have to justify their actions, or sometimes, inaction. When we created the RAP process, we based it loosely on an organizational development model called Appreciative Inquiry (AI). AI focuses on discovering what is going well and the strengths and assets and seeks to create more of what already “is.” This approach is very unlike the medical model or problem solving model which focuses on the deficits, illness, or problems. 

The first question in the RAP process is “Tell me what is going well.” As the administrator (or sometimes entire leadership team) begins talking about their successes, my next question is “and what else?” We continue with this line of questioning until they can no longer name another success. The power of this approach is that it often leads to the interviewees saying, “Wow, I didn’t realize we had accomplished so much!” 

The next part of the conversation is geared towards next steps or discovering what hasn’t gone well. Instead of asking about the problems, the focus is on what the hospital would be doing to create the best possible outcomes from this project. The question then might be, “If you could imagine the best possible outcomes for this project, what would you all be doing more of or differently?” This very naturally leads into a discussion about recommendations not implemented or setbacks to the project. Done in this way, the conversation is not defensive or negative because in the spirit of AI, it focuses on “what could be.” It is a subtle, but very effective way to get at the barriers or sometimes resistance but does so in a way that is motivating to moving forward.

The other critical piece of RAP that reinforces “meeting people where they are” is the way the stage is set from the beginning of the conversation. We have discovered that most projects take one to two years to implement. I always begin a conversation by letting the hospital know that. There is often a sigh of relief heard through the phone followed by, “Thank goodness, we were worried you would think we hadn’t done enough.” It is amazing the incredible amount of work most hospitals have already done on a project but they expect to be told that they should be finished in nine months. Thorough and thoughtful implementation takes time but is more likely to lead to a sustainable project with lasting results.

Next time, RAP Lesson Learned #3: The Power of Team.

RAP Lesson Learned #1: The Power of a Conversation

Rhonda Barcus, Program Specialist

The Rural Hospital Performance Improvement (RHPI) Project is a federally-funded initiative that supports performance and quality improvement projects in eligible rural hospitals in the eight-state region of the Mississippi Delta. One of the ways hospitals are supported is through onsite, consultant led projects designed to impact operational, clinical, or financial issues. About 2 ½ years ago, we created a process called RAP, Recommendation Adoption Progress, as the vehicle to gather information from the participating hospital administrators concerning the extent to which they were able to implement consultant recommendations, outcomes, and the impact on the hospital and community.

Hired to create and implement this process, my background is actually in behavioral health and organizational development. Pure data collection and analysis is not my passion! But, I do know how to gather information and one of my closely held beliefs is that looking at data in the form of numbers alone will only tell a piece of the story. We began discussing what the RAP process would include and I knew that sending an impersonal questionnaire to be returned to me was not the way I wanted to go. Most people are “surveyed out”!

So RAP became a conversation with the hospital administrator. Yes, it involves the discussion of data and outcomes and “what has this project meant to the bottom line” but more importantly, it has become an opportunity to dive deeper. My first lesson learned was that just having a conversation can become a powerful motivator for the hospital. In the midst of impersonal communication, actually TALKING about the process, keeps the hospital focused. It also is an opportunity to coach and educate about the importance of the non-measureable ways the project impacts the hospital. If we only discussed measurable outcomes, we would miss the value of project impact such as “staff is more engaged” or “managers are taking responsibility for their budget” or “staff are now bringing ideas for quality improvement to their leadership.” While not necessarily measurable, these are the indicators of culture change. What we know is that without a change in the hospital culture or “the way we are”, there would not be sustainability, regardless of the excellence of the project.

And so, my first lesson learned with RAP is that we intuitively named it well. While an outdated term from the 60’s, it’s still a powerful way to receive and share information and build trusting relationships along the way. It’s just the power of a conversation.

Next time, RAP Lesson Learned #2: The Power of Meeting People Where They Are.