By Beth Blevins
Loan repayment programs in rural Nebraska are showing huge payoffs: family medicine providers who participate in them are significantly less likely to leave small towns and rural areas than those who don’t.
“We’re trying to maximize the impact and the opportunities for loan repayment in rural and urban underserved areas in the state,” said Thomas Rauner, Program Manager at the Nebraska Office of Rural Health (NORH). “So we are assessing how effective the programs are, and how are they working.”
Towards that end, NORH issued a report in July that examined the impact of incentive programs on retention of family practice providers—the most frequent specialty participating in loan repayment programs and serving in rural areas, Rauner said. The findings showed that these programs are especially effective in rural areas of the state—for example, participating small town and rural area providers are more likely to remain in their positions than non-obligated providers by 23% and 42%, respectively. They remain significantly longer by 2.3 years (small town) and 4.3 years (rural) than non-obligated providers.
One thing that makes the report interesting, Rauner said, is that it offers visual representations of the data. “We’ve been working in the last few years to come up with more visualization components,” he said. “You can look at number, but a picture makes it easier to understand and share with a much broader group.” In the future, he said, they will share data by a place-based and legislative format.
Though the report was issued earlier this year, it has been in the making for nearly two decades with resources from the State Office of Rural Health and Primary Care Office grant programs, Rauner said. “The data on family medicine providers was analyzed by a graduate student intern in our office, using information from the University of Nebraska Medical Center (UNMC) Health Professions Tracking Service (HPTS), which they collaborated with our office to develop over 20 years ago,” he said.
HPTS tracks providers enrolled in all state and federal loan repayment programs during and after their obligation, Rauner said. “Using HPTS, we’re able to track all the healthcare providers in our state,” he said. “The system also allows them not only to track whether physicians who served their obligation out there stay longer in practice than those who did not have obligations, but also gives them the capacity to look at that data over time.”
HPTS data can also be used for economic analysis, Rauner said. “Some of the more interesting findings from the report was that analysis based on years worked shows there is a significant economic benefit associated with rural healthcare providers—a total of $3.6 billion,” he said. “This benefit far outweighs the financial investment in incentive programs.”
HPTS tracks physicians as well as dentists, physician assistants, nurses, graduate-level mental health providers, and allied health providers—those who qualify for loan repayment in the state. Its data also has been used by UNMC authors for reports on primary care nurse practitioners, on physician assistants, and on the status of healthcare workforce in the state.
In addition to HPTS, Rauner said, NORH uses the Practice Sights Retention Management System “to solicit feedback from the providers while serving their obligation, determining if they would like and need to continue receiving loan repayment assistance, and their anticipated and actual retention.”
The data from the two systems benefit both providers and communities, Rauner said. “There are many variables when it comes to assessing workforce needs,” he said. “Each community desires the right care, right time, right place, and the right cost. NORH is continuing to work with communities to develop such a system of care, while working to improve the process and utility of loan repayment programs.”
With the proven success of the loan repayment programs in Nebraska, NORH also has been working to get more healthcare students enrolled in them. “We’ve been trying to simplify it as much as possible,” Rauner said. “We recently combined and changed our loan repayment applications to be a single online application. This will allow NORH to track and process applications for loan repayment and determine the best fit for the provider and the site.”
Does your SORH have a “Promising Practice”? We’re interested in the innovative, effective and valuable work that SORHs are doing. Contact Ashley Muninger to set up a short email or phone interview in which you can tell your story.
How did you get to where you are now with the Nebraska SORH?
Most of my career has been in nursing. I started out doing hospital work and taught nursing courses at the University of Nebraska at Kearney and the University of Texas at Tyler. I was then a rehabilitation consultant and started my own company doing consulting work for insurance companies. When I first went into business, case management was in its infancy. I developed a lot of nurses in that role and did a lot of speaking on it. I’ve gone between teaching and consulting work for several years and still occasionally teach case management and nursing administration classes at Nebraska Wesleyan. I started at the Nebraska Office of Rural Health 3 ½ years ago under Dave Palm and moved into the position of administrator for the Office when he left. The entrepreneur in me has been perfect for my role at the SORH because I have been able to develop pilot programs and come up with new ideas to try in the state. That’s the part I love!
What is the most important thing you are working on right now?
We are working hard on integrated care, which includes building patient-centered medical homes, dental and oral care, and the mental health aspect of it. Because we are a large state with 64 CAHs and over 140 RHCs, we must rely on telemedicine because we just don’t have the number of providers needed in the state. This includes the recruitment and retention of healthcare providers.
It’s also important to know what’s going on nationally. The opioid crisis hasn’t hit Nebraska as strong as other areas, but it doesn’t mean we must wait until it gets here. How do we keep ahead of it? Being involved in national organizations helps me do that. Our Department recently applied for a SAMHSA grant we have been part of and we have started on a pilot project where we will have a rural hospital be the hub for opioid patients. I’ve been working with our prescription drug monitoring program as they have been identifying where our “hotspots” are. Communities can send patients to this hub with a provider and nurses on staff who are trained to care for those individuals, supplementing with telehealth. What I hope to do is use swing beds if patients need to go through withdrawal. We will be bringing these parties together and using a facilitator to help build the infrastructure. Right now, I have momentum with the behavioral health providers and a payor on board who are willing to participate. It will take all of us.
What is the biggest challenge facing SORH leaders today?
As a newer SORH Director, my challenge has been to get myself out there so people know what’s available through our Office and how we can assist them. How do you build those collaborations and include everyone, especially in a large, mostly rural state? How do I let those hospitals know that they don’t have to do things all by themselves? I am trying to make our website more current and interactive so people are aware of what we have to offer and can easily access our resources. We’re also working on moving from paper to electronic applications and resources.
What are you doing to ensure you continue to grow and develop as a SORH leader?
I’m always making sure my team has the ability to attend classes and conferences to increase their knowledge of current issues. I want to give them opportunities to grow and develop in areas they want. I challenge them to take on new things and look at how we can do things differently. If it sounds crazy, that’s okay! I have a lot of crazy ideas, but I’m willing to try them. I hope as a leader that I lead by example; that they see me come up with these ideas and actually get them up and running.
Dave Palm is the director of the Nebraska State Office of Rural Health, a position he has held for two years. Prior to that, starting in 1999, Palm worked as the Flex Coordinator there.
What do you think is the biggest challenge facing your SORH—and other SORHs, as well?
I feel that our greatest challenge is to understand the changes that are occurring in the health care system (e.g., value-based purchasing, and the shift to population health) and to determine how our office can be most effective in helping rural providers and residents adapt to this new environment. While the path is somewhat “fuzzy,” our office can play a crucial role in helping rural communities overcome resistance to change.
For example, we are trying to figure how our office can promote Patient Centered Medical Homes (PCMHs). We’ll probably use some of our SORH money to leverage this, along with the Nebraska Medical Association, to educate clinics on what it means to be a PCMH. Right now we have between 30 and 40 physician clinics in the state that are at some stage of PCMH.
We also are involved in helping local health departments with their community needs assessments (CNAs). The deadline has passed for Critical Access Hospitals (CAHs) to complete the CNA, and now those hospitals are in process of implementing their plans. We’re compiling information, documenting what the implementation activities are, and helping connect hospitals with other partners in their county area (like local health departments) that are working on similar things. We have funded some of these projects. CNAs generally have three to five priorities, including mental health/substance abuse; access to care; chronic illness or risk factor such as diabetes or obesity; and cancer screening. We have high colon cancer rates here, so that’s a priority.
How can a SORH succeed in meeting these challenges?
To be successful, we must learn to become better change managers, create more effective collaborative partnerships, and know when to lead and when to follow. While all rural communities must change, there is not a single solution that will work in all communities. As a result, we must listen to them and help them meet their unique needs and desires. We need to be a voice of optimism, and understand that communities move at a different pace. Maintaining the status quo is not an option.