Idaho Rural Health Association Summit Proceedings
Healthcare Workforce Summit: Exploring New Directions
Please note this is not an exact transcript of the proceedings. Some editing occurred to remove unnecessary narrative and all efforts were made to retain the meaning and content.
April 10, 2008 Panel Question/Answer Period
Suzanne Allen, MD, MPH |
University of Idaho |
Deanna O'Toole, |
Ted Epperly, MD, |
Denise Chuckovich, MA, |
Robert Vande Merwe, |
James Girvan, Ph.D., MPH, |
Susan Ault, RN APPN-NP, |
Linda Hatzenbuehler, Ph.D., |
Laura Rowen, MPH, |
Rolf Ingermann, Professor and Allied Health Advisor |
Cheryl Brush, Workforce Policy Advisor Idaho Department of Labor |
Hartzell Cobbs, Executive Director, Mountain States Group facilitated the discussion and had each panelist introduce his/herself. He explained how the panel had been asked to address 4 fundamental questions. |
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Introductions
- Suzanne Allen, my name is Suzanne Allen and I am a family physician and I see my patients here at the Family Medicine Residency of Idaho and work with the residents there. My administrative job is I run the WAMI Program and WAMI stands for Washington, Wyoming, Alaska, Montana and Idaho and that is Idaho’s medical education program.
- Susan Ault- Executive Director of Idaho Alliance of Leaders in Nursing, and we are a non-profit organization that looks at the nursing shortage from the perspective of hospital and health care professionals and educators. I am also a nurse practitioner part time at Central District Health Department and work primarily for the uninsured population.
- Cheryl Brush – I am the workforce policy advisor for the Department of Labor and I support the Governor’s Idaho Workforce Development Council which is responsible for advising the Governor and Board of Education on workforce and on related issues and more recently I had the honor of being able to support a nursing workforce advisory council that is charged with dealing with the nursing workforce shortage and there is a number of members.
- Denise Chuckovich - I am the Executive Director of the Idaho Primary Care Association and we are the membership association for Idaho’s 12 community health centers, federally qualified health centers located in 34 communities across the state.
- Ted Epperly – I am a family physician as well. I am the Chairman and Program Director of Family Medicine Residency of Idaho that is a residency program that has been here in Boise since 1974. We teach medical students for 3 years to become family physicians, at present we have 30 family physicians in training 10 in each of the 3 year groups. We also have a rural training track located in Caldwell and we have 2 in each of those year groups and we are setting one up in Twin Falls that will start this coming year. We also have a sports medicine fellowship on the campus of BSU.
- James Girvan – Dean of Health Sciences at Boise State University and certainly we prepare some of the health care providers for their careers. Prior to being at BSU, I was at Idaho State for 13 years and I get to sit next to my mentor here, Linda Hatzenbuehler, which it is always great to see her. Actually it is interesting in what goes around comes around I guess because we have been talking about health workforce issues for about the last 16 years. It should be very interesting to hear today other perspectives.
- Linda Hatzenbuehler – Dean of the Casiska College of Health Professions at Idaho State University. The majority of health professions programs at Idaho State are under my administrative wing.
- Rolf Ingermann – Professor of Biology at the University of Idaho, pre-med, pre dent, pre physical therapy advisor since 1986.
- Deanna O’Toole – Vice President of Human Resources of the Idaho Hospital Association.
- Laura Rowen – I manage the Primary Care Program with the State Office of Rural Health here at the Department of Health and Welfare and the program I work most closely helps support the health professional shortage area designations for the underserved area population for the state of Idaho.
- Robert Vande Merwe – Executive Director of the Idaho Health Care Association and Idaho Centers for Assisted Living so our members are nursing homes, assisted living, ICF&R facilities throughout the state of Idaho and we have about 250 members.
Panel Discussion
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(Hartzell) What type of workforce do we want? What types of services need to be enhanced? What direction should we be taking that is new? I would like to begin the panel today with that particular question – Are there existing programs that we have right now that could be enhanced and need to be maintained that can take us where we want to be and what does that say about where we want to be. Why would we enhance them?
The Idaho Hospital Association has done some wonderful surveys; in fact there have been several of them that I believe is included on the CD in your packets.
(Hartzell) Deanna I would like to start with you (IHA) and have you begin to respond to this. What kinds of things from the Hospital Association perspective, I know it is an issue you have been looking at, I am inviting the panel to jump in, you don’t have to have me recognize you, just jump in and go at this topic and feel free to feed off of each other and play back and forth with this.
(Deanna) What you will see is and what we took a look at was about 150 health care positions within our hospitals and we asked our HR individuals what their top concerns were. From those top concerns were about 10 positions that were their top concerns regarding turnover and vacancy. And from those positions we did another survey that showed us what the turnover vacancy rates were for those positions. What we found was that it wasn’t all nursing that was the problem. Here are the problems that we found:
1. Staff RN was number 1 with the highest vacancy rate
2. Medical Technologist was also on the list
3. Physical Therapist
4. Pharmacist
5. Respiratory Therapist
6. ICU Nurse
And it is interesting to know that what we did was we broke down the survey from different regions of the state. We found in the Southwest region the ICU nurse had a very, very high vacancy rate, so much so, that it could impact care and cause emergencies because of the high rate. Others were Director of Nursing Services, Ultra Sound Technologist, and this is an interesting one Housekeeper, you wouldn’t think that Housekeeper would affect patient care but when you have an extremely high turnover rate in Housekeeping, think about it you have a facility that does surgeries, and you are constantly having new folks in there cleaning the surgery rooms, there could be problems in that area, so even the position of Housekeeper is very, very important to us. Radiology Technologist is also one, and that one actually did have a higher turnover rate than our Staff RN. Also Medical Records Coders. So that told us we have a problem pretty much all over the workforce.
The next thing that we did was got together a committee of HR Directors to work on this issue throughout the state and what we have decided to do is obviously because it is such a big problem, we wanted to take a look at creative opportunities that pretty much were in the infancy in our state infancy, and I am going to talk about a couple of these.
One of the programs which is the Lean Program you will be hearing more information on later this afternoon.
I found something this morning and I want to read it to you and then let you know why I feel it is so important. I have a position paper in my hand and it is dealing with the nursing education problems in Idaho and basically in a nutshell saying that nursing educators are telling us that we have a problem in our state with not enough adequate funding for nursing schools. There is much more that this paper does reveal, however, what is important here is the date of the paper, it was dated June 2, 1976. This is a problem that has been going on for a very long time. The reason why it is worse now is because we have a state where people want to move and we also have workforce folks that are older and we have an aging population. So I just wanted to let you know, like our keynote said there has been a lot of talk on this issue but no walk.
I am going to talk about a couple of programs real quickly that we looked at and we feel maybe very very creative and one is called The Lean Program for Health Care. In Idaho we have a couple of hospitals that scored this and I am going to read the definition of the Lean program for those of you who have not explored this. It’s the Toyota model and it’s the whole system approach that creates a culture in which everyone in the organization continuously improves patient services. For example, one project that might focus on processing lab orders, a small team including a physician, nurse, lab technician and phlebotomist would use this process the breakdown in what they do at each step. Each step of the process that they take to process a lab order and adopt a process to identify and minimize waste, such as searching for lost paper work, the end result would be the ability to process more orders with the same number of staff. And that is crucial as we become as we move into shortage and have more positions that are impacted by the shortage. The goals are to improve patient care delivery system and job retention. The essential premise is that when applied to health care Lean improves process steps that are necessary, relevant and invaluable to the patient experience while eliminating those that fail to add value. The improvements possible using lean technique allows staff to have increased direct patient time and to be able to focus on care delivery. This increases the efficiency of the patient care delivery system. In addition the culture change brought by Lean can significantly impact the current workforce crisis and improve working conditions. As a result of having a great deal of control over participating in these improvements, health care providers feel empowered to improve their patient care and more satisfied with their jobs contributing to increased employee retention and subsequently to successfully recruiting and retaining these new employees.
You will hear about this later on this afternoon, but I want you to know that this has worked mostly in large hospitals; Washington has been very successful in some of their critical access hospitals. I was at a program about three weeks ago in which Administrators from small hospitals were talking about their experiences with this program and a couple of things stood out. One thing that they did tell me was when individuals from each area that actually touch process get together in a team environment and it does make them feel empowered and they might be working together for the first time in an environment that is open and they do a lot of it for them. This particular process is a process in which the people actually do the work are creating the new process, which makes them feel very, very empowered and we believe that this information has shown it really impacts their work environment and adds to the success of retaining these folks and also recruiting.
Another area and I am going to wrap things up real quickly is that we believe is very crucial in this environment is Idaho Simulation Network. This particular network is fairly new but it will provide the opportunity to use clinical simulation in nursing and allied health education and staff development. It provides a unique opportunity as we know, as we all know to train nurses and allied health students as well as health care professionals.
(Hartzell) Let’s start getting some of the different perspectives on the kind of foundation that Deanna has laid for us here. From the University perspective, when you look at what needs to be enhanced and what can grow, how do you address that? What do you do with that? What kind of directions are you seeing that we need to be looking at the University community? Jim, Linda
(Linda Hatzenbuehler-ISU) There are two ways that universities look at program development, one has to do with the market for our graduates which is what you all are interested in, but the other thing we look at is the interest from students in terms of getting into the pipeline and into a profession. So there is input and there is the output. So when we develop a program we have to look at both as well as issues and ***(LINDA CLEANING UP THE DISHES AND MAKING A HELL OF A RACKET)!!!!!!! Often they are poorly. The job market, the index the interest in to a profession is not always the case so we have to be very careful about how we make our decisions based on both of those issues.
Very quickly I just wanted to talk about funding if I might. Jim and I were at a very interesting State Board of Education meeting on Monday and we were discussing student fees and an unprecedented event occurred on Monday. Boise State University and Idaho State University together made a request for professional fees be attached to baccalaureate nursing programs and that is a very, very significant move in this state. Backing up just a moment and I will come back to the issue.
How is higher education funded? No longer are we funded using general tax dollars and tuition only. As a matter of fact, my personal budget in my college about anywhere between 43% and 46% of my budget has anything to do with general fund tax dollars. The rest of it comes from other sources, and one of those sources is what we refer to as professional fees, those are special fees that are levied upon students over and above tuition and the State Board of Education has defined which types of programs can have professional fees, and the majority of the professional health care professional programs fit under that definition. We have to be licensed and so on and so forth. So maybe health care administration program would not fall under that health education might not but everything else does all the other 15 professions in my college do meet that requirement and so this is the first time that we have imposed a professional fee upon baccalaureate nursing, we have had it on some of our other programs, as a matter of fact many of you know that our PA program is almost entirely funded through professional fees. One percent of state dollars goes into our PA program here is Boise and Pocatello. So when we start a program we are not just waiting till tax dollars come our way anymore because they are not coming our way and we have to be very creative and innovative and to a great extent the burden is falling on the students to pay for these very high cost programs. A quote was given on Monday and I would back it up that Boise State cost for credit hour for baccalaureate nursing program is about $400 and mine is very close to that as well. So starting in the fall our baccalaureate nurses will be levied a in my case $500 and in Boise State $450 in addition to their circulation (??) fees.
So the other thing I want to mention because there are so many people from the health care system in the room is, first of all the other source of funding for our programs are hospitals and agencies they pay for my faculty, they give me money, they write me checks and so if I have a check from a hospital I can hire additional faculty member and can increase the class size, so that is how all these funding streets are coming together these days, it is not a simple program anymore, as a matter of fact St. Luke’s is going to be participating in a program pretty soon here is Boise with us.
Last comment I want to make is a little bit off the topic and we may come back to it later, when the issue of nursing in Allied Health comes up don’t forget that the health care agencies are competing with other places for our graduates. Health care is only one of the places they work; they work in school districts, corrections, private practice and so on. So when we are talking about the big picture of health care and health care professionals we need to keep that in mind.
Jim Girvan (BSU) – I would echo exactly what Linda said. I just have a couple of other remarks in terms of programs we could in fact increase. Certainly the list that was given and every one of those programs would be great to be able to accept more students. At Boise State we have in our clinical programs we accept about one student for every 3 to 4 that apply, that are qualified and you can talk about that certainly as Linda said it is partly a funding issue, you would need more faculty and actually faculty shortages are contributing somewhat to this and certainly space and so on. But the other piece and I will speak in particular to Ultra Sound or Radiology or Respiratory Therapy in this case nursing may fall in the same boat (??) here, clinical sites. Clinical sites are maxed even in Boise and so our advisory boards for those programs tell us these are the number of students you can accept because this is all we can support in our site. So consequently while it might be nice to accept twice as many people for Respiratory Care or twice as many people in Ultra Sound or something like that. We really have people placed in every single place that, in fact right now we have satiated that, which is one of the reasons that, for instance simulation, the Idaho Simulation Network becomes so valuable because in fact that will enable some of that clinical practice at least depending on the profession to be off loaded, some portion of that maybe 20% - 25% estimates around the country may in fact be able to be done in simulation and so on. Of course the advantage to that is not only are the students beginning to get a chance to work in teams, but they are practicing not on one another or on people so you can keep programming in essence certain health conditions and they can practice, practice and practice. When they go to facilities they are better. There are some things happy in that, but clinical sites are a bottle neck for increasing the numbers of students, it is not that we don’t have the student interest.
Rolf – Actually I want to take the pipeline a little bit earlier in terms of students, dealing with high school students who come to the university system thinking that they come to ISU and I deal with the incoming freshman. The vast majority of students that I deal with that come to the UOI who are interested in health, a lot of them come as pre med or want to be in pre med or their parents want them to be in pre med. Occasionally there will be a student who comes in and who is really interested in perusing dentistry or physical therapy or pharmacy and that always catches my interest and I ask why and almost every time it is because they had a role model. The physical therapist – the high school student had a injury and the high school student had the physical therapist was there and helped him get back to recovery. What I would urge you folks are to give shadowing opportunities to junior high school and high school students, let them explore options. One of the toughest jobs I have is to get our students to explore options - they have tunnel vision into medicine so before they get to us give them some opportunities to see what the alternatives are.
Suzanne Allen (WWAMI) – I would love to talk a little bit about physicians, the programs we have and expansion on those programs. Dr. Epperly and I Co-Chair the IMA Medical Education Committee – the IMA Board has come out and recommended we expand the WWAMI program from 20 medical students to 40 medical students and expand our Utah program from 8 students to 12 students and we work to expand our graduate medical education in the state. We currently have the ability to do both adds, the WWAMI program has said they can go up to 40 students and the Utah program said they can go up to 12 students. We are actively increasing graduate medical education in the state currently, and I will let Dr. Epperly talk a little bit about the family medicine piece of that. We do have a new psychiatry residency track; those residents will be arriving here in July which is very exciting. We are working right now to expand our internal medicine residency and working to have residents come into the state who will do surgery and we already have a pediatrics rotation so working to expand the programs. Do you want me to talk about funding or should we wait for the funding portion? Wait.
Ted Epperly (FMRI) – There is so much to say to you and so little time that you will have other questions, but I will stick to the specific area. For any of you that are in the know of what is going on in our health care system is that Dr. Dodson’s point about everyone they have heard from says that it is broken. We have the worlds best sick care system but not the worlds best health care system, part of the problem is the production of the types of physicians and I will just shoot, I will just focus on the physicians right now that we are producing from medical school. 75% to 80% are going into sub specialties we have all neurosurgeon and orthopedics we need, in fact, in Idaho we rank 8th in the nation per capita but we rank 49th in the nation per capita for family physicians, we don’t have the infrastructure of generalist that focus on the whole patient, on the integration of care, coordination of care. So subsequently we get a lot of Dr’s. that continue to order redundant tests, over prescribe, over refer, we lack the coordination of the entire system. What we are trying to do at the Family Medicine Residency is to be a pipeline for our state along with the program in Pocatello another excellent internal medicine program to produce family physicians that have the broad scope of practice from birth to death, all ages, all genders, to be able to care for 98% of all their problems that walk through a door and then to help coordinate and integrate that care in a way that the patient then when appropriate gets referred on to the next level of care to a sub specialist or to truicary (??) care center even outreach if needed. We started the program in Boise as a 444 program and that is 4 the first year and 4 the second year and 4 in the third year, the Governor has requested from us and it is very appropriate for Governor Otter to do this he would like to see the expansion of our program both in Boise and Pocatello to produce more family physicians because the type of Doctor that needs to go to Montpelier is not the type of Doctor that needs to go to Salmon. The type of Doctor that needs to go to Cottonwood isn’t a neurosurgeon; it needs to be a family Doctor. And so we have increased and heeded that call to get to 10 per year as I mentioned to you a little bit earlier and to start what are called “World Training Tracks”. World Training Tracks are the first year is spent either in Boise or Pocatello and then the later two years are spent in more rural communities. Right now in our training we encourage our family physicians to get out and into Idaho, we have 23 different rotations throughout the state, so our residents practice in these communities, they work with the family physicians in those communities all in an effort to get those physicians out there. In the 33 year history of our program I am proud to tell you we have had 221 graduates from our program and we have had 58% of those stay in Idaho and we’ve had 45% of those stay in rural or underserved areas of Idaho. I think that we are certainly meeting that mark but there needs to be a greater production, as was alluded to earlier, Idaho is growing. If you take a look at the US Census Bureau report it is the 4th fastest growing state in the United States, USA Today had a report about 6-8 weeks ago that the fastest growing state in the United States per capita, what that means is that by the year 2020 there will be about a 29% increase in Idaho’s population. We are not keeping up with that growth; in fact we are way behind that growth. The American Academy of Family Physicians projects that Idaho will see a 30% increase in Family Physicians alone. And one more thing I will just leave with you that is really an eye opener and many of us in this room can really understand this is that us baby boomers get older the amount of need in terms of management again, coordination of chronic diseases, chronic care will just explode. I’ve mentioned to you that by 2020 we will have a 29% increase in growth in Idaho will have a 117% increase in those over the age of 65. So it is something as Hartzell Cobbs said earlier and that is back to Alice in Wonderland “where do we want to be”? We must grow the system at all levels, physicians, nurses, technologist, and we must grow it fast.
Hartzell Cobbs (MSG) – Ted has a foot is both worlds and you make it interesting transition for us, part of him is tied to the University of Washington and has a deep foot in academic and also in the delivery system as the residency’s work in the hospitals and clinics in the areas around Idaho, so you have that kind of transition area.
One of the things I am going to start blaming the first question along with the second question because the second question for the panel is “how do we forecast”, “how do we look at what we are going to be doing”?
In theological terms in the Old Testament the prophets became a prophet by their ability to analyze the present accurately. If you can not analyze where you are now you cannot set direction. False prophets for those that misanalyses the prophets that are listed in the Old Testament are those that were right on in analyzing in present and therefore able to predict the direction that they going.
It is the same principal here. We have on the panel a lot of people that represent different organizations that work with individuals that are in the health care delivery system. We have groups that represent the clinics, nursing homes, hospitals, provider groups, all of labor and then we have the nurses represented and I would like to invite you into the discussion now.
“How do you go about making clear, making projections about what your needs will be?” “How do you get those into communication then with those providing the educational base for this?” “How do they hear you?” “How do you become a part of the decision that they have made in terms of who they train and where they go from there?”
Who would like to start on this?
Bob – while we still have one foot in the ground are there existing programs?
Bob - I will touch on that and what we are forecasting we know that all of our small towns the senior populations that are growing and our nurses in nursing homes on average are older than the nurses in hospitals, we do not have a lot new grads coming to nursing homes saying I can’t wait to go and work in a nursing home when I graduate. That’s how I felt when I was in school when I was in those health care classes and they said where so you want to work and I said I want to work with the elderly. Everyone turned their head and thought what is wrong with him? That is just a fact of life in our culture, but our smaller towns are aging dramatically. We have CNA’s that are in dead end jobs that can’t really progress and there is a 100% turnover in many facilities with CNA’s. So we collaborated with BSU as well as CSI and have a pilot project which we have in Elmore Medical Center with a career ladder for those CNA’s. So for a two year project there is a faculty member that teaches them every Friday skills above and beyond the CNA and in some of those classes they were taught are given credit for their LPN program and 12 of the 14 that started 2 years ago are still there are still CNA’s. They are excited about being LPN’s, they haven’t moved on, I’m not sure of the number but I think 4 or 5 are in the LPN program and we need LPN’s desperately in the small towns. So that is a program we are excited about. It was made possible by a $50,000 grant with Idaho Alliance of Nurse Leaders several years ago. So that kick start fund was important to help the facility hire that person who could work with them every Friday. Now they are funding it themselves because they seen turnover is so costly to keep those same CNA’s for two years it can pay for itself, but to convince other facilities to say “yeah”, if you would upfront the costs now I’m sure you would save later, it doesn’t work that way so we are trying to find public /private partnerships to help kick start this in other facilities and every college around the state is eager to help us to train CNA’s to become LPN’s.
Hartzell – someone else?
Cheryl Brush (ID Dept of Labor) – I am the only person who doesn’t work in health care so we probably have a little different perspective with the problems that the health care work force is experiencing really are the same as those of the rest of the Idaho labor force is experiencing. We’ve had record growth, record low unemployment, and like everyone else we are aging as a population, so these issues we have been dealing with these issues for some time. One of our key products at the Dept. of Labor is census information and labor market information so I think we can help the group in understanding and forecasting some of their anticipated work force needs. We have our key researcher here, Sara Caseeki, who does both long term and short term forecast for labor. Short term forecast are for 2 years and long term are for 10 years. It is not surprising to find out in our short term forecast 7 out of the top ten hybride (?) occupations are in health care. So across the board from the highest levels to the more entry level positions and if you balance that you take that look across the labor force and see that health care comprises currently only 7% of the entire workforce. So healthcare is obviously growing more rapidly than the workforce than other industries.
A couple of other points I wanted to make, we are finding that information and that Laura has included in your packets. Healthcare in any region of the state can be found in a wisdom (??) of what we call at the Dept of Labor “hot jobs” and those are jobs that are characterized by the abundance in the labor market, the wages in the labor market and their growth. So that is true statewide, true in every region and I think not surprisingly RN’s show up in that group and now Sara is going to correct me, and I can’t remember whether it is Pharmacist or Pharmacy Tech and there is one more and I don’t have my glasses. Healthcare is a very critical industry, the fastest growing industry in the health care occupations are RN. Not surprising to any of you. I think if we look at the data we have been looking for partners we think this kind of forecast information is important and it helps inform educators and government in terms of where we should make our investments and where we can have the greatest impact. We were fortunate last year to become charged with housing the Nursing Reports Advisory Council and the Nursing Workforce Center, as I said earlier many of the members of our council who are directing our research are in this room. What we have been able to do, building on the work that BSU had done before, we have been able to consolidate a lot of administrative data, collected by the Dept of Labor, collected by the Board of Nursing, and by the Board of Education and we think we will be able to find and improve upon that kind of forecast data that we have been doing in the past. We think that we will be very successful with this and we have great, great advisory council providing us directions, we hope that this serves as a model for forecasting and working with other industries and other businesses. We did, by the way meet with Robin and others who work in the healthcare area and we think it is a very good idea assuming this all works, I think it will, to develop a single depository for healthcare workforce data as well. Workforce is going to be the issue, you can’t deny the demographics, it will be the top issue for every industry in the state as we go along those that demand high levels of education and training will only be exastibated by that.
NOT SURE WHO IS TALKING - Community Health Center – we feel like we are the canary in the mine, we are out there in rural communities and we don’t have the funds to offer higher salaries. Some of our communities have had a horrible time recruiting; I think one community has had a vacancy for a physician for over 2 years. They just can not recruit. So we are out there and we are living it out right now. In terms of forecasting, one of our biggest concerns is the increasing numbers of the uninsured. Our health centers in 2006 served over 105,000 people and over 50% of those people did not have insurance, not to mention those who are under insured. So as we see more and more people who don’t have insurance, the health centers are really stretched in terms of what they can offer, it’s scary. So there is the uninsured, increasingly elderly population, and the health care centers has traditionally served lots of Moms and babies, younger people now we have had to shift our focus to an older population and retool in terms of our providers and what we are able to offer. We also see a lot of people with chronic conditions which you all know are very expensive to take care of. Our emphasis is more and more towards providing not just a medical home, as Dr. Dodson mentioned this morning coming out of the Governor’s summit but what we call health care home which because in many of our sites we offer medical care, dental care, and behavioral health to serve the full person with a focus on prevention. One thing I wanted to mention getting back to the first question is existing programs, I hope you have heard of the Search Program its when you can place medical students in a lot of settings with Community Health Centers, it is a great way to get people early on out into rural communities to see what it is like to practice in a rural site. The funding for that unfortunately this year is at cap but I hope next year it will be back to full funding. My point though is that it is a great model. The funding we get is from the Federal Government but there might be other ways to fund this. Once last comment is again on the existing programs I think there are a lot of things that we know work in terms of getting people coming to work in health care settings. We know that people coming out of medical school, residency we know they are looking for a life long health record because they like it and we need to work to get that CHR in all of our health care settings, we need to, I think this afternoon there is going to be a discussion about the lean model and yesterday there was recruitment and retention, conference was just excellent. Dr. Butler, from Washington State had talked about the patient center and care model, tras eccentric model - these are models that improved the quality of care that providers like to work in because they feel like they are providing quality, so we really need to think ahead and start remodeling how we provide care. Community health centers one side are really pressed and stressed around financing and on the other side we are trying to develop a model that’s out there.
Sue Ault (IALN)– I just want to put a big plug in for whatever the problems are there are so many different issues we need an ongoing source of reliable statewide data to solve problems in health care. The Idaho Alliance of Leaders in Nursing we were very fortunate 4 years ago to get a HRSA grant which provided funding for us to contract with BSU to develop the Idaho Nursing Workforce Center, and for several years they were able to start pulling together some of the data that is now in the Dept of Labor’s hands to look at nursing from a statewide perspective and to really bring it with all the different aspects, as Robert mentioned, that issues vary across the state. There is a nursing shortage throughout the state our nursing shortage is about a 6% vacancy rate overall, but rural facilities is like 12%, and rural facilities don’t have a lot of funds to offer bonuses and reallocation funds, so that get to be a little bit more creative. We also need to look at ways to use this data to keep a line on those areas with special needs such as uninsured, certain populations in rural areas but it is important that we always have that ongoing source of data that we all know is independent and it’s not biased by law by my part of the state competing with your part of the state or live program because the needs are so varied and great.
Hartzell, Laura I would like to bring the state into this. The kinds of things that are starting to come out in this discussion are moving into the areas that are very fundamental principals that we have serious problems with the uninsured; we have a growing elderly population, we have a shortage of nurses, we do have organizations like the Hospital Assoc, Dept of Labor, BSU, the coordination of getting together a lot of data. How is the State Office of Rural Health looking at these different areas bringing them together and is there a coordinating point through your office or where does that lie or bringing this information together and responding to it?
Laura Rowen (ORHPC) I think there could be a coordinating point for bringing data together and a lot of us in this room who sat at the table together again and again talking about better ways to do that and the data that my program houses of course has to do with access and there is challenges in plugging a lot of data, you mentioned one of them and that is the uninsured. There is currently something called BRFSS data that collects data for adults that describes whether or not the person in the hospital that they were able to complete a survey on has access to insurance. But what are we calling insurance? I mean, if you are eligible for Medicaid are we counting them as an insured person, they are covered, but just because you are enrolled in Medicaid does not mean you have access to a provider that takes Medicaid. So how are we counting what we are trying to describe? We can do a better way of it, I think we can look at how we do it and see if there are ways to figure out if we could do it better. I wanted to echo really quickly for keeping a foot in both categories, its something that Deanna said earlier the scope of the problem that we are talking about for a project that our office did some time ago we google rural providers because we were looking for pictures, to borrow pictures, and we came across an article that was done in Life Magazine and we found this wonderful photos and a feature article about this rural doc and the whole article was about the challenges delivering health care to rural America. The article profiled this rural family practice provider and there is a picture of him walking across the countryside with his black satchel, the article was written in the late 1950’s, but every word of it was true as if it could have been written yesterday and I don’t mean to be doom and gloom but if we are going to be doing a really good job about being prophets and describing what is going on right now something has to be acted upon in order for us to see real change happen and it’s a multifaceted problem and one I don’t think is going to be a one fix solution, some of the proposals are growing to the Residency program are great, even having done that we are not finished. There is a resource that is documented in your CD that sort of profiles some existing resources that the State has access to or could have access or you might want to consider and that is an important document to expand upon even though it is just bullets and highlights to various programs, it’s four pages and its not comprehensive and I think if you folks are aware of other programs that could add to that document we can house that somewhere and keep pulling it out and looking at the programs to see what can we improve upon, what things are working well and how can we make them work better. I think the RHA did a really nice job today and every state struggles with this not just Idaho, by looking at what other states are doing and writing some best practices we recognized that to come in and showcase what they are doing and how they handled this. It is important to have venues and conversations like this and look around and see what all is being done and what we can learn from, we don’t have to invent the wheel.
Hartzell – As we look at the different types of information that is being gathered and we start doing projections are we with all the different information sources, all the different experiences, all the different education that is going on, are we siloed in the state or is there a systematic approach to this where there is a coordination. Sue you were talking about working with BSU and gathering the information – what ends up, is there any place where we do bring together all the information that is necessary and then it informs policy and it informs the educational system, it informs the group that Robin and Steve are working with so that there is an information that is systematically coordinated that is provided. Do we have that?
Cheryl Brush (Dept of Labor) – I mentioned earlier that the Nursing Workforce Center Advisory Council and the Nursing Workforce Center is attempting to do that for nursing. It builds upon work that Susan and the Idaho Alliance for Leaders in Nursing and BSU did the past 4 years. It was recently transferred to the State. Our real hope is that by combining this data, doing some additional survey work with industry we can use this as a model to create really creditable, integrated data. And of course the only reason you would collect this data is so that we can inform policy. That’s the ultimate charge of the group is to create a strategic plan to address the nursing workforce shortage. So we are trying to bring all the resources together. We did meet with the Idaho Hospital Association, ISU, BSU. Laura, Susan, I am not sure if you were there, but we are looking at this proposition for all of health care. But like everything else no one has any money to do this yet, so we are slowly trying to manage it through. If I think the Nursing Workforce Center data is viewed positively we may be able to get some support for going further with other groups.
Helen – Can I respond? I will say something in an exaggerated form just to make a point. Medicine and nursing gets a lot of press. I as a Dean need to be careful in making the decisions I have to make in terms of program development, to make sure I am addressing areas of greatest need not just those that are the most salient. For example, Is the need for nursing in the State of Idaho as great or equal to the need for speech language pathologist particularly in rural areas in our school districts. I don’t have data to answer that question, when I have a vacant position in my college, where do I move it? Do I move it into my speech language pathology program here in Boise or in Pocatello or do I expand my nursing class? It is sort of like the squeaky wheel ends up getting the grease, but I don’t have good data on which to make that decision. If you were all Special Ed Directors and not members of health care agencies, you may say to me you have been making some really bad decisions because you have been putting all of your very scarce resources some of which by the way are checks you are getting from us and you’ve been putting it into nursing, which by the way we have, and you haven’t been paying attention to Speech Language Pathology and we are desperate, with IDEA there is no child left behind our rural areas are crying for some Speech Language Pathologist. What are you doing about it?
Robin Dodson – My hat as the Board of Education. We attempted many times to have some type of a central agency that would pull together the players to look at what you just described in the workforce issue. At least 3 different times in states where that has worked there has been a partnership between the Board of Regence (let’s say) of the post secondary system, the Dept of Health as well as with the Dept of Labor, they actually came together and they agreed as an umbrella. Years ago we attempted this as one of the things we wanted to do was take the occupational codes cross walk them with zip codes and you could get an idea of how many people you had in the supply line, how many vacancies you had out there, when we did that we found out that those code numbers, that if they are mis-coded you end up with a real mess. So we went down through that, it turns out the BSU had a College of Pharmacy, College of Medicine, College of Dentistry, and a College of Science, because the system didn’t allow for the clerks to put that in, it seems to me that we cannot go down this road in the future unless you have very good data and that means we have to pull the right shareholders together to do that. And we do not have the will or the leadership to do that. I am not sure exactly where we are going to go. I am somewhat hopeful the Governor’s Select Committee at least be a spearhead for this because we talked about the clearinghouse issues for clinical rotation sites, somewhat which are huge, the idea of how to keep the crosswalk, the occupation codes with zip codes. We’ve been down this road and I wish that we hadn’t because the point made earlier is the in the 1950’s we are still doing the same thing with rural health and in 1976 we had our nursing crisis and a nursing crisis in the 60’s. Einstein said it best “we are all crazy”.
Hartzell – I would like to take one second – Linda – as to what you were saying to begin with confessional this is a serious problem. In what I am hearing you say is that often you have to play on your experience and on who you know and if you are like me and when I get caught in decisions like that I play on where I have strengths of staff to make decisions on what I focus on. While that is a given in the difficulty of what we are facing raises I think the exact question that needs to be on this table – “Where are the weaknesses in the data that we are gathering”, “How can we fill those gaps” and “How do we create a communication system so that we are working together”. So that Sue the nurses you are representing know that there is an avenue that you are talking to the Universities and the kinds of education that is needed can take place. That the labor demands that you are seeing Cheryl are being responded in response to long term care that is this growing area that has been neglected and really has not had the focus.
Cheryl Brush - Policy short, I know our research analyst, I drive crazy I think the biggest gap that we see in collecting data is the supply side and a lot of it is what Robin just said because we don’t have consistent information about how many people are coming down the pipeline. I have great confidence about data Jet Man now it is going to be tempered by things like consider staffing patterns the ways things are maybe not the way things need to be. That would be a different kind of question but I think if we can get some consistency in that reporting and cross walking that will offer a huge step forward. I’ve watched things like this go over the years, unlike Robin I remain optimistic, eventually they will have it. Things are not like they were 30 years ago they have changed and I think we have the stage set to make things change. I also encourage all of you, if you are looking for where there are gaps, we do have a lot of information and we do forget some turnover gaps and opening of new wrote occupations and openings in different positions, please come to us and ask our local labor economist or call Sarah, you have her card, we have some pretty good stuff there, we would like to make it better.
TED?? Man talking – One thing I would like to interject into our discussion because it has all been on the supply side, the whole demand side. How much of all of this does America need? At what point is enough – enough? If you take a look at our health care system we spend 2.3 trillion dollars a year in America - 2.3 trillion dollars a year over double to the next closest country, which is Sweden and if you look at that it is $7,000 per year for every man, woman and child of the US, but what do we get for it? We get twenty if there is a world ranking in terms of our health care outcomes, we get 37th in the world for effective, efficient system and we get 54th in the world for a fair, just and equable system. So part of this is on the demand side, the expectations of all of us is consumers health care of what it is we should get. I make the point to come back to again, we are good at treating disease, we are good at treating illness, but we are not good and we have not focused well on prevention wellness then all this stuff on the front end of health care and I think we are going to need a bit of the societal readjustment because this is not a simple equation or it would have been solved a long time ago. America has become a society of where we expect everything now, and we don’t like it, when we get that. I get frankly, kind of ticked off when I am third in line at McDonald’s drive thru, it’s an expectation you know that you get it now. It’s very true with health care. Do we continue to just throw more at it? So there is a balance here and we have talked along the supply side of that there must be a demand side re calibration of the formula to. It starts with all of us, again re focus on wellness and prevention, it’s a refocus on what exactly is needed. Is it ok not to have things done? And I get back to the concept of a medical home because it is in that concept that you have a relationship with a Physician or a PA or a Nurse Practitioner or it could be with a mental health worker, social worker in which that person understands you and your needs for the client not only in helping you in what you do need but maybe more importantly what you don’t need in the system. I am here to tell you that I have seen a lot of bad outcomes happen because people get to much time. And so again I think when we talk about growth, future growth for health care expectations that we really recognize on the demand side of it that there must be a readjustment and how do you make that happen in a society where again everybody is expecting a cat scan tomorrow for a headache or a dull pain or the physicians if you put yourselves in the physicians shoes who is concerned about liability if I don’t do it. It’s really a perfect storm in many ways to just have a very expensive health care system with tremendous growth needs, it’s expected a 2.36 trillion dollars now that is expected to double in 2020 and double again in 2040, it’s unsustainable as it is.
Hartzell – Don’t know what the big man had to do with preventive health care.
Linda – I was going to follow up on that and there is a third dimension I think and that has to do with the interest of people going into these professions and how that fluctuates over time. Right now the, I use the word “hot jobs”, I love that term “hot job market”. The hot job on our college campus right now is in terms of health profession is the PA profession. We’ve got people lined up around and around the building trying to get into the PA program, ours and others across the country, but there are other professions that’s needed in the health care system that are not quite as popular. Occupational therapy for example is one of those. For a time we saw a slump in nursing, now we are getting back up to where there is a robust applicant pool in nursing, but these things wax and wane and someone brought up the comment health care agencies could assist with this by introducing very young people in these professions, there is not a television program about Occupational Therapy so Forensic Sciences is hot, medicine is always hot, every student coming in health professions as somebody has already said wants to be a doctor and every basketball player wants to go to the NBA when they reach the college campus and then reality hits and it is not going to happen we have to provide them with alternatives. I think that is a third dimension and that is educating our young people about their aptitudes and how those aptitudes interface with the requirements of these various professions that we need in the health care system. Again, health care we define across five different dimensions, not just physical health, mental health, rehabilitation, public health, prevention wellness and oral health of course. So all of those professions think we need to step up to the plate and introduce our young people about those professions. Since Bob Newhart we haven’t had a lot of mental health on TV, he used to be a physiologist, that’s where the media is where the young people understand the health care system, so it’s ER and those exciting, what they consider to be exciting parts of the health care system. It’s no wonder that we have difficulty getting our young people to work in a nursing home site, can’t think of a sitcom with a nursing home that might draw a young people’s attention.
Hartzell – there are as we bring this together there is a third question that we had that was general and that is “Whose responsibility is this to bring all this together to begin to systematically address the workforce issues?” I think that we have answered that – that it is all our responsibility but there is a second part to that question “Who takes the lead on coordinating this”? “How do you do that in a state like this”? Laura I am going to put you on the spot with that because you are representing the State.
Hartzell – I will start the discussion on this “How do we go about coordinating – we are not on different worlds here we are all on the same side of the net – how do we get this thing coordinated in a way in to where it can begin to effect the type of care that is taking place in the rest of the state”. “How do we get that pipeline working”?
Laura – first you work with really great partners like the Idaho Rural Health Association, and then you think about a summit, but it is, we have relationships with each other, its calling up folks that you know that are invested in this and ask them to sit down and hash ideas out together. That is how we get things done. Over the past 8 years that I have been here I mean you sit at the same table again, again, and again with the same folks over and well today we are going to talk about workforce challenges and tomorrow we are going to talk about access to health care challenges and the next day we are going to talk about providing resources for or getting a handle on the uninsured. You know what it is the same people who show up every single time, a lot of the players are here.
Hartzell – we do have though on the panel, Alliance for Nursing Leadership, Dept of Labor, and the Hospital Assoc that are putting together massive amounts of data. We don’t have it all coordinated together, the other thing we have is the academic community making decisions on the types of services that need to be emphasized. We just heard Linda say, some of that is coming from TV. I am sure that is true. What are the needs of the population in this community and we have representatives of the population that receives health care sitting here as well. So we have that there, we have the academic community, that Linda voiced is making some decisions without the kind of data she should have to make those decisions. Whose responsibility and how do we go about coordinating this all together? How do we get this together?
Female voice – Jim Gordon and I decided it was yours.
Hartzell – the only part of this conversation that was personal has been this thing on older people and I want you guys to start training the elderly. That’s all I have to say.
Jim Girvan – Hartzell I was going to show a little bit of my bias here but actually government can do some positive things. I am not so sure that is the mantra in Idaho. We talk about personal responsibility and all of this but in fact I am not beyond the fact that at least at the state level that’s happening right now with the study committee and all of that kind of thing certainly state agencies, academic institutions and so on I think everyone is doing what they do well, however, I tend to think in some cases we may need something like, you know like automobiles, I am old enough to remember when there weren’t seat belts in cars. Finally we said you are going to have seat belts and you can’t even buy a car without seat belts and you will be fined if you don’t wear it. We are probably going to come to the point where we really need to ask from our state and in tandem with other public and private entities to say “let’s coordinate this, let’s get this together and make it a requirement to participate and put a system together. Because when that happens when something like that occurs as it has in other states the coordination is better. I just see us and I am a I like my freedoms and there are some times when I think we refuse as a society, and I am part of the society, so I am pointing fingers at myself, we either refuse to say you know what maybe we have to give up a little bit of this and allow ourselves to be mandated and even demand ourselves to be mandated and put something together, because there are an awful lot of issues that we can talk about 1976 reports and 1950 reports and to be real honest I don’t want to be reading 2006 or 2008 reports in 2025 that appeared the same stuff. That is exactly where we are going with a lot of really, really great people and we have the expertise we really need some type of mandate and say you are going to sit down and you are going to work this out and in a year or two from now we are going to be coordinated because that’s your job. Sorry I was a little bit on my pedestal there, I really get unhappy sometimes because Laura is right, fantastic people, the same people, very interested, ok, but I do think sometimes its just from someplace on high God or someplace else you are going to do this for the good of the state and we have not had that to be real honest, type of leadership and I think there is where we need to go.
Hartzell- Deanna, how does the Hospital Assoc reflect on this question, it’s got to be one you have raised?
Deanna – absolutely we have just begun looking at this from our perspective. I think that the Nursing Workforce Advisory Council is a wonderful start, its just a start. I would like to see that be a Health Care Workforce Advisory Council and the reason why we take a look at the players that are involved in that council, it involves everyone, all of us, public, private, federal, state government but what is very important here is that it also involves our legislature, involves 2 Senators, and 2 Representatives from the House and the reason why that is so important is because once the data is there we are going to have to go to them to get their buy in on funding and this is a citizen legislature, they are only in session 90 days for the most part, they all have their own jobs and if we need them to understand our issues we’ve been struggling with for 30-40 years it is important to get those players on this type of committee, and they are already there. So I would just like to see it moved into a Healthcare Workforce Advisory Council, we have different models in other states, OK has one, it is a great model we could take a look at.
Sue – While we are waiting for the Legislature and God to intervene, in the meantime we should be doing something like we are doing today, sharing information, because a lot of things we already know work very well, and we can continue to share those best practices with focusing on this pipeline but we also need to look at retaining qualified workforce members as well and that is where the job of industry and healthcare facilities there are some great models out there, the CNA program at CSI and I know a lot of our small rural hospitals have done some great jobs with growing their own nurses and there is a lot of turnover especially with LPN’s in long term they have about a 20% turnover rate, and that is a huge costs to those facilities so we need to work with those facilities talk about best practices and about leadership things we can do and assure them that when we do get qualified staff in healthcare we maintain them as long as we can. As we all get older that becomes more important that we don’t loose as we call ourselves “knowledge workers” that we need to find ways innovative ways to keep those people working longer. The demands of health care are very physically tiring. I think there are things we can do to make workplace safer and easier for people who continue to work as they age. I encourage everybody to wait for the solution, but in the meantime we just need to keep talking and sharing, because there are a lot of things that are working very well.
Denise – one suggestion I have is this morning we heard about the Governor’s Select Committee on Healthcare and one of the issues that was identified at the summit was workforce. There is an opportunity there as they put together their recommendations back to the Governor to say its best to address this issue. My experience has been, and I have been here a much shorter time than all of you, there is great good will, there is great people, there is a lot of partnering, but there hasn’t been, that I am aware of, a unifying force as people are saying as coming from the state. So there is an opportunity, I know the Chair pretty well, he is one of our health center people.
Cheryl Brush – I want to just bring up a couple of things. I think one of the big problems in working together in Idaho is that we really don’t know what is available. I was kind of waiting to speak to a couple of issues when we got to this part. One I wanted to talk about is lean, every university in this state has a group called Tech Help that was originally put together to help with manufacturing, but they can help you by coming in and assess your work processes, helping you work with your employees to work through solutions, so that might be a good resource for folks who are there. I also heard discussions about we need to do more with our pipeline informing our students. The workforce council is advising the Governor on workforce issues and one of their big issues has been improving the quality of our academic achievement of our students. They also in line with high school reform, very controversial, but very necessary, we are expecting people to go into post secondary education, the other side of that has been to ensure all students are introduced to the career choices that are available to them in the state. We have a very good system here of exploration called ECIS Career Information System, every student should be using that to make a career plan. The other part of that that is being promoted is the use of the Career Cluster Concept, occupations or industries that are organized in 16 career clusters, one of those is health care and the expectation is that students should be introduced to at least one of the career clusters as they move through the pipeline. So that if you are going in healthcare, for instance, you might even be able to exit high school with a dual credit and allow you to go on to post secondary education or stop as a CNA or you may become a physician and beyond. So I think those are the kinds of things going on that people don’t know about and we could really use the help of industry to help promote that. There are a lot of fear often times from parents who are going to be tracking students, when in fact you are introducing them to new opportunities. So from that insight I also want to say that we do a lot of work at the Dept of Labor of connecting folks. I heard you talk about housekeeping, we do a lot of recruitment and we do testing, we do referrals and we are working with a number of hospitals and other groups simply to connect folks. We can connect you to training resources we even have training resources available in some cases where we can use incentives to help business able to make those connections. We would very much like to be your partner in solving workforce issues if we can’t do it we need your participation and we are there to help make some investments and to help move things along.
Ted – I would just like to add a couple of things. There are reasons we are in this situation and if you take a big look back part of the reason is that it’s all about money. When we talk about 2.3 trillion dollars in the healthcare system we are talking the largest single economic sector in the America economy. There are a lot of forces that are very happy with that staying just where it is. We are all a part of the problem, from the pharmaceutical industry to the insurance companies to the hospitals to the physicians its all part of that so what breaks us out? Well there are a couple of different points, 1) is the growing uninsured, that’s a travesty, it could be with the growing population and the impact of the demography, it could be a big epidemic of influenza that really brings us to our knees in terms of our health care system the lack of infrastructure is truly there or it could be what lead us into this and that is money. What is really causing it now to have a new re look is the finances in this its imploding, and probably no better felt than by businesses who can’t afford health care for their employees so the tipping point I think will come in those factors but its primarily around money. What I think for Idaho breaks us out to get to Hartzell’s question is we have the ability to transform we just haven’t had the will to transform, and I think that will come from the Governor and Legislature and it is what Jim was getting at is we need to understand the predicament we are in, the predicament we will face and have true leadership, truly step forward, I am very happy to know that we have several committees working on this and hopefully they won’t work cross purposes and just get into a gridlock in terms of what their recommendations are. It is the Governor’s foresight to push something forward, the working committees to do it and then as Dr. Dodson said earlier we talk a lot but what do we do about it. Are we truly going to make a change? I am going to be very interested to see what comes from this in terms of truly making significant changes because I am here to tell you it will impact every single one of us, someway and I think we all must give a damn for this to happen.
Female voice – I just wanted to talk a little bit about pipeline issues that I brought up earlier. If we don’t invest in our students at a young age you are not going to go into healthcare because there are all kinds of other opportunities for them in the job market. We do have a wonderful organization here is Idaho called HOSA (Health Occupation Students of America) and it does exactly what Cheryl was talking about, it exposes those students to all of the different professions in the health care field that they have an opportunity to go into. Our HOSA chapter has really been only up and running in the last 4-5 years, it is run through the Division of Professional Technical Education underneath the State Board of Education and they have a leadership conference every year and students come from all over the state they meet together the go through all kinds of contests really and people who win for the state go on to nationals and last summer we had people can in second and third nationally in some of these competitions, so we have students out there who are really capable of going on and becoming our workforce future, it is up to us to really encourage them to participate in organizations like HOSA and especially in our rural communities we need to work with high schools to make sure those students know about HOSA, whether they have their own chapter or can be a part of chapter at a school close by or if they just participate in the state leadership conference and the national leadership conference. So I would encourage all of you to participate in that and allow high school student the opportunity to shadow in which ever one of those professions they are interested in going into.
Hartzell – we have about 10 minutes, boy this is going fast, before we take a break and there is one last issue from the last three people that have spoken and they have really moved us into this area the wording that Suzanne just used moving to making an investment so the question becomes “How do we in the workforce issue move from cost to investment”? The costs that Ted shared with us are staggering. “How do you in that environment and yet it still comes down to money how do you begin to address the workforce issues financially and make them appropriate investments rather than costs, how do we deal with that”? This is tough, who wants to talk? Go for it Jim.
Jim Girvan – I guess I would like to say first of all there are lots of examples right now of investment. So people use those terms but in fact they are getting and I am sure anyone else here could tell you related at all to the academic institutions without partners, and Linda has talked about this, without our partners and our partners make huge investments in our programs, the hospitals, clinics, investments not only in sites for students, but in dollars to fund research to fund faculty positions, graduate assistantships, that’s already happening, they see a value in it because they is why they are doing it, but it also enhances the experience for everybody. Certainly the State has made investments and a couple of years ago we got more dollars for nursing faculty salaries. So that really helped, at BSU that really helped retention of faculty. So that is an investment. Our university we optimally we like all of our of our nursing faculty but we don’t have right now, to have doctorate degrees, but over the past 5 to 7 years with great leadership from Dr. Springer, and our central administration office we have had a lot of support for people going back and getting advanced degrees. So we have gone from 6 or 7 of our 35 faculty, I guess 38 nursing faculty right now with PhD to 18 and we have 6 more that are enrolled in PhD programs right now. It makes a lot of difference in terms of the research experience and being able to integrate. I wanted to start out I guess by talking about the fact that there are those entities, we invest in ourselves, the State has invested and certainly the private sector is already doing some investing but I still go back and would say that there is a real difference a real mindset between “does this cost us money or is it an investment”? That is kind of the mental shift that I think we need to take as a State in a society in general that in fact investing in people is the best investment we can make. Paul Zellus who was a professor at ISU and now retired to Boise and I knew Paul over there so he and I just did a paper this last year for the Boise Metro Chamber and it was talking about the health care industry in Boise. What is that worth in the Boise metropolitan area – talk about investment, because sometimes you go well do we get any bang for our buck in terms of this well, just in the Boise metropolitan area the value of goods and services by the health care sector in 2005 which is the latest year available was $1.7 billion. It is not insignificant. It is also 13% of the wages paid in this metropolitan area were to health care providers. So if we just look at that and in fact that is going to become most likely an increasing sector certainly in the area where we spend plenty of money but we can look at that as an investment but also in a business sense, trying to say well I might look at it as an investment because I am not in a business, I recognize the need for profit businesses but I look at it from a social sector investment but a business person or a legislature would look at it as are we getting a return on our investment. Well I can tell you there is a huge return in terms of dollars as well as certainly care and coordination of care so I think the case can be made. In Robin’s talk he ended up by saying one of their charges was to be bold and I agree with that because Ted gives the idea of will. Boldness stands up there and said I think we are going to put some dollars into this for people because ultimately that and the coordination because ultimately that is what is going to pay off and look at that as an investment instead of a cost.
Hartzell – I am going to at this point and there will be opportunity if you want to make other comments on the investment point after the break but we will be taking a break, 15 minutes and during that time if you have questions that you have jotted down or thought that have come to you wanted to discuss with the panel bring those back because after our break the next hour is yours and you will be given and you can ask your questions and enter the discussion with this panel.
[Second Tape]
Hartzell – what we will be doing it take the next half hour and the questions will come from you. We will have a half hour and we would like to have the questions still focused on the issues of the four categories that we were talking about today, rather than moving into other areas. And before we begin the questioning as you are thinking of them and jotting them down Denise you wanted to make a few comments as we on the cost to investment.
Denise – yes just one quick comment on that last part of the discussion on costs vs investment and again building on Ted Epperly’s figures he tossed out lets focus on prevention – there is an investment and primary care and work toward shifting all that money that is going into emergency rooms, hospitalizations and y care back towards prevention to me that is the best investment we could make.
Hartzell – thank you.
Are there any questions?
Annette Phillip, Assistant Research Faculty at Idaho State University and I was just wondering what you see as the role of telemedicine in the workforce filling the needs in the next 15 years?
Female voice – Especially in rural America using telemedicine in some format is much more likely to happen. Certainly from a physician’s standpoint, if I am a physician in Salmon, I am unable to get a patient to a larger turserary care facility, the ability to communicate with a specialist in a larger facility makes my life much easier. I think you will see a lot coming in the future as far as different ways to achieve that telemedicine. So what is the exact platform that you utilize to be able to make that timely cost effective those sorts of things, but I do think you will see an expansion in that area. I know one of the hospitals here in the Valley have been utilizing a program where they can actually have robots or computers that are in certain locations and go back to the larger facilities so that physicians can communicate with each other. The specialists have the ability to see the patient physically, to look at the EKG physically or whatever it might be to really enhance the care of that patient out in the rural facility.
Suzanne I know this has been an issue at the University of Washington (WAMI program) in relationship to Idaho. Is there an update on where the School of Medicine at the University of Washington and how it’s looking at telemedicine in relationship to rural Idaho?
Suzanne – Yes, a large piece of that is actually the platform by which telemedicine will occur. The ISLIP, which is the assimilation facility up at the University of Washington is actively working with our Idaho assimilation network to really increase the oversight of simulation throughout the state. They are working with Microsoft to develop a platform to make that ability much easier and we have been playing around with it a little bit and doing demonstrations of what that can potentially look like. With the ability to potentially link multiple different critical hospitals into one teaching environment through some interesting things that I don’t really understand about technology, but it’s really using the X-box platform to be able to have an interactive session and that is where they are focusing their efforts for the future.
Rod Jacobsen, Montpelier Idaho – This is probably an editorial as much as a question so indulge me but I did drive 350 miles to get here today. I am tired and frustrated and I hear the comment at least 3 times that we need more data. My comment would be what other career field on any campus in Idaho turns away 3 out of 4 eligible qualified applicants besides nursing? What other career field has industry paying for faculty positions and getting full ride scholarships to anyone willing to become a nurse? Where can you go for any other career field and charge a $500 professional fee and not chase off every student that is looking to come into it and yet to me what University has reduced, eliminated the program or diverted significant money to nursing. Have they closed a law school, there is certainly no shortage of lawyers in the Valley, in this town. How about political science, there seems to be no shortage of politicians in this town. Our geology schools, arts, humanities, history, I wonder if we changed anything with the way we funds schools or is it we just need more money for this and we are not going to change and I think we are doing a service to many of our students when we encourage them or recruit them go into a field where it is a dead end. My question is I guess has colleges diverted funds from dead end careers and put them into health care?
Linda H ? Rod, you will be happy to know the University of Idaho is bringing their law school to Boise so we will have two of them, which happened on Monday to, so. Yes we actually have put a lot of new resources into health care from other places. The pharmacy school will be opening here in Boise so we will be doubling our pharmacy class; the PA program is already done that although very little State resources go into the PA program. Both ISU and BSU over the last 7 years has put new resources into nursing in one way or another as have some other schools in the State, so we have new resources and remember the issue I started off with my comments the issue of access to students to the programs that they are interested in and then there is work force demand in the system. We have to address both in higher education so there are a lot of young people in Idaho who still want to become interns and so we have to have access for them and all of the other fields, if they want to become musicians, and so on and so forth, we just can’t focus on demand, the market and the jobs that are out there we have to serve our students and their interests from an access perspective as well. That is how I would address your question.
Rod, my comment is ISU spent money recruiting people to become musicians and artists, I see the brochures nobody is out recruiting nurses you are turning them away 3 out of 4 go away that are qualified.
We don’t have to recruit nurses, they come to us.
Rod, so why do we pour funds into things people are not interested in doing when there is such a demand to become a nurse?
Sounds like Jim Girvan – first of all we do recruit at BSU. We recruit for everything.
Rod, you are wasting your money if you are recruiting for nurses.
Jim – no you are not right obviously we don’t have the capacity to accept everybody. We accept the best.
Rod, you turn away 3 out of 4 qualified
Jim, that is correct, but I would also defend that if someone wanted to be in music or anything else, as I tell students you major in what you are interested in and you will find a job and you can make it work, that is true.
Rod, I can’t argue with that but I can argue that I think we are wasting money advertising when there is already jobs out there. People graduating and then go do something else because they can’t find a job.
Linda H you know the other issue, Rod, in having been in this position for a very long time as you become philosophical in my old age and you reflect upon the past not everyone can become a nurse, it is a very difficult job, it’s physically difficult, emotionally straining and there are some folks who attempt because the market is so good – thinking this is going to be so good, stable profession, salary is going up and I can get a job anywhere in the country, full time, part time, inpatient, outpatient, rehab, whatever because this is a great profession, some of them just can’t do it. It is not because they can’t handle the chemistry and the physiology in someone, it’s a very tough job. So there is a select group of people who can do this job and by the way I am not one of them. Everybody mistakes me for a nurse because my office is in the nursing building and I will get mail addressed to me with RN and I couldn’t’ do that, it is a very, very challenging profession and I greatly admire the people who can do it.
(Not sure who is talking - male voice) I do agree with that but I have employed a nurse who makes double what I make now because nursing is such a good foundational education that there is so many opportunities that they offer the best people managerial, good tech savvy nurses don’t stay by the bedside forever. I wish sometimes they would but there are so many opportunities and I am not sure we are telling our potential students that as well. Yes you might think you might not be able to do this job, but with that foundational education the sky is the limit. There are so many types of jobs, desk jobs and others that you can do with an RN.
Other comments?
Cheryl Brush – you are not the first to make these comments for sure. A number of people have suggested that colleges and universities reallocate their funds to the most in demand, but that is probably not always realistic. One of the other solutions is making sure that students are aware of and value the opportunity of the jobs they may have after graduation. As parents you know we have heart attacks when our kids choose philosophy or women studies or something and that’s not why you are sending them to school. I think there are really good career information systems and if we can help our students with information choose careers that are valuable and this does not say anything, and I think everyone in this room knows the capacity issue there is for health care. We don’t need more data to tell us that we need more refined data to persuade others to help us address this.
Ted – I would like to add one more piece here in terms of Rod’s question this could apply to physicians to, in his question I think there is a lot of truth that we have a lot of good people that because of the constraints of Idaho can’t find a health care position. It’s very true for the physicians, we are the hardest state in the United States to get physicians in medical school and so what tends to happen when there is a demand and there is for nursing it is the number one workforce job in Idaho that is being sough after and there is certainly a demand for physicians the market place will start to start to solve that. On the physician side of this, despite the work of the University of Washington and the University of Utah to produce medical students what’s happening is starting in July of 2008 in Yakima is the development of an osteopathic school. They will start on July 1 producing 60 physicians per year, they have over 1,500 applicants for those 60 spots so there is a need and it will help Idaho students who applied to the University of Washington, the University of Utah or elsewhere who don’t get in potentially have other options and potentially that may need to happen for Idaho in the sense again if the infrastructure isn’t going to support the demand then business interests will move in to produce further nursing schools, or community colleges or medical schools. It’s just the way the system works.
Hartzell, Rod thank you for that question, I let the conversation go some because I think it was an important question and one that is not easily responded to.
Tim Oliker – Benewah Medical Center – One thing that we experienced and maybe this is more of a statement, or maybe something everyone already knows but a huge obstacle for us to recruit and retain qualified health care staff is the level of education that is available in our area, in a lot of Idaho rural areas level of education is available through public schools is a significant obstacle if you are trying to recruit for hire whether its from Idaho or another state to come in and have their students educated in an area where they are not comfortable with the local professionalism, even by the instructors so I think that is definitely a consideration because those are the people that are providing role models bringing providers in and providing those mentors and role models for the students so they can look to expire to and to maybe further develop the demand for those professions in our areas. I guess my second statement or question is we are turning away 3 - 4 students, qualified students, do you have numbers on the percentage of retention in the nursing programs of those that begin the nursing program and those that actually end and go into the profession?
Jim Girvan – I do for ours. We are around 3-4%, we have a retention rate of about 96%-97% and then we have done a program in the summer to fast track some people in and so that makes it makes up the difference so we end up basically with 100% of the people, in terms of numbers that we admit we end up graduating.
Linda? Hartzell help me with the biblical sense of getting through the eye of the needle.
Hartzell – You don’t have to you are not a camel.
Linda – well help me – what does the Bible say of the eyes and the needles and so on.
Hartzell – That getting into the kingdom of heaven is easier to go through a camel than through the eye of the needle.
Linda – yes, so in the health profession, the majority of the health professional programs that analogy works. It is so difficult to get in, we had 90 applicants for 8 seats in dentistry, we had 250 applicants for 50 seats in the PA program, so it is well beyond 3 to 1, it’s 10 to 1 in some cases. So once they get in the eye of the needle closes they stay in because they are the best and the brightest and highly motivated people some who have multiple applications to the program, so once they are in they work hard to stay there and they graduate.
Hartzell – I would like to ask a question here that I know is difficult but it important to the members of the community. I know you have a nursing program in Boise and I know Jim, you have one at BSU the coordination of the two programs is a very important question to us as citizens of this stat. Qualified nurses are coming out of both programs but what we care about is a qualified nurse. How can the coordination of these two programs enhance the nursing programs, enhance the nurses coming out, what kinds of steps can be made to enhance the coordination?
Linda – well they are different programs – the only baccalaureate nursing that we do here in Idaho is the fast track, which is a special program for people, BSU accepts folks like this to, but we have a cohort of people who come in from all who have baccalaureate degrees in another field so in 16 months, Hartzell, if you’d like to have your RN you will get a BSN actually. And so the nature of curriculum is quite different from the generic program that’s at BSU. It was our intent to help with the pressure from the large hospitals here for additional nursing personnel; we didn’t want to duplicate what was at BSU so we set up this niche program and its really quite different.
Hartzell – apples and oranges type thing.
Linda – In terms of timelines it is the curriculum for the fast track program is very compressed and so the students in our program may have to take some basic science courses from BSU if they are philosophy majors as an undergraduate, but after that then they are in the fast track – truly a fast track it is a compressed curriculum where we do have to coordinate the courses with the clinical placement and we do that and we all do it. And the other thing we have here now is the Master degree program which is fully online with the exception of the precipitating which happens on an individual basis.
Hartzell – that is informative to me, thank you.
Gayle Lewis NPH Program BSU – This is an observation, I was talking to Pam Springer earlier and it is something I noticed over the last 20 years or so that the role of admissions now is so much different that what was done in the past. There is more of a demand not only for doctors and nurses but open nurses that are involved in strategic planning and community planning type thing. That is just something that needed commenting. It is gratifying to me to have the NPH program and Pam has the Masters of Nursing population, which is very similar that teaches these types of skills. The other thing is, that was just an observation so I think our education needs a change. Linda, you brought up a good point, not only is the nursing program that we have at ISU completely online but we are one of 10 Masters of Dental Hygiene program, it’s a Masters program and there are only 10 in the country that is completely online. So my question is this when we talk about investment – given the rural nature of Idaho, like the gentleman from Benewah was saying having access to education - do you see us making more of concentrated move/investment toward online education? Just as a comment on the online classes, it is very sophisticated way of teaching it is creating a virtual classroom – it’s not just putting stuff on the web. Jim and Linda, what are your thoughts on that?
Linda – we have to take advantage of the advances in technology and I didn’t tap into the telemedicine question, but we are already doing it in Southeastern Idaho in a big way. John Smith is not here but all of the 16 coordinated facilities in Southeastern Idaho are part of the telehealth network there. I thinking it is working well with Mental Health issues, the only barrier had to do with payment and I think the Legislature did pass some rule changes so that we will be able to get paid for telehealth. So higher education has been doing sort of the educational end of telehealth for a long time, now we are doing it based on computers rather than on televisions and so on. Our next program that will go online will be speech language pathology it’s the only way we can get rural providers, for example public school teachers who would like to retool and become SLP’s. We already have the pre professional year online and the rest of the curriculum will come online and then do the clinicals the way we handle them in nursing, they obviously won’t be online but the rest of the didactics will be online.
Jim we have in our respiratory care program all of our senior year is online. Many of our nursing classes are online and some of our rad science courses are online and we have half of our Master Health Science online and we have 4 to 5 courses for environmental health are online so we are also migrating to more of that and obviously the piece as Linda said the clinical pieces are not online but if it is a clinical discipline, anyway the other courses are. I would say that our Masters in Nursing that we have a core part of that online and actually ISU and we share the core because it is a Masters in Nursing so that creates a good access for students a lot of the time.
Hartzell – let me invite Ralph or Rolfe into the discussion to get the University of Idaho perspective as well.
Ralph or Rolfe – we are all under pressure to reach out, for example dual enrollment, that kind of thing. There is a pretty heavy emphasize to try to go electronic and reach out to rural areas. There is a mandate from Boise here to do that, so we are doing that throughout the campus.
Hartzell – we have about 2-3 minutes left, one more question.
Barbara Sleeper from Qualis Health a BSU grad been a RN for about 30 years and 2/3 of my career professional has been in the hospital the last 1/3 has not. – this is not so much a question but a request of the educational system. One of my concerns and we realize certainly that we have to use online education and all sorts of technology because there is limited space and limited faculty and all that, but my concern is that in my experience is that since I have been out of the hospital and my husband has had health issues and in multiple hospitalizations I have seen younger nurses who are engaged in the technology and not with the patient and I don’t know if that is exasperated by educational modalities now. They are getting the education online as oppose to face to face with instructors interacting with peers and I have had this conversation with lots of other nurses with my peer group, people I went to school with and people I work with in Boise and I was at a conference just a couple of weeks ago and this was a subject of conversation amongst a group of nurses who are in their mid 50’s. The nurses today, the ones who are in their 20’s and 30’s always seem to be drawn to ICU to technology, my husband was in the hospital and he felt that nobody every looked him in the eye but that they were all over the IV pump. So that is one of my requests is that nursing education continue the compassion and the things that took people into nursing historically.
Hartzell – we have about 2 minutes left and I would like to ask Lauren if you could make a couple of comments of what happens with this discussion in terms of the notes that have been taken and what we do with those and what the next steps are that we are going to do.
Lauren – I was going to hand them over to the Idaho Rural Health Assoc, we have through the registration process we have everyone’s email and we could probably send notes out to everybody. We are also going to put them up on our website.
[Lauren and someone with a softer voice is talking about email addresses and I can’t hear very well and now saying a White Paper that summarizes our talk up here today and that IRHA would take the lead in this.]
Hartzell – one of the points that is hard to do is hard to speak for a university or any organization on their behalf - the panel consented in saying if the IRHA did the paper they were happy to be acknowledged as a participant in the panel and felt that was a legitimate endorsement of the White Paper. So there will be a White Paper developed out of this discussion.
Hartzell – I would like to thank the panel again, not only for the backgrounds you offered us but for the preparation you did that has reflected itself in the last couple of hours.