1

Model

Five Year Outcomes for a Collaborative Technology Model

Of Rural Health Care Education

Michael J. Rice Ph.D., ARNP., BC

Professor

ICN\WSU

Five Year Outcomes for a Collaborative Technology Model

Of Rural HealthCare Education

Michael J. Rice Ph.D., ARNP., BC

Professor

ICN\WSU

At the close of the twentieth century, the Pew Commission revealed a grim picture for the future of rural health care. The Pew Commission on Health Professions (1991) reported that the infrastructure of rural health care was disintegrating. Marked by poor rural economies, lower Medicare reimbursement rates and hospital closures, rural areas were faced with a rapid decline in the number of available health care professionals.

Washington statewas similar to many large rural states with a land mass of almost 100,000 square miles. When compared to the eastern United States, Washington state’s land mass was greater thanseven states on the eastern seaboard ( Figure #1). The state

Figure 1. Land mass of WashingtonState vs. Eastern Seaboard of the United States

was sparsely populated by slightly less than two million people and faced with a declining number of health care professionals in rural areas. The decline in the number of health care professionals contributed to the large distances separating health care resources and service.

By the year 2000, thirty six areas in 39 counties were federally designated as medically underserved or identified as suffering from a shortage of health care professionals (Washington State Department of Health, 2005). More that fifteen percent of eastern Washington counties had no primary care facilities. Of the 31 primary care facilities operating in eastern Washington, 54 percent were classified as rural and 29 percent were identified as frontier care facilities. This left a large portion of the population without direct acess to medical care.

No area of health care was more in need than that of mental health care services. However, by the end of the century, the licensed psychiatric nurse practitioners with prescriptive authority were few and seldom found in the medically underserved communities in the state (Figure 2).

Figure 2. Psychiatric Nurse Practitioners with Prescriptive Authority by County

Source: Institutional Planning Subcommittee, 1997

In 1999, there were three masters programs in the Pacific Northwest region that offered advanced psychiatric nurse preparation, two of which were in eastern WashingtonState. Institutions with similar programs of study in psychiatric nursing in Washingtoncould be found at the University of Washington campuses in Seattle, Tacoma, and Bothell. These programs were geographically unavailable to the students in Eastern and Southwestern Washington due to the distance as well as problems crossing the Cascades in the winter.

Oregon, which is geographically close to the Vancouver region had a similar program at the Oregon Health and Sciences Universities Center (OHSU). However, OHSU did not have enough enrollment openings for Oregonstudents and out of state tuition made access not feasible for students from southwest Washington.

Grant Objectives

In 2000, the federal Health Resources Services Administration (HRSA) funded a grant to the Washington State University Intercollegiate College of Nursing to address some of the health care needs of the medically underserved populations in WashingtonState. The overarching purpose of the grant was to develop an educational model to address the health care education needs of rural America. Inherent in the purpose was the goal of developing a model that was accessible, cost effect and self sustaining. Specific objectives of the grant were:

Objective 1. Develop collaborative relationships with educational and health care agencies to leverage the grant and outreach efforts; and .

Objective 2. Increase the number of minority/disadvantaged graduates and/or graduates from the Psychiatric Nurse Practitioner program who practice in rural and federally designated medically underserved areas of WashingtonState

The proposed program sought to prepare place bound and minority individuals as psychiatric nurse practitioners with a focus on rural and medically underserved populations. Using state of the art distance learning and videoconferencing technology, the psychiatric nurse practitioner program would be offered from the main campus in Spokane and the extended campus sites in TriCities, Yakima and Vancouver to a wide variety of locations through out the state. To encourage enrollment of place bound students, video conferencing technology was integrated into the Psychiatric Nurse Practitioner’s masters program. It was expected that through the videoconferencing supervision: 1) graduates would obtain the hours needed to sit for ANCC Certification in Psychiatric Mental Health, 2) increased numbers of nurses would become licensed as Psychiatric ARNP’s with prescriptive authority by the state of Washington, 3) graduates would practice successfully in psychiatric mental health care, and 4) that more than half of the graduates would be doing so in medically underserved areas.

As part of an agreement with the University of Washington, the MIRA program was not offered in the upper peninsula and along the Interstate # 5 corridor. This area area consisted of 14 counties which had traditionally been served by the University of Washington. As a result, the MIRA project provided services to only 25 of the 39 counties in Washington.

Identifying Collaborative Agencies

The cost of developing such an expansive educational network was clearly beyond the scope of a single grant and the ability of any single educational entity. It was not beyond the scope of collaborative efforts with other established agencies. The first step in developing these collaborative relationships was to identify appropriate collaborative educational and health care agencies.

Determining viable partners for the development of a new educational model required identification of agencies that would provide the best fit with the overall grant objectives. First, an agency had to have an existing video communication network. Leveraging the videoconferencing network developed by the grant would be difficult without additional systems in tandem. The features of the “fit” with the grant were dependent on both the expressed and instrumental operations of the agencies.

The expressed operations of the agency are defined by the published mission and objectives of that agency. While an agency might have an existing videoconferencing network, the closer the match between the mission of the grant and the mission of the collaborating agency,the less friction that could potentially develop in the working relationship. This fit between the expressed operations of the two agencies focused both agencies on the tasks at hand and facilitated overcoming agency roadblocks to problems.

The next stage in the assessment of potential collaborating agencies required an assessment of the agency’s instrumental capacity. The instrumental capacity of the agency determined not only the potential gain to the grant, but the potential strain on the grant. As there needed to be some trading and sharing of resources, the present and future operating capacity of the collaborating agency was both a growth and limiting factor. Inherent in the instrumental capacity were individuals who were “movers”. These individuals were defined as having a track record of committing to and achieving a set of goals related to the agency’s technology mission. These individual’s were essential in activities between the agencies for resolving obstacles that would hamper the grant objectives.

Included in the instrumental capacity of the agency was the status of the existing technologies, bandwidth and potential for connectivity. These three technological features determinedthe ease with which the technologies would “handshake” or connect. The status of these technologies would also provide some cost estimate of any new equipment that would be needed to bridge the gap between the two agencies. Interaction of new technologies with older equipment often requires some upgrading of software or bridging architecture as older systems can be slightly outdated.

Collaboration

Once the expressive and instrumental capacities had been assessed, agencies began to share missions. At times, this required an expansion of the stated missions. In example, the objective of the educational grant was to increase the number of psychiatric nurse practitioners in rural communities. The Washington State University Extension Services had a stated mission “to advance knowledge, economic well-being and quality of life by fostering inquiry, learning, and the application of research ……. to create a culture of life-long learning.” This was much broader than the objective of the grant, but the grant objective fit within the mission of the University Extension Services.

The Intercollegiate College of Nursing and WSU Extension Services entered into negotiations to collaborate on their shared missions. Neither changed the goals or objectives of the individual agencies, however both agreed to share equipment and sites which significantly expanded the service delivery of both unites. The grant also allowed WSU Extension Services to take advantage of cost sharing for technicians at some of the more remote sites. This permitted the College of Nursing to placeadditional equipment at sites that further leveraged the outreach of the grant activities.

Outcomes

The evaluation of any model is based on not only how well its achieves it goals, but also on the long term outcomes. From the onset, the grant relied heavily on leveraging resources through collaborative relationships and worked extensively with the organizations with related interests to leverage the activities of the grant . This cooperative venture allowed core academic courses to be delivered through videostreaming to virtually any household in WashingtonState with an internet connection. Students and faculty could be connected for the clinical conference and supervision courses through the higher bandwidth videoconference connections at6 College of Nursing Sites, 18 Washington University Extension Network sites, K-20 network sites and 89 hospital on demand Telehealth sites throughout rural Washington State. This provided for a total of 104 potential videoconference sites that could be used to connect the students and faculty for supervision of their clinical course work.

Figure 3: 2005 MIRA Activity in Federally Designated Medically Underserved

Shortage Areas*

:

* Dark Shading indicated Medical Shortage Areas served by MIRA project

The ready access to the educational programs resulted in a sudden surge in enrollments. While nationally, masters level psychiatric nurses make up less than 3 percent of most graduate nursing programs, enrollment enlarged to the point that the psychiatric nursing students made up to 38 percent of the graduate program at WashingtonStateUniversity. This was 118 percent of the level of enrollment projected for the grant with less than 50% of the qualified applicants being accepted into the into the program. At the height of enrollment, tuition generated $600,000 per year for the students in the MIRA program alone.

Students

The program continues and the student population has grown and changed with each year of the program. Demographics of the current students indicate that the mean age is 44 with a range of 20-59 years of age. Of particular note is the location of the students. Sixty eight percent (n=51) of the students lived more than 100 miles from the Spokane Campus. Twenty two (29%) of the students drove into the Vancouver campus at the opposite corner of the state. The remainder of the students (n=3,or 4%), attended classes via videostreaming and/or IP videoconferencing. Over 80% (n=60) of the students attended courses, including clinical experiences, at a site less than 20 miles from their home.

The location of the students clinical experiences is also worthy of note. The College of Nursing presently has contracts with over thirty three clinical agencies for practicum experiences for psychiatric nursing graduate students. Clinical training includes independent practice under the oversight of a nationally board certified nurse practitioner preceptor and an individually chosen internship during the last one or two semesters of the program. It should be noted that 24 (73%) of these clinical sites provide psychiatric care to medically underserved populations. Each student in the program was, and continues to be, assured that more than 50% of their clinical practice is with medically underserved populations.

One of the key questions behind the MIRA project was the viability of conducting psychiatric nurse practitioner education via IP Videoconferencing. While the IP Videoconferencing equipment reduced the number of hours and time that faculty spent traveling around the state to do clinical supervision, the question remained about the student’s level of satisfaction with the equipment. The question was whether or not the students felt the IP videoconferencing facilitated their ability to take the course in their rural settings. As seen in the graph, for the twenty percent of the students who were

Figure 4: Student Agreement on use of IP Videoconferencing for Supervision

able to attend the courses on the main campus sites, the question was irrelevant. However, for the remainder, 13.3% of the students agreed and 56.3% of the students strongly agreed that the IP videoconferencing made it possible to take the courses at their rural locations.

Graduates

The majority of the graduates of the WSU Psychiatric Nurse Practitioner program met the objectives of the grant by passing the national board exams and becoming licensed. By the end of 2005, there had been a total of 75 graduates. Seventy four (98%) had passed the national board exams, had obtained an advanced practice nurse practitioner license and were practicing as advanced practice psychiatric nurse practitioners. Seven of the graduates had left the state but were practicing as psychiatric nurse practitioners in other states. One graduate had left the country as a result of her spouse being relocated to Australia.

Three of the graduates have established practices in both Washington state and also in a border state(Idaho or Oregon) in rural medically underserved communities. The vast majority of the graduates, (n=68) remain in WashingtonState of whom 67 (89%) have established some form of practice as psychiatric nurse practitioners. Many also have obtained part time teaching positions, often as clinical preceptors, adjunct or part time faculty and continued their association with academic settings ranging from community colleges to the University setting.

Of particular interest is the locations where the students have established their clinical practices. Fifty five (73%) of the students participate in patient care in either rural medically underserved communities or participated in serving underserved populations located in the middle of urban areas. As at least 50% of their clinical training occurred with medically underserved populations or in rural communities, the results support the position that providing education to students in rural areas enhances the possibility that they will remain there once they graduate.

Rural Impact

The use of collaborative effortstoprovide rural health care education in an effort to address rural health care disparities clearly offers promise for addressing workforce issues. The question remains, however, as to the true impact of such a program on the overall health of the community and state in which the program is located.

In an effort to test the question of the impact of the collaborative model on the overall health of rural and medically underserved areas, there was a need to reexamine the suicide rates in those areas where the graduates had established practices. One source of data difficult to refute are the state morbidity and mortality statistics. These statistics are collected each year by the state department of health and reported in crude raw numbers. The rates are reported by county and are comparable over time. In order to establish a fair rate of comparison, the mortality statistics were collected beginning in 1999, the year the psychiatric nurse practitioner program started, through 2004, the five years that the statistics were available. This provided a five year span of data that could be analyzed for trends and changes in suicide rates.

Logically, the absence of services in rural areas would be the areas most affected by the placement of a psychiatric nurse practitioner. Thus, the data were coded into the following categories; 1. counties with established urban areas, 2 counties which carried a federal designation of being medically underserved as of 2005 and 3. counties that were identified as having a majority of the population living at or below the established federal poverty level. Each country was also coded by the presence or absence of a MIRA training site. A MIRA training site was defined as a county in which there had been the placement of an Internet Protocol Videoconference Unit. Each county was also coded as to whether or not a graduate of the program had established a professional practice in area. Agraduate practice in the county was defined to include private practices, work in community mental health centers, work with hospitals and work with migrant clinics. As there were large differences between the sizes of the populations between the urban and rural counties, the rate of suicide was adjusted to the rate of suicide per 100,000 people. All data on the rates of suicide were then analyzed using repeated measures Analysis of Variance (ANOVA) procedures.

Results.

Analysis of the data indicted that there are MIRA training sites in 11 of the 25rural and medically underserved counties served by in WashingtonStateUniversity. The graduate Psychiatric Nurse Practitioners established full or part time practices in 20 of the 25 medically underserved counties served by the MIRA project. This figure amounts to 55% of the medically underserved counties in WashingtonState.

The ANOVA results indicate that there were several significant effects of the MIRA program on the suicide rates in the rural and medically underserved counties. The data indicate that there are both direct and interaction effects on the rate of suicide due to having MIRA training sites and graduate practices established in the medically underserved communitiesover time (Table 1).