Envision 2030

May 23, 2016

Breakout Session – Healthcare

Session Facilitators: Dr. Kevin Melicher, Gary Hagen

Subject Matter Experts: Dr. Josh Wynne,Dr. Charles Peterson, Dr. David Glatt

Scribe: Beth Swenson

Kevin Melicher, SBHE member, introduced himself and invited those in the room to introduce themselves. They included:

  • Julie Traynor Director Dakota Nursing program, a consortium of four nursing programs, located at LRSC, BSC, Dakota College Bottineau, Williston State College
  • Dr. Stacie Iken, Chief Institutional Effectiveness and Strategic Planning Officer at Bismarck State College. She was previously an occupational therapist. She stressed the need for providing quality care and feels the mental health aspect of healthcare is very important.
  • Marvin Lein – Chief Executive Officer with Mid Dakota Clinic in Bismarck
  • Dr. Gary Hagen – President of Mayville State
  • Carla Gross – Associate Dean for Nursing at NDSU – Upcoming chair of CUNEA, College and University Nursing Education Administration
  • Dr. Charles Peterson – Dean of the College of Health Professions at NDSU
  • Dr. David Glatt - Chair of Department of Family Medicine at Sanford in Fargo
  • Dr. Josh Wynne – Vice President of Health Affairs at UND, dean of Med School, practicing cardiologist, Medical privileges at Altru and Sanford
  • Jane Opdahl – Works with Senator Heitkamp in healthcare issues
  • Lisa Feldner – Vice Chancellor of University System, information technology, institutional research
  • Sharon Two Bears – Standing Rock Reservation – works for the tribe – Health concerns on reservation are of concern to her.

Opening Statement – Melicher – The North Dakota population is aging at a greater rate than the national average. There is big pressure in the need for services, especially in rural areas. Medicare is an integral part of system. There are many people going into long term care facilities. Financial issues are great. Costs of medical care continue to grow. There are needs in the area of pharmacy and all types of healthcare workers.

Dr. Wynne shared his expertise:

Nationally, there is a looming physician shortage – statement from Association of American Medical Colleges.

The U.S. will face a shortage of between 61,700 and 94,700 physicians by 2026.

There is a particular shortage of primary care and surgical specialists.

Trifecta challenges of access, cost, and quality

In North Dakota, the biggest issue is access. We score pretty well on cost and quality, compared with other states.

Predictions are that ND will be short about 175 physicians in 2025.

UND School of Medicine and Health Sciences has 15-member board mandated by state legislature. Advises med school and the legislature on healthcare matters. Compiles a biennial report, also mandated by state law, on health issues in North Dakota. This is available in hard copy or online at med school website. Several hundred pages, with charts and figures. Current state of health and healthcare in North Dakota is also a part of the publication.

Findings in ND:

  • ND marked by relative high quality and low cost compared to other states.
  • As noted nationally, looming shortage of physicians and other healthcare providers, especially primary care and general surgical
  • Striking misdistribution of providers, with relative paucity in rural regions, resulting in long-standing access problems.
  • Aging population, with localized population growth
  • Challenge of healthcare delivery in areas with low population density.

The chief medical officer for American Association for Medical Colleges has stated that it’s important to look at this over 10 years.

In ND, the program began to be addressed in a real way with the establishment of the Healthcare Workforce Initiative (HWI) in 2011:

  • Reduce Disease burden – Master of Public Health degree programs at UND and NDSU
  • Further programming approaches under study to address mental and behavioral health issues in the state.
  • Retain more of our healthcare provider graduates for North Dakota
  • RuralMed program
  • UND SMHS recognized as #1 in the nation for the percentage of its graduating class going into family medicine.
  • Train more healthcare providers
  • Medical student class increased by 16/year (total of 64)
  • Health sciences students increased by 30/year (total of 90)
  • Resident slots increased by 17/year (target to be achieved later this decade according to current plan) (total of 51)

Improve the efficiency of healthcare delivery system

  • Trainingin inter-professional healthcare teams
  • Use of “learning communities” in new UND medical school building
  • Tele-psychiatry training program (modeled after NDSU tele-pharmacy program. Most psychiatrists are located in the Red River Valley, but services are needed in western part of state too.

Purpose statement. The primary purpose of the University of North Dakota School of Medicine and Health Sciences is to educate physicians and other health professionals and to enhance the quality of life in North Dakota. Other purposes include the discovery of knowledge that benefits the people of this state and enhances the quality of their lives.

UND SMHS Medical students make up 292 students – 78% come from North Dakota

At 99th percentile of graduates who are Native American

Many other students are studying for other medical occupations.

Differences in medicine today – millennium generation, women in healthcare, doctors are retiring early, healthcare burnout, population growth, competition from other parts of the country include higher salaries, better weather, etc.

Dr. Charles Peterson shared his expertise:

NDSU College of Health Professions was originally the College of Pharmacy, but other dimensions have been added recently. Still includes the school of pharmacy. In 2005, established independent fully accredited nursing program. College educates nursing students, pharmacy students, allied sciences students, public health students, MS and Ph.D. degree-seekers.

Major supplier of health professional graduates

Students’ training includes rural locations.

2015-16 Health Professions Graduates at NDSU – 399; 163 nurses, 89 pharmaceutical sciences; 84 pharmacists

North Dakota placement

  • 75-80 percent of nurses stay in ND
  • 90% of pharmacy graduates stay in ND. 90% of the practicing pharmacists in ND are NDSU grads

ND Tele-pharmacy project – Rural areas are medically understaffed and pharmacists are being lost to retirement. NDSU received grant in 2002 and developed the tele-pharmacy program where a technician is in rural place, but supervised by pharmacist in urban area. More than 80 sites across ND use tele-pharmacy. There are now fewer medication errors happening.

What needs to be done to meet future workforce needs?

ND has approximately 700 nursing openings each month, by 2020, ND will have 2040 nursing openings.

  • Increase supply of health professionals, especially in ND’s critical shortage areas of nursing, mental/behavioral health, substance abuse, addiction counseling
  • Add the necessary faculty, academic facilities, and clinical training sites to support program growth
  • Assess the need for new models of healthcare delivery and changing roles of health professionals to address future needs of ND
  • Provide work environment that allows health professionals to utilize their full scope of skills (DNPs and Pharm.Ds)
  • Offer competitive salaries, reduce workloads, and flexible hours
  • Increase use of tele-health in medically underserved areas
  • Assist students denied admission (because of limited number of positions available) in finding another program, preferably a program at an NDUS institution.

Does ND need a new model for training healthcare professionals? Create a new model that works best for us.

Chronic disease management is a big problem. Since there won’t be enough physician providers, need to use other healthcareprofessionals.

Need to explore tele-health for services in rural areas of state. Currently, health services are over-regulated and insurance providers hesitant to reimburse. Regulations need to be loosened.

241 nurses applied to program, but could only place 88. Need to work a mechanism for getting students denied admission at NDSU into NDSCS, or other programs, then track back into LPN to BSN. Allow two-year programs to be offered on the bachelor’s degree-offering campuses.

Establishmore clinical sites, preceptors, rotations, and residencies in rural communities, rural HUB teaching sites.

Provide affordable housing for students in rural communities – very important

More IVN classrooms to connect faculty and students in rural areas

Assist rural communities in marketing and recruiting health professionals to their communities

Establish an online employment matching program that connects prospective employees with employers who have job openings.

Formally market North Dakota to graduating seniors annually – create a registry of openings available

With fast-growing healthcare problems, would it be possible to have NDUS students work on class projects, internshipswhere they are charged with coming up with creative, innovative solutions to challenges and opportunities in the field of healthcarein ND.

Assess needs of western ND and deliver relevant programming

Dr. David Glatt shared his expertise:

We have good quality in the state. If you had diabetes, the best place to live would be in ND - stat from CMA.

Debt for students - $275,000 to $300,000 in debt. Could we reduce their debt?

Could high school students shadow physicians?

40% of primary care patients have some type of a mental health issue. How many patients are not taking their medicine, following the directions, because they have mental health issues?

We’re not able to academically accommodate the number of students who are interested in pursuing nursing. Potential students have to be turned away.

A new team approach to healthcare just beginning at Sanford. Each MD will have an NP and/or PA under him/her, together with several LPNs, RNs, etc. People other than MD can see and work with the patients, saving the MD time for the most critical needs.

  • This model is what was in place with Dr. Wynne was in the Army and was battalion surgeon. He was the only physician, responsible for the medical care of 1,000 troops, but had a medic and five corpsmen. This demonstrated a team approach to healthcare in 1973.

General Discussion:

Julie Traynor

Loves idea of engaging the help of NDUS students to come up with innovative ideas to help solve healthcare problems in ND.

Dakota Nursing Program shares common curriculum and common faculty. Use IVN and share learning management system. Very consistent. Pediatric nurse in Bismarck teaches all students across the consortium.

Shortage of faculty is a problem. It is difficult to get a nurse working as an NP to come as a nurse educator because of salary concerns.

Many of the Dakota Nursing Program faculty have just graduated with master’s degree in last five years. It’s hard for them to go back to school because of cost, and also the need to continue working. Of the 14 faculty, 12 went out of state to get their master’s degree. It was more convenient, more flexible.

When nurses come into LPN program, they are encouraged to continue to their education to the highest degree. Need to provide education to single parents who are place-bound. Need better pathways to education.

Stacie Iken

The last five years in the NDUS grads as a whole, there are many times when graduates are being produced to meet the needs, but it’s difficult to have them move into the rural areas. We have access to national clearing house databases. If we have student names and ideas, we can track where they have gone, and where they are. If we can use those databases within the NDUS, we could potentially tag scholarships, etc.

Holistic healthcare and behavioral healthcare is highly important. This has been a real void.

Reimbursement is changing how we deliver. Productivity is impacted by the high demand of regulations. How do we make sure that holistic healthcare remains in focus?

We have the graduates. How do we get them to move and transition to where needed in ND?

Where does higher education fit into the team model to healthcare?

Split career counselor and behavioral counselor in K-12?

MarvinLein

Marketplace is driving the team approach model to healthcare. Short term need is crisis, re-training, refocusing existing healthcare professionals to be able to initiate the team approach.

Dermatology – 9 positions available to every graduating dermatologist

Distinction between east-coast North Dakota and west-cost North Dakota. Communities need to create opportunities for physicians to come to rural areas.

Work on finding and equipping NPs who want to go into specialty practices.

Health coaches are newly defined positions. There’s a whole skillset focused around being able to deliver access to care. Nursing teams who know how to communicate effectively with patients … why taking your medication is so important, etc.

What do we need in the area of non-physician specialists?

Dr. Wynne said … The actual numerical shortage of physicians in ND is greatest in the four cities, the impact is the greatest in the rural areas.

Prioritization of academic areas that are critical needs, such as healthcare professional education. Maybe eliminate other programs that aren’t as critically needed and may be low enrollment.

Carla Gross

NDSU has been very responsive to nursing needs. There are all kinds of avenues to get BSN. There will never be a shortage of nurses who want to upgrade their education.

Biggest challenge is getting preceptors for nurse practitioner program. Need pass-through dollars.

In the mental health nurse practitioner program, they’re having difficulty finding qualified faculty to keep it running. Can we attract faculty somehow? Nurse practitioner with mental health background would be beneficial.

Salaries maybe going up to make this more attractive.

There are several community colleges in ND. Models across nation demonstrate partnering of bachelor’s degree colleges with community colleges to help provide education for healthcare professionals.

Jane Opdahl

Senator Heitkamp talked about starting the education of people very young, while in Head Start, K-12, etc. Plant the seed of possibly entering healthcare field while children are young.

If there is tele-medicine, there must be technology infrastructure in rural areas.

Need to convey the message about federal regulations that may be a hindrance to solving healthcare issues.

Sharon Two Bears

Concern is access for students. We start to educate students about careers too late. Need to start talking with them earlier. Juniors and seniors aren’t really prepared to get into healthcare professions because they haven’t been prepared. Need to start talking and thinking about this earlier.

Do we need a longer school year for K-12?

Need to get K-12 and higher education together. There is a big gap.

Top points discussed in this session:

  1. Native American healthcare needs to be a high priority
  2. Regulatory issues must be considered in team approach to healthcare. Regulations may need to be relaxed.
  3. Nursing shortage
  4. Other allied professionals should be added to RuralMed.
  5. Funding for nursing educators. Make loans available, consider loan forgiveness, scholarships
  6. Expansion of Sudro Hall at NDSU to accommodate more students
  7. Inter-professional training centers in rural areas to include training in all healthcare areas. Include need for housing.
  8. Expand tele-health
  9. Encourage full implementation of the Healthcare Workforce Initiative (HWI)