CoChairs:

1
Co-Chairs Representative Sharon Cissna Senator
Donny Olson
2
Check out our new website at www.akhealthcaucus.
org
Filling the Need Mid Level Health Providers
Wednesday, February 21st 2007 Noon to 100
PM Butrovich Room, State Capitol A light lunch
will be served
3
Cathy Giessel, MS, ANP, FAANP

• Lifelong Alaskan
• BSN - University. of Michigan
• MS - UA Anchorage
• Fellow, American Academy of Nurse Practitioners
• Alaska Board of Nursing, chair
• RN - 32 years
• ANP - 7 years

4
Nurse PractitionersYour Choice for Healthcare

• Accessible
• Cost-effective
• Quality Primary Care

5

• Advanced nurse practitioner
• Registered Nurse
• Specialized education and experience
• Certified to perform acts of medical diagnosis
• Prescription and dispensing of medical,
  therapeutic, or corrective measures
• Regulated by the Board of Nursing.
• Independent practice of healthcare

6

• Anchorage Municipal Health Dept hired the first
  NP in Alaska in 1970
• Independent practice since 1984 with full
  prescriptive authority for all medications.
• NPs make treatment decisions based on clinical
  judgment and evidence-based research, not
  standardized protocols.

7
High quality, acute, chronic and specialty
healthcare

• Order and interpret diagnostic tests
• Diagnose acute and chronic illness
• Prescribe medication or other treatments
• Manage patients care
• Refer to specialists as appropriate

8
Maintain and improve health

• Individualized comprehensive health education and
  counseling
• Provide information necessary to make healthy
  choices and educated healthcare decisions
• On average, NPs spend 31 more time with patients
  than physicians (2002, BMJ)

9
Reduce future healthcare costs

• Focus on promoting health and preventing illness,
  which reduces healthcare costs for the patient.
• NP patients have fewer emergency room visits and
  lower average hospital length-of-stay. (2003,
  Hospitals and Health Networks 2000 JAMA 1995
  JAANP)

10
Education

• Registered Nurse (4 year baccalaureate)
• Experience as Registered Nurse
• Masters (2-3 years) and/or doctorate (2-3 years)
  in a specialty
• National board certification exam required by
  Alaska

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Types of NPs

• Family, adult, pediatrics, geriatrics, womens
  health, mental health, certified nurse midwife,
  emergency, neonatal, adult and family
  psychiatric/mental health
• Some subspecialty practice settings in
  allergy/asthma, cardiology, oncology, neurology,
  pain management

12
Reimbursement

• Designated as primary care providers in Alaska
• NPs practice in hospitals, private and public
  clinics
• Reimbursed by insurance companies
• Reimbursed by Medicaid and Medicare at 85 of
  physician reimbursement

13
Alaska NP Education

• University of Alaska Anchorage
• Program began in 1981, first graduates in 1983.
  Estimated gt160 Family NPs, gt 45 Psych Mental
  Health NPs
• Family
• 15-20 applicants for the12 openings/year
• Psychiatric
• 8 students admitted every other year
• 90 of graduates practice in Alaska after
  graduation
• HRSA traineeship grants available for full-time
  students

14
NPs meet Alaskas Primary Care needs

• More than 540 NPs in Alaska in both urban and
  rural Alaska
• Alaska has one of the highest ratio of nurse
  practitioners per capita in the nation- 66.9 per
  100,000. (2000 HRSA data)
• Many NPs practice in rural Alaska, often as the
  only HCP in a community
• Most NPs accept Medicare and Medicaid patients.
  (Only 10 of physicians accept Medicare.)

15
Safe, quality care

• Only 1.4 of NPs in US have been named as
  primary defendant in malpractice case
• Numerous studies finding NP care comparable to MD
  care (1991 Annuals of Internal Medicine 1979
  CBO 2002 BMJ 2006 Cochrane Database of
  Systematic Reviews 2004 Medical Care Research
  and Review 2000 JAMA 2004 Medical Care 1974
  NEJM)

16
Certified Registered Nurse Anesthetists (CRNA)

• Another type of advanced practice RN
• Deliver anesthesia in hospitals or outpatient
  surgery centers
• Independent practice
• More than 100 in Alaska
• Urban and rural practices
• No in-state education programs in Alaska

17
NPs in Alaska

• NPs are nurses with advanced training and skills
  who combine the philosophy of nursing, with the
  tools of both nursing and medicine, to address
  healthcare needs of Alaskans. They provide
  accessible, cost-effective, quality primary
  healthcare.

18
WORKFORCE DEVELOPMENT

• Alaska Mental Health Trust Authority
  Beneficiaries

19
ISSUES AND CONCERNS

• High staff turnover
• Low social status
• Insufficient training
• Limited educational and career opportunities
• Poor wages and benefits

20
OVERVIEW

• One of five focus areas for the Alaska Mental
  Health Trust Authority
• Involves a wide variety of stakeholders
• Looking across the workforce from executive staff
  to mid-level managers to direct service staff
• Trust funds used as seed money and springboard
  for long-term programming

21
GOAL 1 RECRUITMENT

• Develop Credentialing and Quality Standards
  Steering Committee
• Develop comprehensive grow your own recruitment
  strategy for youth
• Develop comprehensive in-state and out-of-state
  marketing strategies
• Develop partnership with the Department of Labor
  Workforce Development

22
GOAL 2 RETENTION

• Provide loan forgiveness, scholarships and other
  incentives
• Provide technical assistance to help providers
  develop agency-specific recruitment and retention
  plans
• Develop strategies to increase wages and benefits

23
GOAL 3 TRAINING/EDUCATION

• Establish three regional training cooperatives
• Provide support for the Geriatric Education and
  Training Program
• Support and enhance existing education and
  training programs

24
Dental Health Hygienists
Vickie Hauff, Hygienist
25
Hygienists could increase cost effectiveness for
oral healthcare
26
Preventing Chronic Health Problems for Alaskans

• Caries risk in Alaska is 2.5 times greater than
  the national rate
• Systemic illnesses related to oral health
• Heart Disease
• Diabetes (2.6 times greater than the national
  rate)
• Pre-term birth
• Millions of dollars are spent trying to fix oral
  health problems when early intervention is being
  ignored and could prevent these chronic diseases.

27
The Problem

• Many Alaskans cannot afford oral healthcare
• Preventable oral diseases can cause life
  threatening emergencies
• Many factors exacerbate oral health disparities
• The current structure of the oral healthcare
  delivery system
• Maldistribution of providers
• Geographic, educational cultural barriers
• Cost of care

28
Hygienists Can HelpWe have the education to
provide the needed oral health care

• The registered dental hygienist is a licensed
  oral health educator and clinical operator who,
  as part of the dental team, uses preventive,
  educational, and therapeutic methods which aid
  individuals and groups to attain and maintain
  optimum oral health.

29
Our Limitations

• Cannot go independently to places that need the
  care.
• For Example villages, schools, homebound
  facilities, etc.
• Unable to see a patient prior to a dentist exam
• Additional current licensing limitations
• Cannot do anesthesia without a dentist present
• Cannot do restorative procedures
• Current system does not enable us to provide
  access for preventative services

30
Hygienists as Mid-Level Providers

• California, Minnesota, Oregon, Idaho, Ohio,
  Kentucky Washington, etc. all have additional
  expanded functions beyond the procedures allowed
  by Alaska statutes
• American Dental Hygiene Association
• Proposed ADHP (Advanced Dental Hygiene
  Practitioner) a cost-effective response to the
  oral health crisis
• Services provided
• Diagnostic
• Preventative
• Therapeutic
• Minimally invasive restorative

31
A possible future for Hygienists as the
mid-level provider for Alaskans

• The possibilities
• Key to cost effectiveness is early intervention
• Education is prevention
• Collaborative Agreements to expand services

32
Where we need help

• Expand our scope of practice and geographic range
• We need to improve Alaskans access to a full
  range of dental services
• Win Win solution for all

33
Nurse Retention Even More Important than
Recruitment

• A Conversation Prepared by the Alaska Nurses
  Association
• 2000, and Revised 2007

34

• In January of 2000, seven months after the
  Nurses Strike of 1999 at Providence Alaska
  Medical Center, the administration there
  noticing a out flux of nursing staff -- requested
  that the Alaska Nurses Association offer
  suggestions for the retention of nurses.

35

• What I am offering today is an updated version of
  the ten suggestions offered at that time with the
  idea that they can apply to any 24-hour health
  care facility in Alaska.
• This is not a scientific document, but is meant
  to open a conversation on the topic.

36
Retention Idea 1

• Address staffing/working condition issues
  immediately. Do not let them molder. Involve
  Registered Nurses in finding solutions to
  identified problems. Take their suggestions once
  in a while.

37
Retention Idea 2

• Recognize that a culture that recruits RNs, also
  retains RNs.
• Treat RNs as responsible, valuable adults, worthy
  of respect and occasional accommodation.

38
Retention idea 3

• Provide qualified staffing to cover meals and
  rest periods on a regular basis, i.e. an
  uninterrupted meal break of 30 minutes at a
  reasonable time and a 15 minute rest period
  after each four hours worked.

39
Retention idea 4

• Address working conditions that lead to workplace
  injuries
• Eliminate risk factors such as mandatory overtime.

40
Retention idea5

• Provide recruitment bonuses for currently
  employed RNs to encourage them to talk their RN
  colleagues into applying for and accepting
  employment at their health care facility.

41
Retention idea 6

• Provide on-campus (or near campus) childcare and
  sick child care at reasonable rates for ALL
  shifts.

42
Retention idea 7

• Recognize work done above and beyond the call
  of duty
• Premium pay for part time nurses who work on days
  off
• Preceptor pay for helping train new nurses
• Certification pay for obtaining additional
  training
• Provide additional Paid Time Off for long term
  nurses.

43
Retention idea 8

• Encourage management and nurses to utilize
  overstaff hours to orient to areas/units where
  there is a shortage of RNs. Provide
  scholarships for nurses obtaining training in
  needed areas.

44
Retention idea 9

• Improve physical environment, comfortable break
  areas, for nurses with the same care and concern
  as provided for the general public physical
  environment.

45
Retention idea 10

• Provide for health care after retirement for all
  nurses between retirement age and eligibility for
  Medicare.

46

• The nurses of Alaska stand ready to discuss these
  and other ideas for improving the nursing
  profession in Alaska and retaining qualified,
  dedicated nurses in that profession.

• 907-274-0827
• 3701 East Tudor Road, Suite 208
• Anchorage, AK 99507

47

• Filling the Need Distance Masters of Social Work
  Education in Alaska
• Wednesday, February 21, 2007
• Elizabeth A. Sirles, Director
• University of Alaska Anchorage
• College of Health Social Welfare
• School of Social Work

48
The Demand for Social Workers in Alaska
49
Locations of MSW Distance Students

• Anchorage (3)
• Barrow (1)
• Eagle River (1)

• Fairbanks (3)
• Homer (4)
• Juneau (4)
• Kenai / Soldotna (2)

• Sitka (1)
• Wasilla (1)
• Fernie, British Columbia (1) Canada

• Ketchikan (2)
• Kodiak (2)
• North Pole (1)
• Petersburg (1)

50
Multimodal Approachto Distance Education
51
Our Distance Students
52
Field Placementsof MSW Distance Studentsduring
2004-05

• North Slope Borough Counseling Center, Barrow
• Alaska Psychiatric Institute, Anchorage (Block
  Placement)
• Office of Childrens Services, Anchorage
• Tanana Chiefs Conference Counseling Center,
  Fairbanks
• Homer Community Health Center, Homer
• Bartlett Regional Hospital, Juneau
• Kenai Peninsula Community Care Center, Kenai
• Community Connections, Ketchikan
• Ketchikan Pioneers Home, Ketchikan
• Providence Kodiak Mental Health Center, Kodiak
• Child, Youth, Family Services Society of Powell
  River, British Columbia

53
Field Placements for Distance Students in 2006-07

• Office of Childrens Services, Anchorage
• Providence Alaska Medical Center, Anchorage
• Hospice of the Tanana Valley, Fairbanks
• Tanana Chiefs Conference Counseling Center,
  Fairbanks
• South Peninsula Haven House, Homer
• South Peninsula Hospital, Homer
• AWARE, Juneau
• Commission on Aging, Juneau
• Kenai Care Center, Kenai
• NAKENU Family Services, Kenai
• Kodiak Area Native Association, Kodiak
• Petersburg Mental Health, Petersburg
• Sitka Counseling and Prevention Services, Sitka
• Behavioral Health Community Mental Health,
  Wasilla
• Summit Community Services Society, Cranbrook
  British Columbia
• Hope Cottages, Anchorage along with Waterford
  University, Ireland

54
Physician Assistants in Alaska

• John Riley PA-C, MS
• Medex Northwest/UAA
• Physician Assistant Program Coordinator
• Department of Health Sciences
• University Of Alaska Anchorage
• afjor_at_uaa.alaska.edu

55
What are Physician Assistants (PAs)?

• Physician assistants are health care
  professionals licensed to practice medicine with
  physician supervision.
• PAs conduct physical exams, diagnose and treat
  illnesses, order and interpret tests, counsel on
  preventive health care, assist in surgery, and in
  virtually all states can write prescriptions.
• Within the physician-PA relationship, physician
  assistants exercise autonomy in medical decision
  making and provide a broad range of diagnostic
  and therapeutic services.
• PA's practice may also include education,
  research, and administrative services.

56
Growth of Profession

• The United States Bureau of Labor Statistics
  (BLS) projects that the number of PA jobs will
  increase by 50 percent between 2004 and 2014
• The BLS predicts the total number of jobs in the
  country will grow by 13 percent over this 10-year
  period
• The PA profession was ranked by CNN and Money
  magazine in May 2006 as one of the top five jobs
  in the country

57
PA Training

• Majority Alaskan PAs trained at Regional PA
  training center at University of Washington Medex
  Program
• Second highest percentage Alaska PAs trained at
  University of Utah PA Program

58
Medex PA Training

• 6 or more seats at UW Medex reserved for Alaskan
  applicants
• First year of didactic training in Washington
  State
• Second year clinical clerkships in training sites
  across Alaska

59
PA Program applicants

• The typical applicant already has a bachelor's
  degree and approximately four years of health
  care experience.
• Commonly nurses, EMTs, and paramedics apply to PA
  programs.

60
Two generations of previous Alaska CHAs trained
at Medex
61
Distribution PAs

• Anchorage 29
• Outside Anchorage 71

62
PAs in Primary Care

• Primary Care 60
• Specialty Care 40

63
What are the future Alaska workforce needs for
PAs and other medical providers?

• The following information is quoted from the
  Alaska Physician Supply Task Force Report

64
Report of theAlaska PhysicianSupply Task Force

• There will be a shortage of 1100 physicians over
  the next 20 years due to physician retirement,
  aging of the Alaska population and decreased
  production capacity of new physicians

65
From Report of theAlaska PhysicianSupply Task
Force

• As of the end of 2005, there were 284 active
  physician assistants with Alaska addresses and
  AA status 29 percent were in Anchorage.
• Of 486 advanced nurse practitioners with active
  licenses and Alaska addresses, 51 percent were in
  Municipality of Anchorage.

66
From Report of theAlaska PhysicianSupply Task
Force
Finding 5. Alaska has and should maintain a
higher ratio of mid-level providers (advanced
nurse practitioners and physician assistants) to
physicians than the national average, in order to
make it feasible to provide high quality and
timely care to the population. Without these
providers the need for physicians would be even
higher.
67
From Report of theAlaska PhysicianSupply Task
Force

• Physician assistants and advanced nurse
  practitioners are critical providers of care in
  Alaska, complementing and extending physician
  coverage for primary care, for supervision and
  training of community health aides and
  practitioners, and in some settings for serving
  as specialists in surgery, emergency medicine,
  and other areas.

68
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69

• The Graying of Alaska

70
Population Projection for Alaskans Over Age 65
71

• The Graying of Alaskas healthcare
  workforce

72
Age Distribution of Physicians (MDs and DOs) in
AlaskaN1501
73
Age Distribution of Physician Assistants in
AlaskaN294
74
Age Distribution of Advanced Nurse Practitioners
in AlaskaN 424
75
Strategies

• Physician workforce projections are based on
  trend models. Trend models project current
  conditions into the future. As we increase the
  number of physicians we must also proportionally
  increase the numbers of midlevel providers to
  maintain current ratios

76
Strategies to increase numbers of PAs educated in
Alaska

• Expand UW Medex/ UAA collaboration to provide
  both years of PA training in Alaska
• Develop bridge program to support professional
  development of CHAPS to PAs
• Expand support of clinical year training costs

77
Strategies to increase numbers of PAs educated in
Alaska

• Create loan repayment assistance programs and
  funding for physician assistants practicing in
  shortage areas Alaska
• Alaska Participate in the HRSA Bureau of Health
  Professions State Loan Repayment Program
• Expand and support programs that prepare Alaskans
  for medical careers

78
Co-Chairs, Sen. Donny Olson and Rep. Sharon
Cissna thank you for participating in the
Legislative Health Caucus. A copy of this
powerpoint, as well as other up-to-date
information, can be found on our website
www.akhealthcaucus.org The audio file of todays
program can be found at http//www.ktoo.org/gave
l/audio.cfm (type in the date of this
Caucus). For more information, please call
1-800-922-3785