This document summarizes research assessing factors that influence a community health center's ability to recruit and retain family physicians. The researchers developed a Community Health Center Community Apgar Questionnaire (CHC CAQ) consisting of 50 questions in 5 classes. They administered the CHC CAQ to administrators and physicians at 11 Idaho community health centers. The CHC CAQ was designed to produce an overall score comparable to an Apgar score for infants. The scores can identify strengths and challenges to prioritize improvements. Top important factors across communities included spousal satisfaction, call coverage, income guarantee, and quality perception. Next steps include expanding the Community Apgar Program consultation to other states and developing a Nursing Community Apgar Questionnaire.

1. Assessing Community Health Center Assets & Capabilities for Recruiting and Retaining Family Physicians:The Community Apgar Questionnaire David Schmitz, MD, FAAFP Associate Director of Rural Family Medicine Family Medicine Residency of Idaho Ed Baker, PhD Director, Center for Health Policy Boise State University Virginia’s State Rural Health Plan 2010 Rural Health Pre-Summit: Rural Workforce Danville, Virginia March 16, 2010

2. Presentation Overview Background Study Design Selected Findings Next Steps Questions

3. Background Contributors/Co-Investigators Denise Chuckovich, Executive Director, Idaho Primary Care Association Katrina Hoff, Director of Workforce Development, Idaho Primary Care Association Ayaka Nukui, MHS, Center for Health Policy, Boise State University

4. Background Funding Mary Sheridan, Supervisor, State Office of Rural Health and Primary Care, Idaho Department of Health and Welfare through a federal grant from the US Department of Health and Human Services, Health Resources and Services Administration Jim Girvan, Dean, College of Health Sciences, Boise State University, through a College of Health Sciences research fund Research and Physician Faculty time contributions made by Boise State University and Family Medicine Residency of Idaho

5. Background Boise State University and the Family Medicine Residency of Idaho have initiated a four year study of factors impacting recruitment and retention of physicians in Idaho Partners Idaho Office of Rural Health and Primary Care Idaho Hospital Association Idaho Academy of Family Physicians Idaho Medical Association Idaho Primary Care Association Boise State University Department of Nursing

6. Background How did we get here – Why research? An intersection of workforce, education and advocacy Partnerships with those with a natural interest in the work Idaho has a natural laboratory Researching what we do and what we think we know Evidenced based curricular development Accurate workforce assessments: quantitative and qualitative Community-focused differential workforce development: A validated tool improving recruitment for communities Physician-focused workforce development: Improving the educational “pipeline” of a rural physician workforce

7. Background Year 1 Idaho Family Physician Rural Work Force Assessment Pilot Study Year 2 Critical Access Hospital Community Apgar Questionnaire (CAH CAQ) Year 3 Examining the Trait of Grit and Satisfaction in Idaho Physicians Community Apgar Program (CAP) Consultation Pilot Program for Critical Access Hospitals Year 4 Community Health Center Community Apgar Questionnaire (CHC CAQ) Nursing Community Apgar Questionnaire (NCAQ)

8. Background Year One Research Survey of practicing rural physicians and critical access hospital administrators in Idaho Idaho rural family physicians have a broad scope of practice Idaho rural family physicians use technology to help provide care to rural residents and to maintain skills Idaho rural family physicians are satisfied with their practice in rural areas Idaho rural hospital administrators are satisfied with their family physician staffs Subset of findings published in the Journal of Rural Health in 2010 (Volume 26, Issue 1, pp. 85-89)

9. Background Year Two Research Development of the Critical Access Hospital Community Apgar Questionnaire (CAH CAQ) Validation of instrument across a group of 12 critical access hospitals in Idaho Prognosticates the success of a critical access hospitals in recruiting and retaining family physicians Differential diagnosis of strengths and limitations in order to prioritize improvements and to emphasize strengths Plan to submit research to Journal of Rural Health in Spring of 2010

10. Background Year Three Research Grit and Satisfaction Study Survey of 577 Idaho physicians in rural and non-rural areas practicing in primary care and specialty areas assessing trait of Grit and satisfaction with practice in Idaho Grit defined as perseverance and passion for long term goals Idaho physicians high in Grit (especially in subscale “perseverance of effort”) and satisfaction levels Statistical differences by medical training and practice location for Grit subscales and satisfaction levels Plan to submit to Annals of Family Medicine in Spring of 2010

11. Background Year Three Research (Con’t) Community Apgar Program Consultation Pilot Program for Critical Access Hospitals (CAH CAP) Developed and implement the CAH CAP Consultation Pilot Program in Idaho CAH CAP Consultation Pilot Program year one activities implemented in three sites with positive feedback Second year activities for initial three sites scheduled Other critical access hospital sites being recruited

12. Background Year Four Research Community Health Center Community Apgar Questionnaire (CHC CAQ) CHC CAQ developed CHC CAQ validated across all community health centers in Idaho Preliminary data presented to 2010 NWRRHC Technical report due July 2010 to Idaho Office of Rural Health and Primary Care Plan to submit to Journal of Rural Health in Fall 2010

13. Background Year Four Research (Con’t) Nursing Community Apgar Questionnaire Nursing Community Apgar Questionnaire (NCAQ) developed with Nursing Department faculty at Boise State University NCAQ Instrument developed Initial research efforts being presented at the Western Institute of Nursing 43rd Annual Communicating Nursing Research Conference in April 2010 Plans under way to implement and validate the NCAQ in critical access hospitals in Idaho in 2010

14. Study Design CHC CAQ Research Objectives Develop an objective measurement tool (CHC CAQ) to assess the characteristics and parameters of Idaho community health centers related to successful recruitment and retention of family physicians Administer the CHC CAQ to community health center medical leaders in a structured interview format Analyze the results, produce a written summary of the findings and disseminate the results to interested local, state, regional and national parties

15. Study Design CHC CAQ Development Literature review conducted during prior year research Site visits statewide to communities during prior year research Discussions with physicians, administrators and Idaho Primary Care Association workforce committee members prior to study

16. Study Design The CHC CAQ Questions aggregated into 5 Classes Geographic Economic Scope of Practice Medical Support Facility and Community Support Each Class contains 10 factors for a total of 50 factors/questions representing specific elements related to recruitment and retention of family medicine physicians in community health centers Three open-ended questions

17. Study Design:Class/Factor Examples Geographic Class Schools, climate, perception of community, housing, spousal satisfaction Economic Class Loan repayment, salary, signing bonus, part-time opportunities Scope of Practice Class Mental health, inpatient care, obstetrics, emergent care, administrative duties

18. Study Design:Class/Factor Examples Medical Support Class Nursing, allied mental health, pharmacy, perception of quality, call coverage Facility and Community Support Class Physical plant and equipment, EMR, CHC leadership, community support of physician

19. Study Design Community Apgar Score Designed to produce an overall assessment comparable to an neonatal Apgar score Constructed from the sum of weighed parameters in the five classes of the CAQ (similar to the five dimensions of the neonatal Apgar) to create a repeatable measure of a community’s assets and capabilities Intended to prognosticate the success of a community health center in recruiting and retaining family physicians Designed to differentially diagnose a community health center’s relative strengths and challenges in order to prioritize improvements and identify marketing opportunities by examining component Class and Factor Apgar scores

20. Study Design CHC CAQ Target Communities All 13 community health centers in Idaho One site per community health center if community health center had multiple sites Communities classified as alpha [N=9] or beta [N=4] based on historical success in recruiting and retaining physicians Final sample included 7 alpha and 4 beta communities as one community health center was excluded from this data analysis due to potential researcher conflicts of interest and a second only employed physician assistants and no physicians

21. Study Design CHC CAQ Respondents 11 community health center administrators and 11 community health center physicians with leadership roles in recruitment and retention [Total N=22] CHC CAQ Administration Participants mailed the CHC CAQ survey in advance with consent form [IRB approval from Boise State University] and one hour interviews scheduled Separate structured one hour interviews by Dr. David Schmitz for each participant where consent form was reviewed and executed and CAQ completed

22. Selected Findings CHC CAQ Areas of Emphasis Community Advantages and Challenges Community Importance Ratings Community Apgar Scores CHC CAQ Analytical Framework Respondent type (administrator vs physicians) Community type (alpha vs. beta) Across Factor, Class and Summary Differential Diagnosis of Community Health Centers’ Assets and Capabilities

26. Top 10 Important Factors across All 50 Factors 3.95 Overall 3.9 3.85 3.8 3.75 3.7 Mean Score 3.65 3.6 3.55 3.5 3.45 3.4 spousal call/practice income recreational revenue flow stability of physical plant perception of community loan repayment satisfaction coverage guarantee opportunities physician and equipment quality need/support of workforce physician Top 10 Important Factors

49. Continue to implement the Community Apgar Program (CAP) for Idaho critical access hospitals

50. Export the Community Apgar Program (both CAQ and CHC versions) to other states (e.g.,Virginia, Wyoming, Montana)

51. Develop a plan to implement and validate the Nursing Community Apgar Questionnaire (NCAQ) in critical access hospitals in Idaho

52. Develop a NCAP and link with the CAH CAP and the CHC CAP