Remarks to the Joint Forum on Rural Health and Nursing Solutions

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by HRSA Administrator Mary K. Wakefield

June 13, 2011
Washington, D.C.

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Thank you for inviting me today to this important forum on the future of rural health and nursing solutions.

As a nurse with deep roots in rural health care practice, education, rural health policy and research, I know first hand the critical role that nurses have and continue to play in ensuring access to high-quality health care for our rural communities.

Grounded in both the profession of nursing and the characteristics of rural communities, I’ve learned over time the meaning of that adage, “necessity is the mother of invention.”  From a nursing and a rural perspective, today we might reframe it slightly to say  that necessity is the mother of innovation.

Necessity is what has prompted the invention of new care models by nurses at the micro level of intensive care units; the more macro level of nurse-managed clinics; or the co-development some decades ago of an entire generation of a new provider– a nurse practitioner.  

And necessity is what has prompted innovations in improving access to care for rural communities.  Now, in settings hundreds of miles apart, teams of clinicians can seamlessly serve the health needs of patients in rural health facilities.  Now it’s not uncommon to find care for patients in rural hospitals that equals or exceeds  the care quality provided in some urban settings.  That busts the myth that ‘bigger is always better.’

So, as both a nurse and someone with a fair amount of experience in rural issues, I know first hand that a mindset that sees challenges as opportunities to innovate has roots in both nursing and in rural health.  And in times of fiscal constraint, perhaps innovation becomes even more important.  

From a policy perspective, we have real and meaningful opportunities to improve health and health infrastructure in rural areas by virtue of provisions of the Recovery Act and, especially, in the provisions of the Affordable Care Act.   

The ACA provisions have driven much of our work at HRSA now for over a year, just as the Recovery Act did in 2009.  And with the recently released IOM report and in the rural council that President Obama established just a few days ago, we’re renewing our focus on both nursing and on rural communities.

This morning I’m going to say a few words about the nursing workforce, and a few words about the health status of rural populations. I’m also going to talk about a few of the provisions of the ACA and activities of HRSA that are poised to strengthen both.  And I’d ask you to think about how, given the needs of rural areas, we can do even more to help position nursing’s strengths to contribute fully to the health of rural communities.

So, let’s begin with just a few words about nursing.  The IOM report on the Future of Nursing: Leading Change, Advancing Health does a stellar job of painting a portrait of the profession.  

Today, across the nation, there are more nurses  than at any time in over 30 years – about 3.1 million nurses.   This high-water mark is matched by another high-water mark – 85 percent of nurses are in active practice.  That’s the highest rate of nursing employment since HRSA first started tracking the profession in 1977.  These data likely represent a confluence of factors but they also underscore that, just by their sheer numbers, nurses form part of the bedrock of American health care.   

While these numbers and that employment rate are good news, a Health Affairs survey published in May also suggests a nursing workforce under stress.  For example, the survey  found job dissatisfaction and burnout among those engaged in frontline clinical care.  These are characteristics that we can ill afford anywhere – particularly among the relatively thin ranks of nurses in rural communities.  That finding clearly has implications for many things – not the least of which is retention and the ability to sustain the high rate of nursing employment.  

The IOM report also noted that about half of all rural nurses have an associate’s degree, and less than one in four advanced practice nurses works in a rural community.  When you look at some specific rural health settings, however, you can see a robust deployment of advanced practice nurses.  In rural Community Health Centers, for example, almost half of direct care providers are clinicians other than physicians – these include nurse practitioners, nurse midwives, and physician assistants.   

And in terms of rural health itself, the myth of idyllic country living that may hold sway in the imaginations of many urban-dwelling Americans is contrasted by a reality of significant challenges.  

For example, while about a fifth of the nation’s population lives in rural communities, about a third of all households there receive food stamps.  Too many rural areas reflect lower income and higher poverty rates than the rest of the country.  And a greater proportion of rural residents are uninsured or covered through public sources such as Medicaid, CHIP or Medicare.  

Compared to urban adults, rural adults are more likely to work for employers that do not offer health insurance coverage.  Additionally, rural communities often tend to have a higher percentage of elderly than their urban community counterparts.  Given these sorts of characteristics, you can start to see why certain provisions in the Affordable Care Act – like extending the reach of health insurance or removing out-of-pocket costs for preventive health screenings for Medicare beneficiaries – are so critically important to rural communities.  

A glance at the rural health workforce quickly flags the fact that rural counties with designated health professions shortage areas outnumber urban counties with shortage areas by a ratio of 2 to 1.  

In addition, residents of rural America often have preventable illnesses.  They have higher rates of substance abuse – including meth use, alcoholism and tobacco-related health issues – they have a higher incidence of death due to traumatic injury, and they have higher rates of dental caries and diseases like hypertension.  High rates of obesity can be found dotting the rural landscape as well – not everyone is engaging in physical activity or eating healthy food.

These health problems can be addressed through primary care and population health – an important area of focus for nurses, physicians and others.   But in many rural communities, we have particular challenges fielding nurses and primary care nurses with advanced degrees.  The aging of the nursing workforce and the increased, but still insufficient, numbers of new nurses entering the workforce are trends that don’t play well in a lot of rural communities.  

The Recovery Act began to chart a solution to these challenges by strengthening workforce training, by deploying more primary care providers to underserved areas, and by increasing baseline appropriations for health care workforce programs.  That has been followed by the  ACA’s heavy investment in the training of primary care providers of all types – nurse practitioners, physician’s assistants and physicians – against the backdrop of what had been, for years, anemic funding for key programs like the National Health Service Corps.  And that anemic funding occurred in spite of pretty common knowledge that the aging U.S. population was driving an increasing need for primary care resources.

In rural areas we have particularly acute needs for nurses and others with expertise in caring for elderly with comorbidities.

So these circumstances clearly call out for invention – or innovation.  

At the end of the day it’s really about taking on these challenges collectively – no one entity owns all of the solutions.  At HRSA, we welcome partnerships around these issues and we welcome your ideas about how we can deploy our resources more effectively.  

The health and well-being of rural populations and the availability of nursing care are priorities for President Obama and his Administration.  On the rural front, each budget submitted by the President has included funding for the “Improving Rural Health Care Initiative,” which has workforce recruitment and retention as one its key focus areas.  And nursing education, nursing care and faculty support programs have also received a marked uptick in support.

For example, nurses and nursing are mentioned almost 400 times in the Affordable Care Act.  The word “rural” appears 125 times.  And of course most of the provisions of the law impact both rural and urban populations and infrastructure.

Many ACA provisions that address primary care or nursing workforce and care aren’t the substance of radio talk shows but are critically important.

For example, the law’s investment of $15 million to support 10 Nurse-Managed Health Centers over three years strengthens an infrastructure of more than 250 nurse-managed health centers – most of them affiliated with schools of nursing.  These nurse-managed centers provide primary care to about 2.5 million Americans, including some in rural communities.

In addition, HRSA awarded $30 million over the past year to boost the number of primary care nurse practitioners by 600 over five years;

And the ACA’s Home Visitation Program calls for an investment of $1.5 billion over 5 years to fund state and local programs that send nurses, social workers and others into high-risk communities to counsel and guide expectant mothers into care.  Forty-nine of 50 States, the District of Columbia, Puerto Rico and five other U.S. Territories are participating in the program and will be able to deploy evidence-based models in their high-need urban and rural communities.

The Act also authorizes $200 million – half of which already has been awarded – for the construction, renovation and expansion of school-based health centers so that even the most disadvantaged kids can get care before major health problems take root.  I probably don’t need to tell anyone in this audience that school nurses have been on the frontlines of children’s health care  for years.  And nowhere else are their services needed more than in rural communities – where some estimates indicate that nearly a quarter of all children (24%) lives in poverty.  Compromised health and poverty often go hand in hand.

The most significant funding investment that the ACA made in HRSA – and that directly touches on primary care, nursing care  and the availability of care to rural communities – is a 5-year plan for the operation, expansion, and construction of community health centers throughout the nation.

Obviously this expansion is going to require special attention to the health care workforce, particularly in rural communities, where a third of health center sites are located.

Health centers now employ 4,000 advanced-practice nurses and almost 11,000 RNs – a two-year staffing increase of nearly 20 percent.  And more will be coming, adding to what is already the single largest professional class in the health center workforce: about  15,000 nurses.  Meeting and sustaining this growth is an immediate priority for HRSA.

Fortunately, the Affordable Care Act dedicates $1.5 billion to the National Health Service Corps over the next 5 years.  That’s enough to fund about 2,100 new loan-repayment contracts and scholarships for primary care clinicians in the current fiscal year alone.

Of the 7,500 providers currently serving in the Corps – half of whom serve in rural posts – almost 1,400 are advanced practice nurses. That’s about double the number of APNs (692) that were in the field when President Obama took office.

Those advanced practice nurses who join today receive up to $60,000 in academic debt servicing for a two-year commitment – and more debt servicing if they stay longer, all of it tax-free.  The United States isn’t the only country strengthening its health workforce infrastructure by deploying nurses to extend the reach of primary care and other services.  The Organization for Economic Cooperation and Development last year produced a report talking about the capacity for nurses and APNs to improve access to services and decrease wait times from Australia to Finland and other nations as well.

From a total field compliment of 3,600 providers just two years ago, the National Health Service Corps today is on track to reach over 9,000 primary care clinicians by the end of this year. This is a particularly important investment for rural areas because it plays out at a time when a number of states are cutting back on school loan programs.  What is particularly heartening is that we have thousands of soon-to-be-providers asking us to let them know as these resources become available.  That’s a heartening development for rural communities that have had long standing primary care shortages.

Millions more underserved Americans will receive care as a result of this expansion in the health centers and the NHSC, and the additional funding already is providing an opportunity for rapid infusion of new talent, new energy and new leadership into primary care at what I think we’d all agree is a critical time.

One of the key findings of the IOM study is that the career ladder for nurses needs strengthening.  

The ACA certainly speaks to training support and career advancement.  Since last August alone, HHS has awarded $558 million to colleges, universities and other institutions across the nation to support faculty and students in primary care fields, to build capacity, and add training components.

The law authorizes millions of dollars in support for Nurse Faculty Loans; Advanced Education Nursing Traineeships; and Nurse Education, Practice and Retention Grants – to name just a few.

The Nursing Education Loan Repayment Program has seen its budget more than double (from $37 million in 2009 to almost $94 million).  In exchange for a two-year commitment to serve in a health care facility with a critical nursing shortage, RNs in financial need get 60 percent of their education debt paid off by HRSA.  This summer alone, HRSA expects to award $26.5 million through this program.

The Nursing Workforce Diversity Program received a $3 million boost in 2009 from the Recovery Act, and the ACA extended the program’s reach so that it now supports graduate-level and undergraduate candidates.

And since 2009, $40 million in Recovery Act funds have been committed to Scholarships for Disadvantaged Students – and annual funding for the program was increased by some $4 million.  More than 21,000 students training in the health professions have received scholarship support as a result.  All of these are leverage points for individuals interested in applying these investments to work as nurses and to work for rural communities.

While these and other nursing investments aren’t designed to strengthen nursing care exclusively for rural populations, all of us should be thinking about how to strengthen them to ensure that they support health care in rural areas.

We clearly need more health care professionals, and we also need them to serve where they are needed most and working in state-of-the-art care models. To do that, as the IOM report noted, we must have better and more reliable regional and state-level workforce data – particularly in rural areas.

Recommendation 8 of the IOM report called on HRSA to “lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements … with state licensing boards, state nursing workforce centers, and the Department of Labor to ensure that the data are timely and publicly accessible.” (end quote).

The current and planned activities of HRSA’s National Center for Health Workforce Analysis are consistent with this recommendation:

• The Center is now developing a Minimum Data Set for all health professions that builds on the work already done by the State Nursing Workforce Centers. The National Center will work with the National Council of State Boards of Nursing, state boards and others to encourage implementation of the data set for Advanced Practice Nurses, RNs and LPNs.
• This year, the Center is working to develop models for projecting supply and demand that includes advanced practice nurses and physician’s assistants, who are now eligible for rural incentive bonuses under the ACA.
• And since decisions on workforce education and distribution need to reflect input from states and local communities, HRSA provided $5 million in grants to 25 states to plan and implement strategies to expand their primary care workforce.  HRSA funds for State Offices of Rural Health, State Primary Care Offices and Area Health Education Centers also contribute to this effort.

Another element of the Affordable Care Act that will impact nurses in both rural and urban settings is the expanding effort to improve the performance of our health workforce by emphasizing team-based care and care coordination strategies.  Research indicates that teams of health care professionals are associated with better patient outcomes and with greater patient satisfaction.  

In recent testimony to the Senate Finance Committee, HHS Secretary Kathleen Sebelius explained why an effort to advance interprofessional education is so badly needed:

“Too often,” she said, “health care takes place in a series of fragments or episodes.  We need to make it possible for entirely new levels of seamlessness, coordination, and cooperation to emerge among the people and the entities that provide health care, so as to smooth the journeys of patients and families … through their care, over time and in different places.” (end quote)

Health care for rural communities can be at particular risk of fragmentation if we don’t carefully concentrate on the features of care coordination that transcend distance and link different health care systems and care providers.  Rather than training the next generation workforce in health profession silos, interprofessional education means creating both academic and clinical experiences for students that advance the goal of health professionals working in collaboration to provide the best patient-centered care.

Some of you are aware that this past February, HRSA sponsored a meeting with the Robert Wood Johnson Foundation, the Macy Foundation, the American Board of Internal Medicine Foundation, and the Interprofessional Education Collaborative to talk about developing core competences for inter-professional collaborative practice.

Last month, I was pleased to meet with our partners again when they released a set of core competencies to be disseminated for use in health professions education and practice.  It’s a step that represents real progress to push forward team-based care concepts.

Care coordination is crucial to both care quality and safe care.  As part of the implementation of the Affordable Care Act, Secretary Sebelius recently announced the launch of Partnership for Patients – a new initiative to ensure that the care every American receives is the best care possible.  The Partnership involves over 3,300 partners ranging from hospitals, physicians, nurses and employers to unions, patient advocates, health plans and others, all of them joining together to improve the safety of health care in America.  

The Partnership’s goals are simple: better care at lower costs; a 40 percent reduction in preventable treatment errors; and a 20 percent decline in hospital readmissions through team-based measures designed to smooth the transition of patients from hospital care to home.
There is tremendous private sector enthusiasm about this new effort and many organizations have already signed on to participate.  And, of course, nurses and rural hospitals can play key roles in making this initiative a success, given the central roles they play as providers in underserved areas.  How this area of activity unfolds in rural health care is fairly open – that is, it’s open to the innovators who see an opportunity to make health care safer and more effective for patients.  

On the rural front, just a few short days ago the Administration announced the establishment of the first White House Rural Council to coordinate programs across government that will strengthen rural economies, foster innovation, and leverage technology.  Present at the first meeting, chaired by Agriculture Secretary Tom Vilsack, were senior leaders from almost every part of government.  And while much has been already been done to address rural challenges across the various departments and agencies, the president expects even more going forward.

And anyone with a sense of what it takes to strengthen rural communities knows that the economic health of rural communities is inextricably linked to the health and health care of rural communities.  And rural health care is predicated on having a health care workforce and robust access to quality primary care—something that nurses are very much part of.

Health care is one of the Rural Council’s 10 priority areas.  But it’s important to note that some of the other nine areas have components that touch on the rural health and rural health care infrastructure.  These include such things as improving education – which is pivotal to providing a solid foundation for health professions training – and expanding access to broadband services, which is essential for rural health IT infrastructure.

So it’s against this backdrop that necessity drives innovation in rural America.

For example, in my home state of North Dakota, a telepharmacy project funded by HRSA is restoring access to pharmacy services in towns on the brink of losing them, creating about 60 new jobs in the process.

In rural southeastern Georgia, a project called Best Babies that was originally funded by HRSA’s Office of Rural Health Policy now offers comprehensive, integrated perinatal care across four counties for women at high risk for adverse birth outcomes.

And in seven northeastern counties of rural Appalachian Kentucky, five churches have joined forces with local social service agencies and four major rural providers – including Morehead State University – to spread prevention in one of poorest regions of the nation by employing nurses as wellness coaches.

That’s the kind of innovation rural practitioners can bring to health care.  Rural places and rural people are typically nimble, efficient and used to extracting value from investments.  In this environment, we have lessons to teach and contributions to make.

A 2009 report by Grantmakers in Health basically makes this point, noting that rural health professionals “demonstrate a collaborative culture … and a readiness to be creative that … are crucial for providing superior and cost-effective services.”  The report went on to say that “rural workforce shortages drive the creation of new … team approaches to care … that could be usefully adapted” to other settings.

Nurses in this environment can fully contribute their knowledge and creativity in sites that need these talents and present an opportunity to use them.

Contrary to some popular myths about rural America, we are not a backwater.  When it comes to collaboration, creativity, and cost-effectiveness in health care, rural practitioners can be headwaters of invention.  Health care there can be exciting to deliver and informative to study.  Simply put, with challenges comes opportunities—for nursing and for rural America.

Thank you.