1. HRSA DC FLI Presentation Michelle Simon ND PhD May 4, 2012

2. Health Resources and Services Administration (HRSA) – HRSA is an agency of the US Department of Health and Human Services (HHS). – There are 6 bureaus and 10 regional districts that distribute funds to states. – HRSA is the primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. – More than 1,100 health center grantees operate more than 7,900 community-based clinics in every state and territory, giving geographically isolated or economically distressed people access to preventive and primary health care. – One of every 18 people living in the U.S. now relies on a HRSA-funded clinic for primary care. – Determine what the term “primary care” constitutes. – Designate Health Professional Shortage Areas (HPSAs) for eligibility for loan repayment programs.

3. The BCRS is the agency responsible for most loan repayment programs. BCRS coordinates the recruitment and retention of health professionals to work in medically underserved communities. The NHSC falls within HRSA’s Bureau of Clinician Recruitment and Service (BCRS) Bureau of Clinician Recruitment and Service (BCRS) Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Bureau of Clinician Recruitment and Service (BCRS)

4. National Health Service Corps SCHOLARSHIP PROGRAM BCRS Faculty Loan Repayment Program Nursing Education Loan Repayment Program Nursing Scholarship Program Native Hawaiian Health Scholarship Program National Health Service Corps LOAN REPAYMENT PROGRAM State Loan Repayment Program NHHSPFLRP NHSC SP NHSC LRP NSPNELRP NHSC SLRP NHSC S2S National Health Service Corps STUDENTS TO SERVICE LOAN REPAYMENT PROGRAM (PILOT)

5. HRSA Eligible Professions – Primary Care Physician (MD or DO) – Dentist (DDS or DMD) – Primary Care Certified Nurse Practitioner (NP) – Certified Nurse-Midwife (CNM) – Primary Care Physician Assistant (PA) – Registered Dental Hygienist (RDH) – Health Service Psychologist (HSP) – Licensed Clinical Social Worker (LCSW) – Psychiatric Nurse Specialist (PNS) – Marriage and Family Therapist (MFT) – Licensed Professional Counselor (LPC)

6. Health Professional Shortage Areas (HPSAs) – HPSA’s: Originally created in 1978 to identify areas in need of physicians and other health care providers from HHS’s National Health Service Corps (NHSC) programs, HPSA designation is now used by a variety of federal programs—including programs that provide grants for health professions. – HRSA’s Office of Shortage Designation (OSD) develops shortage designation criteria and uses them to decide whether or not a geographic area, population group or institution is a HPSA.

7. Federal Loan Repayment Programs Function at three levels – Federal: HRSA Primary Care Loan Program (PCL) Student to Service Program (NHSC S2S LRP) State Loan Repayment Program (NHSC SLRP) Loan Repayment Program (NHSC LRP) Indian Health Services Administration NIH and NCCAM – Regional: HRSA distributes funds to 10 regional areas of the US. – State: 2 existing programs, Washington and Oregon. Both receive federal (HRSA) SLRP $, States provide matching $

8. ND’s and HPSA’s in the USA The Geography and Distribution of Naturopathic Physicians in the United States A Rising Profession Donald Albert, PhD, and Ferry Butar PhD.. The Edwin Mellon Press. Lewiston. Queenstown. Lampter. 2006. University of Texas Analysis of ND geographic presence and diffusion trends; impact of inclusion of ND’s in HPSA designations would decrease total number of national HPSA’s. Predicts diffusion from urban centered to rural areas as profession grows to saturation

11. Rural retention The potential impact of selecting medical students of rural origin was quantified by Rabinowitz in a longitudinal study that evaluated the impact of the Physician Shortage Area Program (PSAP) in the USA. Rural origin was the single variable most strongly associated with rural practice (OR 4.2, 95% confidence interval [CI] 2.8–6.3) Rabinowitz HK, Diamond JJ, Hojat M, Hazelwood CE. Demographic, educational and economic factors and retention of physicians in rural Pennsylvania. Journal of Rural Health 1999; 15: 212-218. Rural origin is especially linked to the decision to choose a rural community as one’s first practice location Bowman RC. Continuing family medicine's unique contribution to rural health care. American Family Physician 1996; 54(2): 471-4,479,483. Rourke JT. Politics of rural health care: recruitment and retention of physicians. Canadian Medical Association Journal 1993; 148(8): 1281-1284. Barer ML, Stoddart GL. Toward integrated medical resource policies for Canada: 8. Geographic distribution of physicians. Canadian Medical Association Journal 1992; 147(5): 617-623.

12. Strong evidence from various countries that ‘rural origin’ (or rural background) is associated with rural practice Playford D, Larson A, Wheatland B. Going country: rural student placement factors associated with future rural employment in nursing and allied health. Australian Journal of Rural Health 2006; 14(1): 14-19 De Vries E, Reid S. Do South African medical students of rural origin return to rural practice? South African Medical Journal 2003; 93: 789-793. Laven G, Wilkinson D. Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Australian Journal of Rural Health 2003; 11: 277-284. Easterbrook M, Godwin M, Wilson R, Hodgetts G, Brown G, Pong R et al. Rural background and clinical rural rotations during medical training: effect on practice location. Canadian Medical Association Journal 1999; 160(8): 1159-1156. Rabinowitz HK. Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. New England Journal of Medicine 1993; 328(13): 934- 939.

13. Rural and Urban Underserved Health Care Survey 94% of Bastyr University naturopathic students answered yes when asked if they would relocated to a rural or urban underserved communities to practice in exchange for medical school loan repayment. Almost 60% of Bastyr students identified themselves as being from rural communities, an indicator of potential retention rates for ND providers maintaining practices in rural environments after their scheduled service is complete. Student Rural Interest Survey. Simon, M., Snider, P., et al. 2007. Bastyr University, Seattle, Wa. Corresponding author Michelle Simon, ND, PhD. Seattle, Wa 206-399-5451. dr.michelle@earthlink.net. Survey conducted at Bastyr Universitydr.michelle@earthlink.net

14. ND’s providing Primary Care to Underserved Highlights Over 60 community, neighborhood and rural clinics for underserved health care employ ND’s in USA WA: King County’s Health Point (2009): 160,000 patient visits, estimated 50% were by ND’s OR: NCNM (Portland) 16,220 visits at community health clinics, FQHC (9077 ND, 7146 LAc) AZ: Hamilton Elementary School Clinic, (low income)San Carlos Apache Tribal Clinic Diabetes Prevention, Care and Management

15. The way forward Pilot projects – NHSC pilot project – CMS pilot project – Bureau of Health Professions (PCL) Coordinated campaign – Congressional – Agencies