South Dakota Department of Health Secretary Doneen Hollingsworth knows a huge challenge remains to find enough health-care providers for rural residents.
She hopes a just-completed report from Gov. Dennis Daugaard’s Primary Care Task Force will help as the number of high school graduates in the state continues to drop while the elderly population is expected to double in slightly more than 10 years.
“We had a really dedicated group of folks looking at this issue. It’s certainly not a new issue, but it was good to look at it with fresh eyes and new people. and a vigor and commitment to ensure we have primary care providers in rural South Dakota,” Hollingsworth said in an interview last week.
The footprint of the state’s big health systems – Avera Health Systems and Sanford Health Systems of Sioux Falls and Regional Health of Rapid City – covers a lot of ground. However, the report notes that 53 of the state’s 66 counties are federally designated as health professional shortage areas. The report by the 25-member task force says that further compounding the problem is that significant numbers of doctors and other care providers are nearing retirement.
Currently, 19 counties in the state are without a primary care physician, mostly in the northwest and central parts of the state.
Although some of those counties have physician assistants (PAs) or certified nurse practitioners (CNPs), there is a critical need for more help. Major steps were taken in the last legislative session, with money approved to expand the USD Sanford School of Medicine’s yearly class size by four students to 56 and establishment of the Frontier and Rural Medicine (FARM) program to provide as many as six third-year medical school students with a nine-month clinical training in a rural community.
The goal of the programs is to increase the number of primary care physicians in rural South Dakota.
In addition, the past legislative session provided money to increase the capacity of students in the USD PA program from 20 to 25 starting in August. Of the 305 PA graduates to date, almost half are practicing in South Dakota, many in towns of fewer than 10,000 people.
Also, the state’s recruitment assistance program was expanded starting last year. Since July 1, the program has helped place three physicians in Hot Springs, Platte and Custer, one PA in Chamberlain, two nurse practitioners in Britton and Freeman and one dentist in Howard. The effort also includes recruitment of other health care professionals such as nurses and respiratory therapists to rural facilities, and since July 1, 55 health professionals out of an eligible 60 slots have received incentive payments of $10,000 to work in 32 different rural communities.
Hollingsworth noted that the task force is building on those efforts as it continues to promote rural health occupations as part of Daugaard’s South Dakota Workforce Initiatives (WINS) program and ensure accessibility to primary care for all state residents, especially in rural areas.
The task force recommended that health profession education programs work together more closely and that training opportunities in rural areas be expanded.
Another important component, Hollingsworth said, is accountability. “The governor didn’t want recommendations to be put on a shelf and then some governor down the road put together another task force and then bring out the report and say, ‘What did that group do?’ ” she said.
She said a smaller group probably will take over the task of seeing that plans aren’t dropped, that progress is measured and that reports continue to be made to the governor, Legislature and Board of Regents by Nov. 1 of each year.
“We have to keep our eye on the ball,” Hollingsworth said.
The task force didn’t recommend asking the Legislature to expand the medical school or PA program slots again this year, but officials are expected to keep a close eye on the situation and had lengthy discussions about the issue.
One of the problems in this area is finding physicians who have enough time to work with the students. Many times working with a student can cut into patient time, reducing productivity and having a financial impact.
In one major step to help with this situation, the task force recommended investing $455,000 annually to pay physicians to help train PA students in rural areas. The 2013 Legislature will be asked to approve the money.
“The payments aren’t going to be great, but it’s a recognition that what they are doing is valuable,” Hollingsworth said.
The secretary said one thing the task force heard is that USD had to go to neighboring states to find health-care providers that had time to help train students. “That’s a reverse incentive for us. Why would we send a student to another state and develop relationships there and then have them probably stay there to practice?” she said.
The task force also recommended looking into a payment program for those helping train CNPs. Another area that was discussed in-depth by the task force is for students to have high-quality rural health experience while training.
Finding students interested in going to a rural area is a first step, but then the goals are to foster that interest, allow the students to see how important a provider is to the community and show that they aren’t alone in providing care in that community.
The task force recommended that the state Office of Rural Health serve as a clearinghouse of rural health experiences for students, facilities and communities and expand opportunities for students to gain exposure in rural areas, including on American Indian reservations.
“I think some communities do better than others” on being welcoming and giving students a quality experience, Hollingsworth said.
“But I think we can learn from the communities that do it well,” she said.
The new FARM, or rural track program for medical students, will be a good test of how rural South Dakota responds. The first sites selected for the program are Milbank, Mobridge, Parkston, Platte and Winner. Students will participate for nine months in the full spectrum of the practice of rural medicine, following patients and their families over time with hands-on experience in the clinic, hospital and extended-care setting.
Other facets of the task force recommendations were to look at innovative primary care models and partner with the Dakota Roots organization to promote the return of former South Dakota residents.
Telehealth is one innovative method taking hold already in rural South Dakota as it provides the opportunity to conduct patient visits by interactive video, forward digital images to remote specialists and monitor patients in a home setting.
The use of “hospitalists” also is seen as a big help in rural areas. They are physicians who specialize in providing care to patients in the hospital, mostly for acute illnesses. This can help reduce on-call and hours worked for physicians. The task force learned that some rural South Dakota hospitals already use PAs and CNPs in this role to help reduce the workload. There also was discussion on providing help with administrative functions to rural doctors to give them more time for patients and their families.
As for working with Dakota Roots, it’s designed to inform those who have left the state but who might want to return about job opportunities.
Hollingsworth realizes it’s a challenge and that getting a doctor into a rural area can be a long-term task.
“It’s a multi-layered effort. You have to start early and just keep at it and keep at it,” she said.