Maryland Rural Health Implementation Plan RHIP

1. Maryland Rural Health Implementation Plan (RHIP) Michelle G. Clark, MSW, MPH Project Director, State Office of Rural Health October 2, 2008 Co-located with PCO in Office of Health Policy and Planning under Jeanette Jenkins. Rebecca Love, a consultant as a Policy Analyst, Acted in my role as the program administrator during gap.Co-located with PCO in Office of Health Policy and Planning under Jeanette Jenkins. Rebecca Love, a consultant as a Policy Analyst, Acted in my role as the program administrator during gap.

2. Office of Health Policy and Planning (OHPP) State Office of Rural Health (SORH) Workforce Programs (Loan Assistance Repayment Program � LARP) Maryland Rural Health Plan MRHA Listening Sessions Maryland Rural Health Implementation Plan Feel for what we do and who we interact for.Feel for what we do and who we interact for.

3. 24 Counties � 6 are not rural or federal designated�24 Counties � 6 are not rural or federal designated�

4. State Office of Rural Health Mission: The Maryland State Office of Rural Health (SORH) aims to improve the health of rural Marylanders through collaboration, networking, outreach, education, advocacy, and the development of special programs. Federally Funded State Offices of Rural Health (50 SORHs nationwide) Small Hospital Improvement Program (SHIP) State Matching Funds � Area Health Education Centers (AHEC)s Staff Michelle Clark, Michele Pharr, Jessica McKinnie Consultants Jeanette Jenkins, Director of OHPP Liz Vaidya, Primary Care Organization (PCO) Director Rebecca Love, OHPP Health Policy Analyst Office of Rural Health Policy (ORHP), Health Resources Services Administration (HRSA) TA Information Dissemination and Collection Rural Recruitment and Retention Coordinating Special Programs/Rural Collaborators (Help with this, rural health outreach grants, SHIP)Office of Rural Health Policy (ORHP), Health Resources Services Administration (HRSA) TA Information Dissemination and Collection Rural Recruitment and Retention Coordinating Special Programs/Rural Collaborators (Help with this, rural health outreach grants, SHIP)

5. Workforce Programs Within OHPPLoan Assistance Repayment Program Federal Loan Assistance Repayment Program (LARP) Purpose To provide repayment of educational loans to physicians who agree to practice in an approved practice/underserved area for a period of time Program is jointly administered by: Primary Care Office (PCO) in the OHHP in Family Health Administration for DHMH Maryland Higher Education Commission (MHEC)

6. Workforce Programs Within OHPPLARP Funding Funding Federal funds Competitive funding among the states Requires state match (50:50) State funds Source is physician licensure fees Funds provided to MD Higher Education Commission (MHEC) through legislatively mandated Janet L. Hoffman Program Federal Funds: bullets under �competitive funding among the states� FFY 07, 22 states qualified for awards ranging from $66,793 (VA) to 934,550 (CA) 5 states were listed in default (negative awards) MD received $250,000; FFY06 award was $127,338Federal Funds: bullets under �competitive funding among the states� FFY 07, 22 states qualified for awards ranging from $66,793 (VA) to 934,550 (CA) 5 states were listed in default (negative awards) MD received $250,000; FFY06 award was $127,338

7. Workforce Programs Within OHPPLARP Eligibility and Requirements Eligibility Primarily for practicing physicians, but residents also allowed Types of health professionals eligible Currently only two physician specialties included � primary care and general psychiatrists Requirements Only non-profits Federal funds for practice in a designated Health Professional Shortage Area only General funds may be used to fund state-only awards in state designated shortage areas

10. Is LARP effective at recruiting and retaining providers? Each year there are more applicants than funding One national study found that physicians serving obligations to state programs served in needier areas and remained longer in their practices (Pathman, Konrad, King, Taylor, and Koch, 2004) Another study found that 48 percent of students would be more likely to return to their home states if expanded loan repayment programs were available (Miller and Crittenden, 2001) In Maryland, of 24 providers who completed service between 2004 and 2006, 22 are still practicing

11. Workforce Programs Within OHPP J-1 Visa Waiver Program J-1 visa requires physicians with foreign nationalities to return to their home country for two years at the end of their medical training. The waiver is granted in exchange for the physician�s work in an underserved area for three years National Health Service Corp. Reviews sites� eligibility per federal criteria Recommendations to NHSC of eligible sites for placement of eligible health professionals, but final decision is made by the federal government � HRSA in DHHS J-1 Visa Waiver Program addl notes The PCO reviews applications and makes recommendations to the U.S. Department of State 30 J-1 Visa Waivers are allotted per federal fiscal year (Oct. 1st - Sept. 30th). National Health Service Corp addl. Notes J-1 Visa Waiver Program addl notes The PCO reviews applications and makes recommendations to the U.S. Department of State 30 J-1 Visa Waivers are allotted per federal fiscal year (Oct. 1st - Sept. 30th). National Health Service Corp addl. Notes

12. Maryland Rural Health Plan

13. Plan Goals Raise awareness of rural health issues and strategies to address these issues (Vision) Assess the health status of Maryland�s rural residents relative to non-rural residents (health indicators for rural areas) Set forth an agenda to build state consensus on the Plan to gain funding and resource support

14. Rural Health Priority Areas Access to primary and specialty care and pharmacy services (availability of workforce and affordability) Behavioral health (mental health and addiction/substance abuse) Lifestyle issues (nutrition, obesity, wellness) Oral health

15. Priority Recommendations 1. Increase efforts to improve recruitment and retention of rural health providers 2. Establish preventive health centers in rural areas, especially in those areas lacking or underserved by Federally Qualified Health Centers 3. Increase accessibility to pharmaceuticals for low-income rural residents

16. Rural Health Plan in Action Maryland Rural Health Association (MRHA) Listening Sessions - 7 Total October 2007 � 3 on the Eastern Shore December 2007 � 3 in Western Maryland April 2008 � Southern Maryland Disseminated results Rural Health Steering Committee had 5 Meetings in last 6 months Rural Health Implementation Plan (RHIP)

17. Listening Sessions Recruitment & retention of rural health providers Comprehensive Electronic Medical Records Provider reimbursement Telehealth reimbursement Increase and efficiency of Loan Repayment for Rural Providers Primary preventive health services

18. Maryland Rural Health Implementation Goals 1. Increase Recruitment and Retention of Rural Health Care Providers 2. Expand and Enhance telehealth to bring primary and specialty care to rural areas through technology 3. Provide preventive health education and resources in rural areas 4. Increased dental access to low income rural residents, especially the adult population 5. Establish preventive health centers in rural areas, especially those areas lacking or underserved by a Federally Qualified Health Center (FQHC)s 6. Improve healthcare access for the aging population through increased services in rural areas and training of health professionals 7. Increase access to Pharmaceuticals for low income rural residents 8. Support the development of a continuous, integrated systems of care for co-occurring disorders in rural communities 2 Rural Health Outreach Grants written on preventive health FQHC � MACHC/Kent County/SORH - worked to get a planning grant to start the community work that needs to be down to make that happen.2 Rural Health Outreach Grants written on preventive health FQHC � MACHC/Kent County/SORH - worked to get a planning grant to start the community work that needs to be down to make that happen.

19. Maryland Rural Health Plan, June 2007

20. Snapshot of Rural Health Listening Sessions � Workforce Issues

21. Implementation Framework Goal - ONE: Rural Recruitment and Retention Problem Objective Rationale Action Steps Estimated Costs Partners Relates To Evaluation of Success

22. Rural Health Implementation PlanGoal: Enhance Rural Recruitment and Retention Objectives 1.1 Increase funding and efficiency of Loan Assistance Repayment Program (LARP) 1.2 Increase Scholarships in Maryland health professional college and universities for rural residents who agree to practice in rural areas 1.3 Explore and promote the efficiency in portability of health care professional licensing between regional states 1.4 Expand health professional training and education in rural areas, through the use of new health programs and distance learning 1.5 Establish a coordinated Statewide Healthcare Workforce Center 1.6 Increase or supplement compensation packages for rural health providers including reimbursement package

23. Objective 1.1Increase funding and efficiency of Loan Assistance Repayment Program (LARP)  Increase state funding for LARP for at least 20 years of additional loan repayment through legislation, physician fees, or hospital surcharges to allow more flexibility with the use of funds and program staff. Assess the needs of rural Maryland workforce shortages and identify those areas that do not qualify for a federally designated shortage area but are in need of physicians. Restructure Maryland physician LARP program to allow more flexibility with state funds and repayment in rural areas designated as Maryland Health Professional Shortage Areas.

24. Objective 1.2Increase scholarships in Maryland health professional colleges and universities for rural residents who agree to practice rural areas. Assess the number of rural Maryland students attending Maryland Graduate Schools in health professional programs. Create a Rural Health Scholarship Program that includes administrative and fiscal support for Maryland students committed to practicing in rural areas after training.

25. Objective 1.3Explore and promote the efficiency in portability of health care professional licensing between regional states Establish partnerships with other regional states adjoining Maryland to specifically address the need to have more portable licenses. In coordination with neighboring states, identify the capacity of health professionals who practice in more the one state and serve rural populations.

26. Objective 1.4Expand health professional training and education in rural areas, through the use of new health programs and distance learning Assess professional schools that have expanded to serve rural areas and identify best practices and models for the potential to be replicated across the state. Explore opportunities to create new health professional programs in rural areas. Encourage and fund distance learning capabilities of health professional schools to expand scope training available for of students in rural areas. Encourage and fund distance learning capabilities of health professional schools to expand scope training available for of students in rural areas.

27. Objective 1.5Establish a coordinated Statewide Healthcare Workforce Center Build upon workforce shortage areas to determine specific healthcare shortages Develop a statewide healthcare workforce center with all agencies involvement to serve as hub for Healthcare workforce programs (including marketing of programs) AHECs Educate healthcare providers & employers regarding recruitment strategies

28. Objective 1.6Increase or supplement compensation packages for rural health providers including reimbursement package Increase state Medicaid payments to providers in designated health professional shortage areas similar to the CMS Medicare incentive payment Provide tax incentives to rural providers working within health professional shortage areas

29. Questions/Comments!

30. Contact Information Michelle Clark, MSW, MPH, Project Director, State Office of Rural Health, Office of Health Policy and Planning mclark@dhmh.state.md.us; 410-767-5121 Michele Pharr, MA, Health Policy Analyst, State Office of Rural Health, Office of Health Policy and Planning mpharr@dhmh.state.md.us; 410-767-3543 http://www.fha.state.md.us/ohpp/ruralhlth/

31. References Miller, JB and Crittenden, RA. (2001) �The effects of payback and loan repayment programs on medical student career plans.� Journal of Rural Health, 17(3): 160-164. Pathman, DE, Konrad, TR, Taylor, DH Jr., and Koch, GG. (2004) �Outcomes of states� scholarships, loan repayment, and related programs for physicians.� Medical Care, 42(6): 560-568.