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Colorado Health Institute 1576 Sherman Street, Suite 300 Denver, Colorado 80203-1728 www.coloradohealthinstitute.org Data Chartpack Recruitment and retention.

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Presentation on theme: "Colorado Health Institute 1576 Sherman Street, Suite 300 Denver, Colorado 80203-1728 www.coloradohealthinstitute.org Data Chartpack Recruitment and retention."— Presentation transcript:

1 Colorado Health Institute 1576 Sherman Street, Suite 300 Denver, Colorado 80203-1728 www.coloradohealthinstitute.org Data Chartpack Recruitment and retention of Colorado’s primary care workforce: Rural/urban differences October 22, 2009 2 nd Colorado Health Professions Workforce Summit

2 Overview of CHI study Five areas of inquiry --  Workforce diversity  Educational pipelines  Aging of the workforce  Career ladders  Scopes of practice and collaborative models of care Three primary care health professionals reviewed --  Physicians  Nurses  Oral health providers (dentists and dental hygienists) 2

3 Study methods Synthesis of peer-reviewed literature and available Colorado data Literature review included abstract reviews and analyses of evidence-based studies Analysis of CHI health professions’ workforce surveys by age, geography, race/ethnicity and other relevant variables (2005-09 surveys) 3

4 PHYSICIANS 4

5 Physician diversity: What the literature says… E FFECTS ON ACCESS TO CARE Minority physicians are providing a disproportionate share of care to the underserved 1 – Minority status is a stronger predictor of service to the underserved than National Health Service Corp participation, socioeconomic background or growing up in underserved area 2 Lack of cultural sensitivity by health professionals is associated with reduced care-seeking by parents for their children 3 Diversity among medical school students is associated with higher levels of cultural sensitivity of all students and greater willingness to serve diverse populations 4 5

6 Physician diversity: What the literature says… E FFECT ON HEALTH OUTCOMES Language barriers between physicians and patients increase costs and potential for medical errors 5 Cultural competency/racial concordance are associated with higher patient satisfaction and levels of patient participation in their care 6 Lack of cultural understanding and awareness can lead to withholding information, noncompliance, delays in care and incorrect diagnoses 7 6

7 Physician diversity: What the literature says… E FFECTS ON PATIENT SATISFACTION Racial/ethnic identification with physician is associated with: – Improved satisfaction among minority patients 8 – Higher perceived quality of care 9, 10 – Higher levels of patient participation in their care 11 7

8 Physician diversity: A Colorado perspective 8 Race/ethnic background of licensed, active Colorado physicians SOURCE: United States Census: 2008 Population Estimates, Colorado Health Institute 2005 Physician Workforce Survey (Q2), 2009 Rural Physician Survey (Q10)

9 Physician diversity: A Colorado perspective 9 Payer mix by physician race/ethnicity, rural practice, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q10, Q27)

10 Physician diversity: A Colorado perspective 10 SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q10, Q29) Percent Responding “Interested” (4 or 5)

11 Physician pipeline: What the literature says… KEY FINDINGS The success of particular pipeline interventions such as pairing middle and high school students with mentors to increase students’ interest in the health professions varies depending on age of student 12 Pipeline programs and interventions can have an effect on physician supply 13 Selective admissions, institutional commitment, debt forgiveness and other efforts are effective in promoting rural practice and primary care specialties 14 11

12 Physician pipeline: What the literature says… F ACTORS ASSOCIATED WITH CHOOSING A RURAL PRACTICE Growing up rural 15 Selective admissions by medical school 16 Medical school focus on primary care and rural medicine 17 Financial incentives, such as NHSC funding 18 Medical school experiences, such as rural clinical rotations 19 12

13 Physician pipeline: What the literature says… FACTORS ASSOCIATED WITH CHOICE OF PRIMARY CARE PRACTICE Interest at time of admission to medical school 20 Selective admissions policies of medical school 21 Growing up rural 22 Having less medical school debt 23 School’s commitment to primary care practice 24 Being female 25 13

14 Physician pipeline: A Colorado perspective 14 Where physicians practicing in rural Colorado grew up and state conferring medical degree, 2009 Place where grew up Percent of rural physicians Urban18.0% Suburban42.4% Rural39.6% SOURCE : Colorado Health Institute 2009 Rural Physician Survey (Q32, Q9)

15 Physician pipeline: A Colorado perspective Two medical schools in Colorado (DO and MD) 132 MD graduates in 2008—UC Denver only; no graduates from Rocky Vista (DO) until 2012 Colorado family medicine residency graduates: – Of 172 family medicine residents in 2007-09, 114 remained in Colorado to practice – Approximately 87% of Colorado’s family medicine residents are from out of state 15 SOURCE : American Association of Medical Colleges Graduation Data, 2009, Correspondence – TonyPrado-Gutierrez, University of Colorado at Denver

16 Aging of the physician workforce: What the literature says… K EY FINDING Many retired physicians are interested in volunteering after retirement, but barriers include malpractice concerns, paperwork and bureaucracy 26 16

17 Aging of the physician workforce: A Colorado perspective 17 Percent age 55 and older Colorado’s workforce17.3% Non-rural physicians28.7% Rural physicians33.6% Proportion of physician workforce and overall Colorado workforce, age 55 and older, 2009 Proportion of rural Colorado primary care physicians by age group, 2009 Age 44 and younger45-54 yrs55-64 yrs65+ yrs Primary care*57.0%42.1%45.8%31.1% * Primary care includes family medicine, general pediatrics and internal medicine SOURCE : U.S. Census Bureau 2008 Workforce Estimates, Colorado Health Institute 2009 Rural Physician Survey (Q8, Q4), Peregrine Database April 2009

18 Aging of the physician workforce: A Colorado perspective 18 Physician practice Ages 44 and younger45-54 yrs55-64 yrs65+ yrs Proportion working part time12.8%15.0%24.5%51.4% Proportion volunteering, not billing0.4%0.0%1.4%7.5% Volunteerism and part-time practice among Colorado’s rural practicing physicians by age, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q2, Q8)

19 Collaborative care models: A Colorado perspective 19 % reporting staffing model that includes MLPs All rural practicing physicians35.6% Primary care rural practicing physicians45.8% Specialist rural practicing physicians26.0% Percent of rural physicians reporting mid-level providers (MLPs) in their practice, 2009 SOURCE: Colorado Health Institute 2009 Rural Physician Survey (Q17)

20 REGISTERED NURSES (RNs) and LICENSED PRACTICAL NURSES (LPNs) 20

21 Diversity in the nursing workforce: What the literature says… Literature does not include evidence-based studies on nursing diversity/cultural competence relative to patient outcomes and satisfaction Further research warranted to assess these relationships in the practice of nursing 21

22 Diversity in the nursing workforce: A Colorado perspective 22 Nurse by practice area% fluent in another language Non-rural practicing RNs12.3% Rural practicing RNs11.9% Non-rural practicing LPNs8.8% Rural practicing LPNs4.4% Fluency in language other than English used to communicate with patients, RNs (2008) and LPNs (2007) SOURCE: Colorado Health Institute 2008 Registered Nurse Survey (Q38), 2007 Licensed Practical Nurse Survey (Q34, Q34b)

23 Nursing pipeline: What the literature says… Non-competitive faculty salaries contribute to faculty shortages 27 A variety of approaches around the country have successfully improved nursing student enrollment: – Changing to year-round academic schedule and year-long faculty appointments at University of Nevada Las Vegas 28 – In Colorado, partnership between Poudre Valley Hospital and University of Northern Colorado 29 23

24 Nurse pipeline: A Colorado perspective 24 accredited 2-year associate degree in nursing (ADN) degree programs 11 accredited 4-year bachelor of science in nursing (BSN) degree programs 10 accredited licensed practical nurse (LPN) programs 15 accredited 2-year and one 4-year nursing programs with LPN exit option 24 SOURCE: Colorado State Board of Nursing

25 Nurse pipeline: A Colorado perspective Colorado nursing program graduates, 2007 25 ProgramApproximate total graduatesGraduates licensed LPN615544 ADN879717 BSN941847 Area where nurse grew up and was educated, active RNs (2008) and LPNs (2007) Percent trained in ColoradoPercent from rural area RNs – Non-rural46.1%31.9% RNs – Rural47.0%60.7% LPNs – Non-rural58.0%43.5% LPNs – Rural78.7%69.8% SOURCE: Colorado State Board of Nursing, Colorado Health Institute 2008 RN Survey (Q4, Q34), 2007 LPN Survey (Q1a, Q30)

26 Nursing pipeline: A Colorado perspective PIPELINE CAPACITY ISSUES Wait lists—3,579 qualified applicants not admitted due to lack of slots (2008-09) Faculty vacancies (2008) – 15% of associate degree in nursing (ADN) faculty positions – 8% of bachelor of science in nursing (BSN) faculty positions – 15% of licensed practical nurse (LPN) faculty positions – 11% of master of science in nursing (MSN) faculty positions – 17% of doctor of nursing practice (DNP) faculty positions – 76 FTE vacancies for clinical nurse instructors Reported barriers to program expansion include faculty shortages, securing clinical placements, lack of funds, noncompetitive salaries for faculty 26 SOURCE: Colorado Health Institute 2008/2009 Nursing Faculty Studies

27 Aging of the nurse workforce: What the literature says… Incentives such as improved benefits, flexible schedules, ergonomic improvements in the work environment and institutional support/recognition can influence older nurses to delay retirement 30 Turnover highly expensive both monetarily and in terms of loss of expertise 31 No single retention strategy works across all settings, multiple factors involved 32 27

28 Aging of the nursing workforce: A Colorado perspective 28 % 55 and older RNs in a non-rural practice27.4% RNs in a rural practice31.9% LPNs in a non-rural practice20.4% LPNs in a rural practice32.1% Proportion of RN (2008) and LPN (2007) workforce age 55 and older SOURCE: Colorado Health Institute 2008 RN Survey (Q36, Q17), 2007 LPN Survey (Q19, Q31)

29 Aging of the nursing workforce: A Colorado perspective OF NURSES PLANNING TO LEAVE THE WORKFORCE: 14% of non-rural and 10% of rural RNs ages 55 and older reported planning to leave their primary nursing position in next 12 months (2008) – Highest reported reasons included insufficient wages, too much stress, insufficient benefits, lack of respect and retirement 15% of non-rural and 25% of rural LPNs ages 55 and older planned to leave their primary nursing position in next 12 months (2007) – Highest reported reasons included too much stress, insufficient wages, retirement, workplace safety issues, and not feeling respected 29 SOURCE: Colorado Health Institute 2008 RN Survey (Q29, Q30, Q36), 2007 LPN Survey (Q25, Q36, Q31)

30 Nurse scope of practice/models of care: What the literature says… Nurse practitioners (NPs) deliver comparable quality of care to physicians within the scope of their practice Patients report greater satisfaction with NPs and certified nurse midwives (CNMs) than with physicians in specific care settings NPs and CNMs are more likely to work in an underserved area and/or with an underserved population 30 SOURCE: Colorado Health Institute, Collaborative Scopes of Care Study, 2009

31 Nurse scope of practice/collaborative models of care: A Colorado perspective More than 80% of RNs agreed that their relationship with physicians was good (2008) Most nurses (74% non-rural and 77% rural) agreed that they participated in decisions related to their patients’ care Approximately 2,322 practicing nurse practitioners in Colorado* 31 SOURCE: Colorado Health Institute 2008 RN Survey (Q23), Colorado Department of Regulatory Agencies * The American Academy of Nurse Practitioners estimates that 90% of registered NPs are practicing in the field; Colorado had 2,580 actively licensed nurse practitioners as of January 5, 2009.

32 Career ladders in nursing: What the literature says… Robust career ladder opportunities are associated with increased productivity and satisfaction among nurses 33 Two general types of career ladders 34 – Clinical ladder achieved through on-the-job performance and clinical evaluation – Educational ladder based on obtaining higher degrees 32

33 Career ladders in nursing: A Colorado perspective 33 Highest degree Non-rural RNs Rural RNs Associate degree in nursing24.5%37.1% Bachelor of science in nursing46.9%35.4% Master of nursing degree13.8%11.0% Non-nursing doctorate0.3%1.4% Nursing-related doctorate1.5%0.7% Highest degree earned by practice location, active RNs, 2008 SOURCE: Colorado Health Institute 2008 RN Survey (Q1, Q2, Q7)

34 Career ladders in nursing: A Colorado perspective Pursuit of additional education: – More non-rural than rural nurses reported having returned to school for an additional degree – Greater proportion of nurses with bachelor’s degrees in nursing (BSNs) returned to school for additional nursing degrees RNs whose first degree was an associate degree in nursing (ADN) began and ended their education later than BSN graduates 34 SOURCE: Colorado Health Institute 2008 RN Survey (Q2, Q7)

35 Career ladders in nursing: A Colorado perspective Type of facility where first employed – More older, non-rural LPNs began work in hospitals – More younger, non-rural LPNs began work in nursing homes, clinics or physician offices Pursuit of additional education – 15% of non-rural and 18% of rural LPNs reported currently being enrolled in an RN program – 36% of non-rural and 43% of rural LPNs reported plans to pursue an RN education 35 SOURCE: Colorado Health Institute 2007 LPN Survey (Q7, Q7a, Q10, Q11, Q31)

36 DENTISTS AND DENTAL HYGIENISTS 36

37 Diversity among oral health professionals: What the literature says… 37 Racial/ethnic minority dentists more likely to care for underserved patients 35 Lack of cultural understanding by dentists associated with barriers to care-seeking for Medicaid-enrolled children 36 Available literature did not address diversity in the dental hygiene workforce

38 Oral health professionals and diversity: A Colorado perspective 38 SOURCE: U.S. Census Bureau 2008 population estimates, Colorado Health Institute 2008 Rural Dentist Survey, 2006 Dental Hygienist Survey

39 Diversity among oral health professionals: A Colorado perspective 39 Language other than English Rural dentists27.5% Dental hygienists (urban/suburban)6.4% Dental hygienists (rural)5.9% Language proficiency among dental hygienists (2006) and rural dentists (2008) SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

40 Diversity among oral health professionals: A Colorado perspective 27.5% of rural dentists indicate they speak a language other than English to communicate with some or all patients 6.4% of urban/suburban and 5.9% of rural dental hygienists report being fluent in a language other than English 40 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q23), 2006 Dental Hygienist Survey (QC3)

41 Diversity among rural oral health professionals: A Colorado perspective Minority rural dentists report spending greater proportion of time in direct patient care with children and older adults Payment sources – More minority rural dentists offer a sliding-fee schedule than White rural dentists – More minority rural dentists report accepting Medicaid payment, new Medicaid patients, Child Health Plan Plus (CHP+) payment and new CHP+ patients Non-White dental hygienists report twice as many volunteer hours as White dental hygienists More non-White dental hygienists report that their primary worksite provides care to Medicaid patients, accepts new Medicaid patients and provides care on a sliding-fee schedule 41 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q3, Q20, Q22), 2006 Dental Hygienist Survey (QB3b, QC5, QB16, QB16a)

42 Dentist pipeline: What the literature says… Perceived barriers to dental students’ practicing in underserved areas/populations include lack of information about practice opportunities, student debt and lack of access to patient populations in dental school 37 Untested effectiveness of dental pipeline interventions to promote service to underserved populations 38 Secondary school interventions and select characteristics of dental school admissions and curriculum known to promote dental graduates practice with underserved populations 39 42

43 Dentist pipeline: A Colorado perspective 43 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q24, Q32)

44 Dentist pipeline: A Colorado perspective 44 Factor% indicating “Yes” Quality of life95.1% Good place to raise children90.0% Recreational/leisure activities87.2% Slower pace of life86.2% Personal/family reasons57.9% Opportunity to be involved in community57.5% Good schools51.9% Smaller practice48.8% Grew up in a rural area43.1% Took over established practice42.5% Other reason32.5% Factors important in the decision to practice in a rural community, 2008 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q12)

45 Dental hygienist pipeline: A Colorado perspective 45 Trained in COGrew up in COGrew up in rural area Non-rural dental hygienists44.9%38.2%30.3% Rural dental hygienists47.6%36.8%48.4% Dental hygienist background by work location, 2006 Associate degree in dental hygiene Bachelor’s degree in dental hygiene Non-rural dental hygienists61.3%34.7% Rural dental hygienists73.8%20.7% Type of dental hygiene degree of dental hygienists by work location, 2006 SOURCE: Colorado Health Institute 2007 Dental Hygienist Survey (QA1, QC1, QC2, QB5, QA2)

46 Aging of the oral health workforce: A Colorado perspective 41% of rural dentists are age 55 and older Greater proportion of older rural dentists support the independent dental hygienist practice 13% of rural dental hygienists are age 55 and older 46 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q1, Q34), 2007 Dental Hygienist Survey (QC7, QC1)

47 Oral health scopes of practice: What the literature says… Peer-reviewed studies indicate that dental hygienists provide equal or better quality of care within scope of practice Vast majority of dental hygienist patients are satisfied with care 47 SOURCE: Colorado Health Institute, Collaborative Scopes of Care Report, 2009

48 Oral health scopes of practice/collaborative models of care: A Colorado perspective 51% of rural dentists indicate they collaborate with physicians/nurses in the community 72.8% work with at least one dental hygienist 25% indicate support for expanding the role of dental hygienists as independent practitioners 3% of dental hygienists statewide report working in independent practice 48 SOURCE: Colorado Health Institute 2008 Rural Dentist Survey (Q17, Q33, Q34), 2007 Dental Hygienist Survey (QB6)

49 Dental hygienist career ladders: What the literature says… A 2008 study found that a greater proportion of dental hygienists who begin their dental hygiene career with a bachelor’s degree – Have or are seeking a master’s degree – Are in faculty positions or other teaching positions – Are involved in research 40 49

50 Dental hygienist career ladders: A Colorado perspective 50 Degree Highest degree Percent Non-rural highest degree Percent Rural highest degree Associate 53.8%52.5%62.0% Bachelor’s 39.4%40.8%30.9% Master’s 3.8%4.0%2.8% Doctorate 0.2% 0.5% Highest degree (dental hygiene or other) obtained by working dental hygienists, 2006 Percent indicating “Yes” Non-rural dental hygienists18.7% Rural dental hygienists28.5% Dental hygienists intending to pursue another degree/certification, 2006 SOURCE: Colorado Health Institute 2008 Dental Hygienist Survey (QB5, QA2, QA4)

51 References Slide 5 1.Komaromy, et al. (1996); Institute of Medicine; Rabinowitz, Diamond, Veloski and Gayle (2000); Edmunds (2006); Brotherton, Stoddard and Tang (2000); Davidson and Montoya (1987); Saha and Shipman (2008); Cohen, Gabriel and Terrell. (2002); Smith, Ester and Inglehart (2006). 2.Saha and Shipman (2008); Rabinowitz, Diamond, Veloski and Gayle (2000). 3.Lassetter and Baldwin (2004); Kelly, Binkley, Neace and Gale (2005). 4.Institute of Medicine (2004); Saha, Guiton, Wimmers and Wilkerson (2008). Slide 6 5.Brotanek, Seeley and Flores (2008); Lassetter and Baldwin (2004). 6.Lieu, et al. (2004); Cooper-Patrick, et al. (1999); Berger (2008); Institute of Medicine (2003). 7.Institute of Medicine (2003); Berger (2008); Lassetter and Baldwin (2004). Slide 7 8.Cooper-Patrick, et al. (1999). 9.Institute of Medicine (2003). 10.Berger (2008); Institute of Medicine (2003). 11.Halbert, Armstrong, Gandy and Shaker (2006); Cooper-Patrick, et al. (1999). Slide 11 12.Cooney, Kosoko-Lasaki, Slattery and Wilson (2006). 13.Hsueh, Wilkinson and Bills. (2004); Ko, et al. (2005). 14.Hsueh, Wilkinson and Bills. (2004); Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice (1996); Senf, Campos- Outcalt, Watkins, Bastacky and Killian (1997). 51

52 References (cont.) Slide 12 15.Ward, Kamien and Lopez (2004); Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Hsueh, Wilkinson and Bills (2004); Easterbrook, et al. (1999); Curran and Rourke (2004); Henry, Edwards and Crotty (2009). 16.Hsueh, Wilkinson and Bills (2004). 17.Hsueh, Wilkinson and Bills (2004); Curran and Rourke (2004). 18.Bärnighausen and Bloom (2009). 19.Rhyne, Daniels, Skipper, Sanders and VanLett (2006); Curran and Rourke (2004); Henry, Edwards and Crotty (2009). Slide 13 20.Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Owen, Hayden and Connors (2002); Kassebaum, Szenas and Schuchert (1996); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997). 21.Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997). 22.Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997); Kassebaum, Szenas and Schuchert (1996). 23.Rosenblatt and Andrilla (2005); Colquitt, Zeh, Killian and Cultice (1996). 24.Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997). 25.Owen, Hayden and Connors (2002); Kassebaum, Szenas and Schuchert (1996); Ward, Kamien and Lopez (2004); Rosenblatt and Andrilla (2005); Burack, Irby, Carline, Ambrozy, Ellsbury and Stritter (1997); Senf, Campos-Outcalt, Watkins, Bastacky and Killian (1997). Slide 16 26.Sloane, Cohen, Konrad, Williams, Schumacher and Zimmerman (2008). Slide 23 27.Allan and Aldebron (2008); Yucha and Witt (2009). 28.Yucha and Witt (2009). 29.DeYoung, Bliss and Tracy (2002). 52

53 References (cont.) Slide 27 30.Robert Wood Johnson Foundation (2006); Cyr (2005); Blakeley and Ribeiro (2008). 31.Robert Wood Johnson Foundation (2006). 32.Robert Wood Johnson Foundation (2006). Slide 32 33.Nelson and Cook (2008); Goodrich and Ward (2004). 34.Nelson & Cook (2008). Slide 37 35.Butters and Winter (2002); Mofidi, Konrad, Porterfield, Niska and Wells (2002); Okunseri, Bajorunaite, Abena, Self, Iacopino and Flores (2008). 36.Kelly, Binkley, Neace and Gale (2005). Slide 41 37.Davidson, Nakazono, Carreon, Bai and Afifi (2009). 38.Davidson, Nakazono, Carreon, Bai and Afifi (2009). 39.Davidson, Nakazono, Carreon, Bai and Afifi (2009). Slide 48 40.Rowe, Massoumi, Hyde and Weintraub (2008). 53

54 Works cited Allan, JD and J Aldebron. "A systematic assessment of strategies to address the nursing faculty shortage, U.S." Nursing Outlook, 2008: 286- 297. Bärnighausen, T and DE Bloom. "Financial incentives for return of service in underserved areas: a systematic review." BMC Health Services Research, 2009: 86-103. Berger, JT. "The Influence of Physicians' Demographic Characteristics and Their Patients' Demographic Characteristics on Physician Practice: Implications for Education and Research." Academic Medicine, 2008: 100-105. Blakeley, JA., and VES Ribeiro. "Early retirement among Registered Nurses: contributing factors." Journal of Nursing Management, 2008: 29-37. Brotanek, JM, CE Seeley and G Flores. "The Importance of Cultural Competency in General Pediatrics." Current Opinion in Pediatrics, 2008: 711-718. Brotherton, SE, JJ Stoddard and SS Tang. "Minority and Nonminority Pediatricians' Care of Minority and Poor Children." Archives of Pediatric and Adolescent Medicine, 2000: 912-917. Burack, JH, DM Irby, JD. Carline, DM Ambrozy, KE Ellsbury and FT Stritter. "A Study of Medical Students' Specialty-choice Pathways: Trying on Possible Selves." Academic Medicine, 1997: 534-541. Butters, JM and PA Winter. "Professional Motivation and Career Plan Differences Between African-American and Caucasian Dental Students: Implications for Improving Workforce Diversity." Journal of the National Medical Association, 2002: 492-504. Cohen, JJ, BA Gabriel, and C Terrell. "The Case For Diversity In The Health Care Workforce." Health Affairs, 2002: 90-102. Colquitt, WL., MC Zeh, CD Killian and JM. Cultice. "Effect of Debt on U.S. Medical School Graduates' Preferences for Family Medicine, General Internal Medicine, and General Pediatrics." Academic Medicine, 1996: 400-411. Cooney, R, O Kosoko-Lasaki, B Slattery and MR Wilson. "Proximal Versus Distal Influences on Underrepresented Minority Students Pursuing Health Professional Careers." Journal of the National Medical Association, 2006: 1471-1475. Cooper-Patrick, L et al. "Race, Gender, and Partnership in the Patient-Physician Relationship." Jornal of the American Medical Association, 1999: 583-589. Curran, V and J Rourke. "The role of medical education in the recruitment and retention of rural physicians." Medical Teacher, 2004: 265- 272. 54

55 Works cited (cont.) Cyr, JP. "Retaining Older Hospital Nurses and Delaying Their Retirement." Journal of Nursing Administration, 2005: 563-567. Davidson, PL., TT Nakazono, DC Carreon, J Bai, and A Afifi. "Practice Plans of Dental School Graduating Seniors: Effects of the Pipeline Program." Journal of Dental Education, 2009: S283-S296. Davidson, RC and R Montoya. "The Distribution of Services to the Underserved: A Comparison of Minority and Majority Medical Graduates in California." Western Journal of Medicine, 1987: 114-117. DeYoung, SJ Bliss and JP Tracy. "The Nursing Faculty Shortage: Is There Hope?" Journal of Professional Nursing, 2002: 313-319. Easterbrook, M, et al. "Rural background and clinical rural rotations during medical training: effect on practice location." Canadian Medical Association Journal, 1999: 1159-1163. Edmunds, RK. "Increasing Access to Care with Diversity." Journal of Dental Education, 2006: 918-920. Goodrich, CA. and CW Ward. "Evaluation and Revision of a Clinical Advancement Program." MEDSURG Nursing, 2004: 391-398. Halbert, CH, K Armstrong, OH Gandy and L Shaker. "Racial Differences in Trust in Health Care Providers." Archives of Internal Medicine, 2006: 896-901. Henry, JA, BJ Edwards and B Crotty. "Why do medical graduates choose rural careers?" Rural and Remote Health, 2009: 9:1083 (Online). Hsueh, W, T Wilkinson and J Bills. "What evidence-based undergraduate interventions promote rural health?" The New Zealand Medical Journal, 2004: Online: http://www.nzma.org.nz/journal/117-1204/1117/. Institute of Medicine. Balancing the Scales of Opportunity: Ensuring Racial and Ethnic Diversity in the Health Professions. National Academies Press, 1994. —. In the Nation's Compelling Interest: Ensuring Diversity in the Health Care Workforce. National Academies Press, 2004. —. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, 2003. Kassebaum, DG, PL Szenas, and MK Schuchert. "Determinants of the Generalist Career Intentions of 1995 Graduating Medical Students." Academic Medicine, 1996: 197-209. 55

56 Works cited (cont.) Kelly, SE, CJ Binkley, WP Neace, and BS Gale. "Barriers to Care-Seeking for Children's Oral Health Among Low-Incom Caregivers." American Journal of Public Health 95, no. 8 (2005): 1345-1351. Ko, M, et al. "Impact of the University of California, Los Angeles/Charles R. Drew Medical Education Program on Medical Students' Intentions to Practice in Underserved Areas." Academic Medicine, 2005: 803-808. Komaromy, M., et al. "The role of black and Hispanic physicians in providing health care for underserved populations." New England Journal of Medicine, 1996: 1519-1525. Lassetter, JH and JH Baldwin. "Health Care Barriers for Latino Children and the Provision of Culturally Competent Care." Journal of Pediatric Nursing, 2004: 184-192. Lieu, TA., et al. "Cultural Competence Policies and Other Predictors of Asthma Care Quality for Medicaid-Insured Children." Pediatrics, 2004: e102-e110. Mofidi, M., TR Konrad, DS Porterfield, R Niska and B Wells. "Provision of care to the underserved populations by National Health Service Corps alumni dentists." Journal of Public Health Dentistry, 2002: 102-108. Nelson, JM and PF Cook. "Evaluation of a Career Ladder Program in an Ambulatory Care Environment." Nursing Economics, 2008: 353-360. Okunseri, CR Bajorunaite, A Abena, K Self, AM. Iacopino and G Flores. "Racial/Ethnic Disparities in the Acceptance of Medicaid Patients in Dental Practices." Journal of Public Health Dentistry, 2008: 149-153. Owen, JA., GF Hayden and AF Connors. "Can Medical School Admission Committee Members Predict Which Applicants Will Choose Primary Care Careers?" Academic Medicine, 2002: 344-349. Rabinowitz, HK, JJ Diamond, JJ Veloski and JA Gayle. "The Impact of Multiple Predictors on Generalist Physicians' Care of Underserved Populations." American Journal of Public Health, 2000: 1225-1228. Rhyne, RL, ZM Daniels, BJ. Skipper, ML Sanders and BJ VanLett. "Interdisciplinary health education and career choice in rural and underserved areas." Medical Education, 2006: 504-513. 56

57 Works cited (cont.) Robert Wood Johnson Foundation. "Wisdom at Work: The Importance of the Older and Experienced Nurse in the Workplace." 2006. Rosenblatt, RA, C Holly and A Andrilla. "The Impact of U.S. Medical Students' Debt on Their Choice of Primary Care Careers: An Analysis of Data from the 2002 Medical School Graduation Questionnaire." Academic Medicine, 2005: 815-819. Rowe, DJ, N Massoumi, S Hyde and JA Weintraub. "Educational and Career Pathways of Dental Hygienists: Comparing Graduates of Associate and Baccalaureate Degree Programs." Journal of Dental Education, 2008: 397-407. Saha, S and SA Shipman. "Race-Neutral Versus Race-Conscious Workforce Policy To Improve Access To Care." Health Affairs, 2008: 234-245. Saha, S, G Guiton, PF Wimmers and L Wilkerson. "Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in US Medical Schools." Journal of the American Medical Association, 2008: 1135-1145. Senf, JH, D Campos-Outcalt, AJ Watkins, S Bastacky and C Killian. "A Systematic Analysis of How Medical School Characteristics Relate to Graduates' Choices of Primary Care Specialties." Academic Medicine, 1997: 524-533. Sloane, PD, LW Cohen, TR Konrad, CS Williams, JG Schumacher and S Zimmerman. "Brief Communication: Physician Interest in Volunteer Service during Retirement." Annals of Internal Medicine, 2008: 317-322. Smith, CS. TV Ester and MR Inglehart. "Dental Education and Care for Underserved Patients: An Analysis of Students' Intentions and Alumni Behavior." Journal of Dental Education, 2006: 398-408. Ward, AM, M Kamien and DG Lopez. "Medical career choice and practice location: early factors predicting course completion, career choice and practice location." Medical Education, 2004: 239-248. Yucha, CB and R Witt. "Leveraging Higher Salaries for Nursing Faculty." Journal of Professional Nursing, 2009: 151-155. 57


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