SUCCESS FACTORS Impetus
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The impetus for all of the sites surveyed has been to provide primary care to populations with little or no access to health care professionals. The sites utilized teams of professionals to provide care, including physicians, nurse practitioners, physician assistants, nurse-midwives, dentists, dental technicians, and mental health providers. Many of the sites plan to further utilize this team approach at new or expanded sites.
Initial Site Development
Each of the sites interviewed for this report has taken a unique approach to site development based on the needs of the community, existing community groups, local providers and the political environment. In cases where community groups existed, efforts were consolidated and their work was incorporated into the site development process. Each site has utilized a Community Board to oversee different stages of the site development process. It is important to note that in some cases the center administrators may have begun the site-development process before the development or maturation of the Community Board.
Common elements in the site development process included:
- Organization and coordination of interested parties, whether they be health councils, community groups, local providers or community leaders;
- A detailed assessment of need, identifying priority areas and strategies for addressing the need; and
- Development of service delivery models and possible site locations.
Particularly during this phase, the administrators all felt that it was extremely important to work with the local providers and government officials. At a majority of the sites surveyed, hospitals and/or county officials were instrumental in providing buildings for the sites to use or share with other health care or social service providers.
In addition to working with hospitals, the administrators felt that it was important to inform local health care professionals of their intention to provide comprehensive community health to the underserved populations in the area. Most of the sites invited many of the existing providers to participate in their clinics. By clearly stating the purpose of the site and inviting providers to participate, the sites succeeded in diffusing resistance from members of the local medical establishment who felt they would be forced to compete for patients. In many cases, the dialogue resulted in local providers working full- or part-time for the sites or at least admitting the clinic's patients to the hospital through them.
There are, of course, some overriding principles that should be used to guide the site development process. According to the administrators interviewed, there were three general principles central to their success, as shown in the diagram above:
- Sites must be operated in a businesslike manner every step of the way;
- Always explore opportunities to integrate with local hospitals and nursing homes, nearby tertiary care centers, county social services and educational institutions; and
- Always be aware of the resources and technical assistance available through the Health Resources and Services Administration (HRSA), State/Regional Primary Care Associations, State Primary Care Organizations, Offices of Rural Health, and national primary care organizations, such as the National Association of Community Health Centers (NACHC) and the National Rural Health Association (NRHA) whether conducting a needs assessment, establishing clinic operations or recruiting professionals. Their Web addresses are:
Recruitment of Health Care Professionals
The majority of the site administrators interviewed conceded that much of their success with recruitment was due to luck and good timing. Nonetheless, it was evident that the administrators use some of the same guidelines in their recruitment efforts. The following strategies appear to contribute to recruitment success:
- Focus on professionals who are either originally from or currently residing in the general area or at least a similar area;
- Concentrate on seasoned or retired professionals, since they tend to be more certain about where they want to live and practice; and
- Target individuals who do not want to assume the financial responsibilities of a private practice.
As with any phase of site development, it is important to use all available resources, including those in your own community. For example, enlist the support of local hospitals, tourism boards and Chambers of Commerce to help prepare promotional packets and videos for recruitment fairs or interested parties. If you are recruiting through the NHSC program, the recruitment and retention application must be completed and approved. Once approved, the NHSC recruitment list will be distributed to the universe of providers interested in serving the underserved community. As previously noted in Chapter 1, the NHSC Recruitment and Retention Application can be downloaded from http://nhsc.bhpr.hrsa.gov/applications/rraa.cfm.
Onsite visits are costly and require extensive time commitment from many people. Therefore, it is important not to waste time and limited resources on individuals who may not match the community's needs. The administrators interviewed all agree that, once potential candidates have been identified, most of the screening should be done through telephone interviews. The recruitment committee or administration staff should conduct in-depth research of the family's needs in preparation for telephone interviews and onsite visits, including:
- spousal employment;
- educational needs; and
- special needs due to religious affiliation or background.
Once the list of candidates has been reduced to a few, based on the needs of the individual and the community, formal telephone interviews with both the candidate and his or her spouse should be conducted. The interviews should cover everything from salary and incentive plans to call coverage and medical care philosophy. Recruitment Committees, which have tended to play more of a role during onsite visits at the sites surveyed, ought to include various community representatives, including bankers, realtors, educators, and community leaders.
Ideally, the candidates should then be invited to visit the site. There is some NHSC financial assistance for site visits for scholarship recipients, but not for loan repayment candidates. The NHSC can only reimburse the scholarship recipients for site visits, not the sites. Further details regarding NHSC policy for provider travel can be obtained from the NHSC by calling (800) 221-9393.
Candidates should work at least one half-day with the medical director or appropriate health care professional during the site visit. The focus of the initial visit should be more a social experience for the family than anything else. Therefore, it is important to determine, during the telephone interviews, what is important to the family.
The administrators all stressed the significance of showing off the community without attempting to hide anything. In their experience, they have found that sometimes the things that might be seen as detractions are what attracts or motivates the candidate to practice in the community. Any attempt to be less than completely forthright about the community and your expectations of the candidate, clinical or administrative, will only create retention problems.
Retention of Health Care Professionals
Long term retention of quality health care professionals has always been difficult for sites providing primary care to underserved populations. Keep in mind that retention starts with the first contact. Retention probabilities are enhanced considerably if the site can proceed in recruiting professionals who are confident that they want to live and practice in areas with underserved populations, which explains the preference for recruiting seasoned professionals (as mentioned above).
Even though retention may be largely dependent upon selecting the right person, it is nevertheless extremely important to take measures to ensure the happiness of the professional's spouse and family. The administrators interviewed agree that even satisfied professionals will leave if their families do not enjoy living in the community. Therefore, it is important to make genuine efforts to weave both the spouse and the children into the social fabric of the community.
Equally important is the amount of flexibility given to professionals and the opportunity for input into the operation of the centers. Professionals should be given as much flexibility as possible in their call coverage, work schedule, and style of practice. It is good to remember that there is more than one way to do things; and that new practitioners will inevitably have their own style. Centers must be prepared to try things differently and take risks. The centers have experienced greater success, in many cases, when they have increased the practitioners' autonomy. A couple of the centers significantly increased the satisfaction of their professional staff by eliminating the overall medical director and creating individual clinic directors who meet monthly with a management team. An allowance for CME courses to update and enhance skills is also an important retention factor.
Administrators should look beyond periodic performance reviews by continually accepting input from the professional staff in both day-to-day operations and long-term planning. All professionals should play a significant role in Board Meetings and the design of new or expanded sites.
See Module 5 for a more complete discussion of Recruitment and Retention.
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