CLINICIAN RECRUITMENT AND SERVICE

Programs included in this section are:

• National Health Service Corps
• Nursing Education Loan Repayment and Scholarship Programs

NATIONAL HEALTH SERVICE CORPS

Notes:
^a The targeted field strength for FY 07 may differ from that shown in the NHSC waterfall table. Whereas the waterfall table is continually updated, the performance reporting guidelines do no permit changing a previously established target for the "reporting" year.
^b The FY 08 target differs from that shown in the FY 2008 Congressional Justification, as this is an updated estimate consistent with the NHSC waterfall table.
^c DNA = Data Not Available. Retention data was not available in FY 04 and FY 05 due to incomplete data collection. The program has reformatted the survey to reduce ambiguity.
^d The FY 09 target is lower than latest result reported (FY 06), reflecting an anticipated decrease in the number of new loan repayment contracts due to increased amendments to previously awarded contracts.

 INTRODUCTION

The statutory purpose of the National Health Service Corps (NHSC) is to eliminate "...health manpower shortages in health professional shortage areas," (Section 331(a)(1) of the Public Health Service Act [42 USC 254d]). The performance measures gauge the NHSC's contribution to the HRSA strategic goals of improving access to health care and improving the health care systems through the recruitment and retention of NHSC clinicians.

Most of these measures are dependent on the size of the Field Strength (4.I.C.2.). The larger the Field Strength, the greater number of people served, and the pool of clinicians who fulfill the service commitment to be potentially retained increases. Also, as the NHSC has been able to shift more funding to the NHSC Loan Repayment Program (LRP), the cost per patient encounter decreases. In managing performance, the NHSC uses these data to inform policy decisions regarding distribution of Recruitment Line funding between the Scholarship and Loan Repayment Programs. Another strategy used by the program is to target sites that need recruitment and retention technical assistance.

The dependence of many of the performance measures on the size of the Field Strength represents the major challenge for the NHSC: to increase, or at least maintain, a Field Strength that will enable the program to meet its targets while remaining within statutory and budgetary limits. To this end, the NHSC constantly evaluates its options regarding distribution of funds between the programs or limiting the size and/or duration of awards and contracts, always balancing the options against the attraction of the program to both clinicians and sites.

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective: Improve the distribution of health professionals in underserved areas.

4.I.C.1. Increase the number of individuals served through the placement and retention of NHSC clinicians.

The FY 01 baseline of individuals served is 4.44 million. The FY 06 estimate of 4.47 million exceeds the target by 9 percent, and is a function of an increased number of clinicians retained out of the increased number of loan repayers recruited in previous years. These encounters are adjusted for both type of site and by primary care, dental, and mental and behavioral health disciplines, and include patients seen by NHSC alumni in their first year post completion of the service commitment. The projected decreases through the FY 09 target of 3.39 million reflect the decreasing number of vacancies filled by new NHSC loan repayers as the number of loan repayment amendments is projected to increase, leading to the decline in the Field Strength described below.

 4.1. By 2010, increase the number of individuals served in all communities seeking NHSC assistance through NHSC placement, retention and other sources by 20%.
(Baseline - 5.9 M)

4.I.C.2. Increase the field strength of the National Health Service Corps through scholarship and loan repayment agreements.

In FY 06, NHSC Field Strength 4,109, which is 99 percent of the target. This decrease from the FY 05 level was anticipated, due to large numbers of loan repayers have fulfilled the service commitment and are no longer counted in the Field Strength. This trend is expected to continue through FY 09 for the reason noted in 4.I.C.1 above, at which point the number of new loan repayment contracts and amendments will achieve a balance, and the Field Strength will stabilize at the FY 09 target of 3,466.

4.I.C.4. Increase the percent of NHSC clinicians retained in service to the underserved.

Retention of NHSC clinicians preserves access to care for the underserved beyond the period of service commitment. The NHSC measures retention at one year after fulfillment of the service commitment. Retention data was not available in FY 04 and 05 due to incomplete data collection, resulting in too small a sample to be considered representative. For FY 06, the survey was revised to minimize ambiguities, and produced a retention percentage of 76 percent, which was 96 percent of the target. The target for FY 09 is 79 percent.

4.I.C.3. Increase the number of NHSC-list vacancies filled through all sources.

In FY 06, 2,662 vacancies were filled, which exceeded the target due to an increased number of vacancies filled by non-NHSC clinicians. Targets are based on the number of projected new loan repayment awards, plus the number of new scholars beginning service, plus the assumption that an equal number of non-NHSC clinicians will fill NHSC-listed vacancies. Because of a shift in the proportion of recruitment line budget to LRP in FY 03, an unusually large number of new LRP awards were made that year, providing a high baseline. The rise and fall in the target numbers from FY 05 through FY 09 reflect the cyclical nature of the NHSC Loan Repayment Program: as the number of loan repayment amendments increases, the number of new contracts falls, resulting in fewer total vacancies filled from all sources. The target for FY 09 is 2,200.

4.I.C.5. Increase the average HPSA score of the sites receiving NHSC clinicians, as a proxy for service to communities of greatest need.

The HPSA score is a proxy measure for the degree of need for health professionals in an area. Scores range from 1 to 25, with 25 representing the greatest need. Increasing the average HPSA score of site vacancies filled through NHSC assistance indicates success in targeting vacancies of greatest need. The FY 06 actual average score was 13.7, which exceeded the target by 5 percent. This is a function of the fact that the program did not award all qualified loan repayment applications in 2006: no loan repayment contracts were awarded to a clinician working at a facility with a HPSA score below 8, resulting in a higher average score. The FY 09 target is 13.6, while the long-term goal is to increase the average HPSA score to 14.2 by FY 10.
4.E. Maintain or decrease the average cost to the NHSC program of a patient encounter.

This average cost of patient encounter is the benchmark which the NHSC will track over time. The measure of management efficiency will be how well the Program can maintain or even lower this cost regardless of changes in annual appropriations and the resulting fluctuation of the Field Strength from year to year. Though the estimated cost of an encounter in FY 06 is 12 percent above the target, it still represents a 7.3 percent decline from the baseline. As the program continues to gather data to track this measure, future targets will be estimated more accurately. The FY 09 target is $4.15.

NURSING EDUCATION LOAN REPAYMENT AND SCHOLARSHIP PROGRAMS

Notes:
^a DNA = Data not available. Data were not collected for FY 05.
^b DNA = Data not available. Data were not collected for FY 06
^c Recalculation of the FY 05 data for 5.I.C.3 showed that the actual result was 86% and not 92% as previously reported.
^d This replaces 40% estimate provided previously, based on a survey of NELRP participants who completed service. This led to the revision of targets for FY 06 and FY 07.

INTRODUCTION

The Nurse Education Loan Repayment Program (NELRP) and the Nursing Scholarship Program (NSP) are authorized under Section 846 of the Public Health Service Act [42 USC 297n] to work in partnership with other HHS programs to encourage more people to consider nursing careers and motivate them to serve in areas of critical shortage. The performance measures gauge these programs' contribution to the HRSA strategic goals of improving access to health care and improving the health care systems through the recruitment and retention of nurses working in Critical Shortage Facilities.

The major challenge facing NELRP is that the pool of qualified nurses is shrinking. Since the implementation of the NSP, the large number of applications received by the program is evidence of increased interest in nursing careers, but in the short-run, enrollment increases are constrained by a shortage of nursing faculty. As one strategy to assure better targeting of program resources to areas and facilities of greatest need, the programs will test the methodology for identifying Critical Shortage Facilities for nurses.

The other major challenge for the programs is the current difficulty with data collection and analysis. The programs had been using a Nursing Information System which was deactivated in anticipation of another system being brought online. This has not yet occurred. Both NSP and NELRP will participate in the new information management system of the Bureau of Clinician Recruitment and Service, which is scheduled to be operational at the end of FY 08.

Long-Term Goal: Increase by 2010 the number of individuals enrolled in professional nursing education programs by 10% over the baseline.
(Baseline - 2002-2003: 240,500)

5.I.C.1. Increase the proportion of nursing scholarship recipients working in a facility with a critical shortage of nurses within 4 months of graduation.

The NSP is expected to attract more students into nursing education by providing financial support during the training years. Data is unavailable for this measure for FY 05 through 07 due to deactivation of the program's information management system as described above. The FY 09 target is 85%.

5.I.C.2. Increase the proportion of NELRP participants working in shortage facilities such as: Disproportionate Share Hospitals for Medicare and Medicaid; nursing homes, public health departments (State and local) and public health clinics contained in these departments.

Data for this measure is obtained by monitoring automated data on NELRP contracts. NELRP applicants working in shortage facilities, such as Disproportionate Share Hospitals for Medicare and Medicaid; nursing homes, public health departments (State and local) and public health clinics contained in these departments are in the first preference category for awards.
These data indicate the degree to which NELRP resources are being successfully targeted to facilities experiencing the most critical shortages of nurses. All available funds for initial awards were expended to nurses working in those facility types in FY 06. Data is not yet available for FY 07. The target for FY 09 is 90 percent.

5.I.C.4. Reduce Federal investment per year of direct support by increasing the proportion of program participants who extend their service contracts and commit to work at a critical shortage facility for an additional year.

NELRP initial contracts are for two years of service. This indicator will provide a measure of the degree to which registered nurses participating in NELRP are willing to serve in a critical shortage facility for at least one additional year. The target of 45% for FY 06 was met after the program modified its method of contacting participants regarding the third year amendment option. Data is not yet available for FY 07. The target for FY 09 is 45 percent.

5.I.C.3. Increase the percent of States in which NELRP contract recipients work.

Prior to FY 02, information about this program was not widely distributed and contract recipients were limited to a small number of States. Increased funding and marketing strategies in FY 02 resulted in broader distribution of contract awards in more States.

In FY 06 NELRP participants were working in 86 percent of the States, which was 93 percent of the target. Data for FY 07 are not available. Some fluctuation from year to year is expected because awards are based on financial need and type of facility rather than the State in which the recipient plans to work. The target for FY 09 is 93 percent.

5.E. Increase the proportion of NELRP participants who remain employed at a critical shortage facility for at least one year beyond the termination of their NELRP service.

This indicator will address the issue of retention by providing a measure of the degree to which trained nurses participating in NELRP are willing to serve in a critical shortage facility for at least one additional year beyond the termination of their NELRP service. The FY 04 result was an estimated 90 percent. Data were not collected in FY 05, and data for FY 06 and 07 are not yet available. The target for FY 09 is 50 percent.