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Primary care workload and staffing differences in VA urban and rural practices

Mohr DC, Stolzman KL, Osatuke K, Meterko MM, Nealon Seibert M. Primary care workload and staffing differences in VA urban and rural practices. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 6; Portland, ME.

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Objectives: The objective of the study was to compare panel size and staffing utilization for VA primary care practices located in urban or rural settings and by type of facility (e.g., medical hospital or community-based outpatient clinic (CBOC)). Effective workload management can lead to operating efficiency and improved quality of care. The ratio of support staff and use of non-physician providers are also factors that influence practice productivity. Past research has found rural Veterans to have lower health status, lower access to care, and higher disease burdens compared to Veterans in urban areas. Additionally, rural areas are more likely to experience increased demands by OEF/OIF Veterans. Thus, ensuring a sufficient workforce and manageable workload are important factors in addressing current and future demands. Methods: The study used data from the Primary Care Panel Management Module (PCMM) for Fiscal Year 2009. We averaged four quarters of data to obtain an annual score. We had 213 rural practices and 397 urban practices. The dataset contained 151 medical hospitals and 459 VA-staffed CBOCs. We conducted Student t-tests on measures of: observed panel size to unadjusted panel size capacity ratio (i.e., Monitor 1), the unadjusted panel size capacity to the adjusted panel size capacity ratio (i.e., Monitor 2), use of non-physician providers, and support staff per provider ratios. To normalize data, we removed outliers using the 1st and 99th percentile values. Results: Primary care practices in urban areas had higher values for workload monitor 1 (.887 vs. .859) and monitor 2 (.966 vs. .946). A greater percentages of practices in urban areas (47.4% vs. 35.7%) met the goal for being in the target range for this monitor 1 (.90 - 1.05). A greater percentage of urban practices used non-physician providers (79.9% vs. 65.3%). Rural practices had a higher support staff to provider ratio (2.61 vs. 2.31) and a greater percentage met the 1.8 support staff ratio goal (87.3% vs. 76.3%). We observed a consistent pattern of findings for urban and rural differences when restricting the analyses to practices with at least 3 full-time equivalent (FTE) providers (i.e., the average rural practice size) and when comparing practices located in CBOCs and practices located in medical hospitals. Implications: Both settings appeared to have available workload capacity, but rural practices had smaller workload ratios, which should help practices to meet patient demands. Patients not assigned to panels may influence the results. A smaller percentage of rural areas used non-physician providers, which could suggest difficulty in recruitment or skill-mix preferences. A higher support staff to provider ratio existed in rural areas. This pattern was consistent by facility type and practice size, suggesting urban or rural status as more important in explaining differences. Impacts: Rural practices had a lower workload ratio and had a higher support staff to provider ratio compared to urban practice. This may suggest rural areas may be better positioned to manage greater patient demand in the future, but recruitment/retention of staff to meet demand will continue to be an important challenge.

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