Current Projects

Learn more about our ongoing projects here.

Rural-urban differences within primary care scope of practice

Investigators: Ryan Kandrack, PhD(cand), Erin Fraher, PhD, Mark Holmes, PhD

There is some evidence that primary care physicians in rural areas respond to the limited local supply of specialists by offering a broader array of clinical services than their urban colleagues. These studies suggest that there is “plasticity” in the scope of services provided by physicians. Plasticity describes the dynamic and real world nature of scope of practice; physicians within the same specialty may provide different types of services depending on their demographic characteristics and training, the density of other physicians who provide overlapping services in their local area, the needs of their local patient population, and their personal preferences.  Previous studies have described primary care physicians’ plasticity between rural and urban locations but little work has been done investigating the factors that affect plasticity within primary care specialties.  The goal of this project is to investigate how the breadth and volume of primary care services varies within family medicine and general internal medicine between rural and urban areas.

Office-based Opioid Treatment: The Workforce to Treat Opioid Use Disorder

Investigators:  Lisa Zerden, PhD, Erica Richman, PhD, MSW, Brianna Lombardi, MSW

The number of opioid-related deaths has more than quadrupled since 1999  and an estimated 116 people die every day from opioid overdose. A treatment approach that has gained significant momentum to address the opioid crisis is medication-assisted treatment (MAT), sometimes referred to as office-based opioid treatment (OBOT), which includes a combination of medication (i.e., Buprenorphine) and behavioral therapy. Since the Drug Treatment Act of 2000, MAT has expanded to primary care where OBOT is delivered by interprofessional teams, led by a physician who has obtained a required Drug Enforcement Administration (DEA) Waiver.  While OBOT teams are required to have a medical provider with a Drug Enforcement Administration waiver, the mix of professionals necessary to provide OBOT, including the psychosocial components of care, is not well defined. This project will investigate:

  1.  Who is the workforce involved in providing MAT in primary care settings
    •  What are the skill-mix configurations commonly found to be successful for implementing MAT in primary care?
  2.  What are the psychosocial components of MAT provided in primary care settings?
    •  Who are the workforce professionals that provide the psychosocial components of MAT in primary care?

Using Electronic Health Records to Determine Which Health Professionals are Addressing Social Determinants of Health (SDoH)

        Investigators: Erica Richman, PhD, MSW; Lisa Zerden, PhD; Brianna Lombardi, MSW

Increasing evidence about the effect that SDOH have on health outcomes has prompted health systems to implement strategies to screen for and address patient SDOH. As the National Academies of Sciences pointed out recently, countries that commit a higher proportion of spending to social services compared to healthcare have better population health outcomes. Healthcare systems, however, struggle to understand how best to screen, document, and intervene for SDOH especially in clinical settings. Little is known about the skill mix of health professionals involved in, or necessary for, successfully screening and addressing SDOH. Electronic health records (EHR) represent a potentially valuable data source for tracking not only when and how SDOH are screened for and addressed, but which providers are involved in the process.

This feasibility study will explore the mix of professionals documenting patient SDOH in the EHR, to address the following specific questions:

  1. Which health professionals screen for patient social determinants of health in the EHR?
  2. Which health professionals act to address patient social determinants of health in the EHR?
  3. What actions regarding patient social determinants of health are documented in the EHR?

Social Work and Electronic Health Records: A New Frontier for Health Workforce Research

Investigators: Erica Richman, PhD, MSW, Lisa Zerden, PhD, Brianna Lombardi, MSW

The purpose of this study is to explore the feasibility of extracting information from electronic health records (EHRs) on social work (SW) encounters with Medicaid patients. Using mixed methods, the study will develop a data extraction protocol for describing the content, practice, and employment setting of social workers with Medicaid patients ages 40-65, who because of their social determinants of health, are at high risk for hospital readmission.

Developing a GME Policy Toolkit that States Can Use to Evaluate Return on Investment for Public Funds Invested in Training

        Investigators: Erin Fraher, PhD, MPP; Tom Ricketts, PhD, MPH; Ryan Kandrack, PhD(cand)

This study will develop and refine a methodology that states can use to evaluate the return on investment for public funds spent on Graduate Medical Education (GME). Armed with data about the outcomes of GME funds invested—in terms of yield of physicians in needed specialties and geographies–states can make more informed decisions about where to target future GME funds to produce the physician workforce needed to meet population health needs and ensure value for their investment.

Descriptive analysis of the IQVIA OneKey database

Investigators: Ryan Kandrack PhD(cand); Erin Fraher, PhD

In this study, we will explore the IQVIA OneKey nursing, physician assistant, dentist, and Accountable Care Organization files in order to: document what’s in the files, how many of each profession are included (and compare to national estimates from established sources), understand exactly what each variable is/how it was derived, and identify the types of analyses the OneKey data would be well-suited for compared to other workforce datasets. Such an analysis will serve as a resource for future health workforce research.

Experience of Physician Assistants and Nurse Practitioners in Onboarding Programs

Investigators:  Perri Morgan, PA-C, PhD; Mara Sanchez, PA-C; Lorraine Anglin, PA-C, Chris Everett, PA-C, PhD

Newly graduated nurse practitioners (NPs) and physician assistants (PAs) face challenges in adapting to their first jobs, including stressful patient loads and inadequate support. Because of this, some organizations are instituting formal onboarding programs to support PAs and NPs as they transition from students to practicing clinicians. Community health centers (CHCs) increasingly rely on NPs and PAs.  Transition to practice might be especially difficult at CHCs because the patient population faces greater social and economic challenges.

This project will summarize interviews with PAs and NPs who experienced an onboarding program about their experience. Suggestions for improvement will be included.  We will:

  1. Describe the structure and content of onboarding programs that NPs and PAs experienced in CHCs and other primary care settings, and
  2. Identify strengths and areas for improvement in existing primary care onboarding programs.

Understanding Registered Nurse Turnover in the U.S.

Investigators:  Cheryl B. Jones, PhD, RN; George Knafl, PhD; Meriel McCollum, BSN, RN, PhD student

While healthcare has changed dramatically over the past decade, the turnover of registered nurses (RNs) remains a recurring challenge. Prior research indicates that nurse turnover is costly, creates an unstable workforce, and affects patient outcomes. Despite this evidence, we know very little about current RN turnover in the U.S., how it varies between different types of health care settings, or among RNs of different backgrounds.

In this study, we will use data collected through the National Sample Survey of Registered Nurses 2018 (NSSRN) to examine nurse turnover (job or employer change) behaviors as a function of sociodemographic, professional, employment, and economic factors. Study findings can be used to develop targeted strategies that will be more effective in addressing nurse turnover behaviors than a one-size-fits-all approach.

Primary care practice staffing characteristics

Investigators: Valerie Lewis PhD and Ryan Kandrack PhD(cand)

Contemporary health care policy and quality initiatives often explicitly or implicitly rely on primary care practices as a central locus for change.  Despite this, no work has systematically examined the composition of the workforce of US primary care practices; how the workforce varies across key types of practices; or how team composition has changed over time.

This project will provide more comprehensive data on staffing configurations for virtually all primary care practices in the US and will examine how these staffing patterns vary in rural versus urban areas, by practice type and ownership structure.

Trends in Physician Specialization 2004-2017

Investigators: Erin Fraher, PhD, MPP, and Andy Knapton, MSc

Congressional proposals to expand Graduate Medical Education have set a goal of funding 3,000 new PGY1 slots for five years for a total of 15,000 new residency positions.  While these proposals aim to produce the workforce needed to meet population health needs, simply increasing the number of residency positions in core specialties such as internal medicine (IM) and general surgery (GS) will produce only a fraction of the number of physicians needed.  This is because a significant proportion of these residents go on to pursue subspecialty training.

This study quantifies the number of residents in family medicine, internal medicine, psychiatry and general surgery who, between 2004 and 2017:

  1. completed training and entered practice after the minimum training length
  2. continued training in the same specialty beyond the minimum training length; and 3. went on to pursue specialty training.

The demographic, specialty, employment and geographic characteristics of physicians and residents affiliated with ACOs in the United States

Investigators: Erin Fraher PhD and Ryan Kandrack PhD(cand)

The transformation toward value is proceeding rapidly and occurring while hospitals and health systems continue to provide health services and train the future workforce. Preliminary analyses suggest that about 4,000 residents-in-training are in OneKey ACO provider roster which will allow us, for the first time we are aware of, to describe the demographic, specialty, employment and geographic characteristics of residents in ACOs. While it is unclear what being in the OneKey ACO file means in terms of the amount and content of training that is occurring in a value-based vs. fee-for-service practice environment, we will use the merged OneKey/MF data to identify the specialty, training institutions and geographic location of these resident physicians.

Geographic Access Measure for Primary Care in Rural Areas

Investigators: Mark Holmes, PhD, Paul Delamater, PhD

Urban-rural disparities have been of increasing interest in the public policy debate.  A key element in this debate, however, is the definition of rural.   Various federal agencies use distinct definitions of rurality; common definitions include the county-based Metropolitan/Micropolitan Statistical Area definition (OMB) and the Census tract (and ZIP approximation) of Rural-Urban Commuting Areas, the method primarily used by the Federal Office of Rural Health Policy (HRSA).  As the decennial Census approaches, geographers have noted potential challenges and limitations to these definitions.  For example, a decline in rural employment may increase commuting to urban job centers which might render rural areas included in metropolitan statistical areas.

In this study, we will determine how the availability of primary care physicians varies by multiple aspects of geography—e.g. the appropriate areal unit (e.g. counties vs. census tracts), population density, size, and relative proximity to urban centers—and determine the combination of factors that best explains disparities in the availability of primary care physicians. This analysis will provide insight into better targeting HRSA programs aimed at improving the health of rural communities.


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