A Community Development Approach to Rural Recruitment
C. Ken Shannon
shannonk@rcbhsc.wvu.edu
Contents
Abstract Introduction
Development of the RCP
Structure and Operation of the RCP
RCP Implementation and Experience
Discussion Conclusions
References
Acknowledgments
About the Author
Programs designed to empower rural
communities for health care provider recruitment have usually focused on the
health care sector without aggressively addressing broader community
development issues. The Recruitable Community Project (RCP) in
West Virginia
includes community education on recruiting and also assessments of and
recommendations to rural communities on broad-based community development,
aiming to enhance communities' recruiting
potential. The project provides multidisciplinary university-based planning
assistance programs for small communities, involving collaborative
community visits. The project also uses a project manager as a "community
encourager" who participates in community education and in the formulation
of sustained community recruiting efforts. From August 1999 through August
2001, 7 underserved rural communities completed the RCP organizational
processes and hosted planning assistance teams. Members of community
recruitment boards gave high marks to the RCP process, its planning
assistance teams, and its usefulness in establishing community ties to state
and academic agencies. Since working with the RCP, the 7 communities have
recruited 27 providers, success possibly stimulated by their RCP involvement
(data current as of September 2002). This model of community training and
development to empower rural communities to better recruit health
professionals shows early promise. This model could be broadened to include
more collaboration of community development and health science disciplines
programs for recruitment and retention efforts.
Small rural communities have long had difficulties recruiting health care
providers. The role of rural communities in the recruiting process has been
uncertain, and rural community members have traditionally lacked experience
in recruiting, often not addressing links between community development and
recruiting potential. Programs designed to enhance community decision-making
in health care [1-9] have involved sectors other than health care to
a varying degree, although the interrelationships of health care services
and the local economy have been acknowledged [10-12]. Several
programs, including those of national organizations such as the Cooperative
Extension Service and the National Rural Development Partnership, have
included health care system topics in community development initiatives,
although not specifically for enhancement of recruitment. There have
been calls for and examples of academic outreach programs that benefit
community health status and include elements of community development
[13,14],
but these have not included a deliberate community development effort
focused on enhancement of the community's recruiting potential.
Links between prospective providers and rural communities in need of health
care providers have not traditionally been strong. Residency training
programs in this country have not always addressed the problems that the
recently graduated prospective provider may face in a rural location nor
have they uniformly assisted the provider in the transition from an academic
to a rural setting [15-17]. Lifestyle and cultural issues have been
important in rural recruitment [18-21], but there is no consensus on
how these issues should be addressed or whether a combined community
development and education effort may have utility in making underserved
rural communities more attractive to health care providers or in promoting
community recruiting readiness.
West Virginia
is a poor rural state with many unmet health care needs. Fifty of 55
counties have medically underserved areas (MUAs) or health professional
shortage areas [22] despite the presence of 3 medical schools and
multiple rural training sites for health professions students. As in other
states, these MUAs are generally economically disadvantaged areas. The
economic picture is not likely to change substantially in the near future.
Furthermore, there have been reports of a decrease in the number of
physicians in the state due to a variety of factors. It is, therefore,
essential that West Virginia
develop new approaches to enhance rural recruitment to help avoid a
worsening shortage of providers.
The purpose of this article is to describe an innovative approach developed
in response to West Virginia's rural
health care provider recruitment needs. The Recruitable Community Project
(RCP) is centered on an effort to promote general community development,
leadership, and education. Based on the premise that rural community
recruitment potential is correlated with general community development and a
proactive community effort, the RCP combines the efforts of a
project-sponsored "community encourager" [1,6],
university-based community planning assistance programs
[23-26], and
health care provider recruitment initiatives.
The RCP was implemented in late 1998 by faculty of the Department of Family
Medicine at West Virginia University (WVU). Faculty collaborated with state
agencies, university departments, and community assistance teams before
funding application and during implementation of the project. Two of these
university-based assistance teams (the First Impressions Program (FIP) and
the Community Design Team (CDT)), which already had been addressing various
issues of community development in the state, were integrated into the RCP.
With this, suggestions regarding general community development outside
traditional health care topics were available to RCP communities. Thus, the
RCP design represented a new model to help train community members on
barriers to successful provider recruitment, broad-based community
development, and sponsoring elective rural clinical rotations for primary
care trainees. The community assistance teams function through the efforts
of volunteers from various institutions, agencies, and communities and are
founded on the strong service commitment of West Virginia's academic
departments and agencies. The use of these
community assistance teams allowed investigation of the basic RCP premise
that health care provider recruitment to rural communities can be enhanced
through general community development.
The RCP design is based on the assumptions that (1) health care personnel
are attracted by a community's physical attractiveness, local supports for
the practice and family, and the welcome they feel; (2) communities do not
understand what health care personnel are looking for or how their community
is perceived by potential recruits; (3) communities can learn and can effect
positive changes; (4) outside assistance from trusted in-state resources can
provide this needed assistance; (5) assistance is best delivered in a
supportive and collaborative fashion; and (6) an explicit recruitment plan
serves as a good vehicle through which to focus the community's efforts.
Funding for the RCP, as a demonstration project, was initially secured from
the Claude Worthington Benedum Foundation in 1998. With the advent of the
West Virginia Rural Health Access Program (WVRHAP) in 1999, a component of
the Robert Wood Johnson Foundation's Southern Rural Access Program that
operates in 8 southern states, RCP funding was supplied entirely by the
WVRHAP. The WVRHAP derives its funding from both the Robert Wood Johnson
Foundation and Claude Worthington Benedum Foundation. Funding covers costs
of project personnel and travel, administrative costs of the community
assistance teams (total of $3500 for each RCP community), and a stipend for
primary care trainees who elect 1-month rural rotations to sites approved by
project personnel.
The project is directed by a multidisciplinary project oversight committee,
which is composed of personnel from
West Virginia
agencies involved in recruitment and retention, private and community
organizations, and various academic departments. Project personnel include a
physician with rural West Virginia
practice experience, a project manager with community programs experience,
and a part-time secretary.
The RCP functions in a sequential fashion. Initially, information regarding
the RCP was distributed throughout
West Virginia
through a statewide rural training network, the Cooperative Extension
Service, and mailings to chambers of commerce and health care facilities.
Ongoing efforts include an informational brochure and Web site that outline
the program and the application process. The RCP program manager then visits
interested communities and assists community members in supplying the
required information regarding community eligibility for project entry.
Eligibility criteria include the following: (1) location in an underserved
rural area; (2) demonstrated ability to organize for a recruitment effort
(formation of a recruitment board composed of key community members); (3)
willingness to prepare for and host the community assistance teams; (4)
perceived ability by community and project personnel of community ability to
support a viable practice; and (5) identification of a sponsor, such as a
hospital or clinic, that would offer a contract to a prospective recruit. On
the basis of available information, the project oversight committee then
annually selects 2 or 3 RCP communities.
After project entry, RCP communities then perform further self-assessment
and the recruitment board works with project personnel, learning of barriers
to recruitment and positive initiatives that communities may use to help
overcome barriers and to build community capacity. The RCP project manager
serves as an encourager to several communities, traveling frequently to the
RCP communities, providing one-on-one consultation and assistance,
conducting community workshops, and helping communities to plan their
recruitment effort and to prepare for visits from community assistance
teams. The latter requires extensive community assessment and information
collection.
The RCP includes an early educational initiative that focuses on enhancement
of recruiting knowledge and abilities of rural community leaders. Many
community recruitment board members experienced their first opportunity to
learn of important recruitment issues, such as practice viability,
practitioner debt, and lifestyle issues, through their involvement with the
RCP. Educational tools for communities have been developed, including a
short recruitment manual, a video on recruitment and retention, and a board
game that introduces community members to the hurdles and pitfalls
associated with rural medical practice and the important contributions
communities can make to the success of a practice and to the retention of
practitioners [27].
In addition to building the capacity of participating communities to recruit
interested practitioners, the RCP also works to link practitioners and
communities through other efforts. The RCP linkage efforts include
sponsoring funded trainee rotations in any underserved rural
West Virginia community that is recruiting,
presenting information at primary care training sites, and sponsoring
opportunity fairs where prospective recruits can interface with community
members.
One of the essential components of the RCP is the community assistance
offered by multidisciplinary community assistance teams that are
administered from academic departments at WVU. These teams incorporate
expertise from various agencies, institutions, and communities and are
valuable as outside resources that can assist a community in
self-assessment and in suggesting initiatives for community development.
These teams have historically had a role in various community assessment and
development activities and their continuation is based on the strong service
commitment of academic departments and state agencies in West Virginia. When
incorporated into the RCP process, these teams also assume additional
functions by assessing the local health care system and making
recommendations for improvements, particularly those involving recruitment
of primary health care providers.
One such community assistance program is the WVU FIP [23,24]. The
FIP has
supported community assessment at WVU since 1997 and has visited
approximately 20 West Virginia communities. The FIP team is
composed of approximately 5 volunteers who independently visit the community
as anonymous first-time visitors and later present to the community their
impressions of the town and their recommendations about ways to improve
appearances and avoid negative first impressions. The FIP team members gain
their impressions by driving around the community and talking to community
members. The team formulates this information into a written report that is
made available to the community and to a subsequent planning team, the CDT.
The WVU CDT [25,26] visits the community for a more comprehensive
effort, resulting in recommendations in various areas of community
development. The CDT has been functional since 1997 and has visited
approximately 20 communities throughout the state. It has addressed a
variety of individual community development issues that have been
identified by the community, by the FIP, or through the required application
process. The CDT is typically composed of 12 to 20 volunteers from West
Virginia agencies, communities, and academic departments, representing a
variety of disciplines, such as engineering, public administration,
landscape architecture, historical preservation, extension services,
community economic development, and recreation.
When functioning as a component of the RCP effort, the CDT also addresses
issues of health care access, particularly recruitment of health care
providers, previously detailed through the RCP process of community
interaction. In RCP communities, the CDT also includes the RCP physician
project director, project manager, and personnel from health care
disciplines such as family medicine and community medicine. Community
members host these CDT members during a 3-day community visit when
community input is sought, collaborative assessment and planning are
performed, and general recommendations are made for community development
and recruitment.
The
community provides input through the host families, presentations by
community members to the CDT, and a community forum typically held in the
evening at a local facility. The most pressing issues challenging the
community are identified. The CDT members are assigned to various groups to
suggest possible solutions and collaboratively develop recommendations on
each topic. The CDT groups present their findings and recommendations to the
community at the end of the visit and subsequently submit a written report
to the community and county leaders. The topics most often addressed have
involved health care and economic development, including community-specific
topics such as community revitalization and leadership, transportation,
recreation, tourism, and historical preservation. Follow-up consultations
and site visits by CDT members are provided as needed. (Figure 1 provides
an outline of the RCP community process.)
Figure 1:
Recruitable Community Project (RCP) Community Process
Community Education, Recruitment Board Formation |
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Community FIP Visit |
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Community FIP Report, Preparation for CDT Visit |
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Community CDT visit, Recommendations |
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Follow-up by RCP, CDT personnel |
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As of September 2002, 12 communities had submitted applications and 7 were
selected to participate in the RCP. All 7 RCP communities are rural, with
populations ranging from 400 or more to nearly 4500, and are located in
MUAs. As of August 2001, all 7 had completed the self-assessment, convened a
recruitment board, and hosted the 2 planning assistance teams. Since the RCP
is too new to assess its long-term successes, only early experiences and
outcomes are described.
As of September 2002, these 7 communities had recruited a total of 27 health
care providers, including 14 physicians, 6 nurse practitioners, and 7
physician assistants since their entry into the RCP. Given that rural
rotations have traditionally been a major effort to improve rural
recruitment, it is noteworthy that only 2 of these recruits had participated
in an RCP-sponsored rural rotation, thus highlighting the role of these
communities in proactive recruitment of providers who had not performed a
local RCP clinical rotation.
An anonymous survey of community recruitment board members has provided
early evidence of program success from the perspective of those respondents.
Of 25 board members surveyed, the 17 respondents rated the value of the FIP,
CDT, and overall RCP process to community development, attitudes, knowledge,
and recruiting potential. High numerical ratings and positive comments were
given to each program. High value was placed on the FIP in promoting
awareness of community appearance, development, and leadership issues. The
CDT was valued for increasing the level of community interest in
development, leadership, and recruitment issues; increasing the level of
interest of county leadership in development issues; and promoting a
positive community attitude toward the academic institution (WVU) as a
partner in development issues. The overall RCP process was given high marks
for promotion of community knowledge of and readiness for recruitment,
personal leadership and cooperative skills, and a positive community
attitude toward the academic institution.
This report describes the RCP, a unique approach to enhance the recruiting
potential of rural Appalachian communities through general community
development, including enhancement of community knowledge on health care and
recruiting issues. The use of community assistance teams for the purpose of
enhancing recruiting ability through broad-based community development
initiatives is the most unique aspect of this program. General community
development is closely related to economic issues and seems to be an
important issue for maintenance of health care services. A common problem
cited by RCP communities was the exodus of potential patients to more
"developed" communities.
Intuitively, it would seem that a rural community that proactively prepares
for recruitment by actively engaging in community development activities
intended to improve the health of its community is more likely to be
successful in its recruitment efforts. The RCP attempts to assist
communities in making a positive impression on prospective recruits and in
addressing barriers to rural recruitment by promoting community readiness
for recruitment through educational processes and general community
development. These barriers are addressed through a sequential process of
proactive community training and development. The RCP communities had some
successes in recruiting providers after completing the processes of
organization for recruitment and the hosting of the community planning
assistance programs. Aside from any recruitment issues, the community
perception of strengthened readiness for development has been an evident
outcome. The program has also strengthened links between communities and
academic and state agencies.
The success of programs such as the RCP depends on a number of factors: (1)
community interest in proactive efforts in recruiting (interest was
ascertained in this project by evidence of completion of application
materials and through meetings involving community and project personnel);
(2) the role of the project manager as an encourager and resource for
sustained community efforts (the importance of this has been evident); and
(3) the collaborative efforts involving community, state, and academic
partners. With an atmosphere of cooperation initially established by
interaction of community and project personnel, the small Appalachian
communities have been receptive to recommendations from outside personnel
and agencies, and the communities have often acted on these recommendations.
Preliminary evidence suggests
that community efforts in adopting a proactive stance in community
development and recruiting can attract health care providers. Although more
complex and labor intensive, these efforts may be more effective in rural
recruiting than are the efforts in supporting rural RCP rotations for
trainees.
This model for enhancing rural community recruiting potential could be used
on a wider scale in other states and regions of the country where
commitments for funding and multidisciplinary collaboration can be secured.
State agencies and large academic institutions commonly have existing
community development programs; promotion of multidisciplinary input into
such programs, including that of experienced rural practitioners, could
allow recruitment initiatives similar to those of the RCP. Project
initiatives could be expanded to involve a more developed collaborative
program that integrates traditional community planning and development
programs with input from rural health care providers, training programs,
health care workforce planners, and consultants, so that stronger
initiatives could be more tailored to the requirements of the recruiting
site.
There are limitations to evaluation of this model at this preliminary stage.
The effect of community development initiatives in stimulating recruitment
successes is unknown and needs more study. More experience with a larger
number of communities and more information on recruits are needed for a more
complete evaluation. No assessments of practice obligations or of retention
of recruits has yet been completed. There has not been enough experience
with the model to allow a comparison with a control group of communities,
although it is known that past recruitment into rural
West Virginia has traditionally been difficult.
As a program to stimulate recruitment of health care providers by rural
communities in West Virginia, the RCP
has shown some preliminary successes. The attempted enhancement of rural
community recruiting potential through processes of community education and
general community development may have utility in promoting rural health
care provider recruitment, but more study is needed. The use of
university-based planning assistance programs in community development for
enhancement of rural recruitment is the most unique aspect of the RCP
program. These community efforts may be more effective in promoting rural
recruiting than are RCP efforts in supporting rural rotations for trainees.
This approach to rural recruitment may be enhanced through further
collaboration of traditional community planning and development programs
with health care workforce initiatives. This approach may be tested through
further evaluation of the RCP and through its implementation in other rural
areas.
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Thank you to the
Journal of Rural Health for permission to reprint this paper (Vol. 19 # S:
Supplemental 2003: Pages 347-352)
The Recruitable Community Project is funded by the Claude W. Benedum
Foundation and the Robert Wood Johnson Foundation through the Southern Rural
Access Program. The following individuals are acknowledged for their
contributions in review and editing: Donald E. Pathman, MD, MPH, associate
professor and research director of family medicine and co-director of the
Program on Health Professions and Primary Care of the Cecil G. Sheps Center
for Health Services Research, University of North Carolina at Chapel Hill;
Elaine Mason, MEd, director of rural recruitment and
retention at the West Virginia University School of Medicine; and James G.
Arbogast, MD, professor and residency director, West Virginia University Department of Family Medicine. For
further information, contact: C. Ken Shannon, WVU Department of Family
Medicine, PO Box 9152, Health Sciences Center, Morgantown, WV 26506; e-mail
shannonk@rcbhsc.wvu.edu
Dr. Shannon has a background in rural WV primary care and is the
Research Director in the WVU Department of Family Medicine. His research
interests include the community role in recruitment of health care
professionals, the rural training of health care discipline students and
the role of practice-based research networking in rural areas.
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