Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA

Objective: To examine the reasons contributing to the physician shortage in the country’s medically underserved areas using the state of Delaware as a focus state. Method: A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. A review of the “Conrad 30 J1 VISA waiver program,” the most important and primary supplier of physicians to underserved areas of the state was performed. A survey interviewing the physicians recruited through this program to identify any challenges faced by them was designed and conducted. Results: The number of primary care physicians providing direct patient care in Delaware in 2018 had declined about 6% from 2013. The average wait time to see a PCP was 8.2 days in 1998 as compared to 23.5 days in 2018. Forty-six percent of physicians serving in HPSAs in Delaware are IMGs recruited through the J1 VISA waiver program. Eighty percent of these IMGs are actively considering leaving the United States due to anxieties around physician immigration policies, mainly “Immigration backlog.” Conclusion: The existing programs to recruit physicians to underserved areas seem to be inadequate. The state and the hospital systems should be able to utilize the J1 program to its full potential and focus on retaining these physicians after their assigned services. As the challenges of IMGs continue to worsen every day; the medical societies, hospitals, the state and federal government should advocate for policies that resolve these challenges.

Unmet Needs of Families of Adults With Intellectual and Development Disabilities on Waiting Lists

Most adults with intellectual and developmental disabilities live at home with their aging parents. Given the large waiting lists for residential and home-based services, families face many unmet service and support needs. The author will present results of a study that examined the impact of a Medicaid waiver program that provided either home-based or residential placements to 444 families of adults with IDD who were living at home at baseline through surveys at baseline and two years later. Families who did not receive the waiver services still had high unmet needs for person-centered planning training, networking with other families, respite, advocacy services, assistive technology, and home modifications at follow up. Regardless of services received, class members from minority backgrounds had more unmet needs than white class members, indicating the need for more targeted efforts to reach minority families.

Training Clinicians to Support Aging in Place in a Medicaid Home and Community-Based Waiver Program

A randomized trial in 18 home and community-based waiver sites implemented an aging-in-place model for 12,000 disabled older (mean age 78) adults. The trial was underpinned by the Knowledge-to-Action model and utilized 7 implementation strategies, including a 5.5-hour online social worker (SW) and registered nurse (RN) training. Baseline self-efficacy and attitudes of SWs and RNs were measured using validated scales, and knowledge uptake and satisfaction with a tool designed by the team. Characteristics, knowledge uptake, and satisfaction of SWs versus RNs were compared using t-, Wilcoxon, and chi-square tests. Two hundred forty-one RNs and 264 SWs participated. RNs were older (mean age 50; standard deviation [SD] 10.95) than SWs (41.35; SD=11.21) p<.01; and >90% overall were female. RNs had more professional experience, while SWs worked more years in the waiver (p<.01). SWs had greater self-efficacy (t(497)=2.99, p<.04), better attitudes (t(500)=2.59, p<.01), employability (t(500)=2.99, p<.04), and balance (t(491)=2.03, p<.05) than RNs. No differences were found on leadership, organizational culture, motivation, pressure to change, or attitude toward evidence-based practice. Knowledge uptake (range 1-16) was high and did not differ for RNs (Mean=15.2, SD=1.23) versus SWs (Mean=15.26, SD=0.89). Training content, format, role explanation, and information satisfaction (range 0-50) means also did not differ for RNs (Mean=35, SD=10.2) or SWs (Mean=34.9, SD=9.8). While many of the characteristics and outcomes were similar for RNs and SWs, SW’s higher self-efficacy, better attitude, and employability despite less experience in the waiver indicate they may play a positive role in implementation of the intervention that is currently underway.