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Purpose: The landscape of education loan repayment programs for health care professionals has been turbulent in recent years, with doubling of the funding for the National Health Service Corps (NHSC) and cuts in funding for some states' programs. We sought to understand how this turbulence is being felt within the state offices involved in recruiting clinicians to rural and urban underserved communities. Methods: We conducted key informant telephone interviews with staff of state offices of rural health, primary care organizations, and/or related organizations within 28 diverse states to answer questions about perceived changes and interplay among solely state-funded loan repayment programs, joint state-federal programs, and the NHSC federal program. Interviews were transcribed, formally analyzed, and key issues summarized. Findings: Informants reported that solely state-funded and joint state-federal loan repayment programs are greatly valued for their ability to target a state's particular needs and to complement the NHSC federal program. However, budgets for state programs have been threatened, reduced, or eliminated entirely in many cases. All informants positively perceived the NHSC's recent growth and changes, which they feel are helping fill important workforce needs for their states. Nevertheless, the much larger NHSC federal program now competes with some states' programs for clinicians and service sites; states' programs are pushed to adjust their operations to maintain a unique "niche." Conclusions: States' key recruiters lament reductions in funding for states' loan repayment programs, and welcome the NHSC's recent growth and changes. Better coordination is needed to minimize competition and maximize complementarity between state and federal programs.

Purpose: The purpose of this study was to evaluate WIN A STEP UP, a workforce development program for nursing assistants (NAs) in nursing homes (NHs) involving continuing education by onsite trainers, compensation for education modules, supervisory skills training of frontline supervisors, and short-term retention contracts for bonuses and/or wage increases upon completion. Design and Methods: We collected longitudinal semistructured interview and survey data from NAs, supervisors, and managers at 8 program NHs and 10 comparison NHs. To control for selection bias, we matched 77 NA program participants to 81 participating site and 135 comparison site controls using propensity scores in a quasi-experimental design supplemented by qualitative assessments. Results: Managers at seven of eight participating NHs wanted to repeat the program. At 3 months after baseline, participants differed from controls by having (a) more improved nursing care and supportive leadership scores, (b) greater improvement in team care, and (c) stronger ratings of career and financial rewards. Nurse supervisors participating in supervisory skills training reported positive changes in management practices for themselves and peers. Modest 3-month turnover reductions occurred in six settings where the program was fully implemented without incident. Implications: Managers', supervisors', and participating NAs' consistent perceptions of improved quality of care and job quality, along with a promise of increased retention, suggest that interventions like WIN A STEP UP are beneficial.

The education of direct care workers (DCWs) is key to improving job quality and the quality of care in long-term care (LTC). This paper describes the successful integration of a supervisory training program into a continuing education intervention (WIN A STEP UP) for DCWs, identifies the factors that appear to influence the integration of the learning into practice, and discusses the implications for educators. The WIN A STEP UP program achieved its strongest results when the DCW curriculum was paired with "Coaching Supervision". Attention to pre-training, training and post-training conditions is necessary to successfully integrate learning into practice in LTC. (Contains 4 tables.)

A survey of 468 practicing family physicians, general internists, and pediatricians examined relationships between educational debt and specialty choice, practice location choice, and types of patients treated. Results indicate that the high costs of medical training promoted rural work and care for poor patients by prompting generalists to commit to programs with service requirements. Contains 32 references. (TD)

The traditional response of medical education to challenges from the external environment has been to claim that the medical profession must have autonomy concerning educational mission. However, as social, educational, and economic forces change, more explicit, formal, and systematic linkages between practice institutions and educational institutions are inevitable, and the educational mission will likely be dominated by market needs. (MSE)

Abstract AIM The aim of the study was to assess how state-based support-for-service (SFS) programs are used by deans and directors of nursing programs and to evaluate their perceived impact. [...]

Purpose: Residential care/assisted living facilities have become an alternative to nursing homes for many individuals, yet little information exists about staffing in these settings and the effect of staffing. This study analyzed the intensity and skill mix of nursing staff using data from a four-state study, and their relationship to outcomes. Design and Methods: We obtained longitudinal data for 1,894 residents of 170 residential care/assisted living facilities participating in the Collaborative Studies of Long-Term Care. Descriptive statistics assessed the levels of direct care staff (registered nurse, licensed practical nurse, personal care aide). Regression analyses evaluated the relationship between two staffing measures (intensity measured as care hours per resident and skill mix measured as the percentage of total care hours by licensed nurses), facility characteristics, and four health outcomes (mortality, nursing home transfer, hospitalization, and incident morbidity). Results: Care hours per resident decreased with facility size (economies of scale) only for very small facilities and increased with dementia prevalence (case-mix effect). Licensed staff accounted for a greater proportion of total hours in nonprofit settings. Health outcomes did not vary by total care hours per resident, but hospitalization rates were significantly lower in facilities with higher proportions of skilled staff hours; this effect was stronger as dementia case mix increased. Implications: Current staffing levels for the outcomes analyzed meet most residents' needs. Reduced hospitalization in relation to greater use of licensed staff suggests that increased use of these workers might result in reductions in acute care expenditures. Key Words: Resident outcomes, Licensed staff, Care hours

To assess the effects of physician--patient racial concordance and continuity of care on hypertension outcomes, we described patterns of care for hypertension; we used cross-tabulations and repeated measures (generalized estimating equations) analyses with panel survey data from elderly persons interviewed and examined in 1987 and 1990. Continuity of care was associated with recognition of hypertension, receipt of medication, and lower incidence of undetected hypertension. Physician race had little effect, but continuity is important for successful management of hypertension in older persons. doi:10.2105/AJPH.2004.046177)

Objectives. We tested the assumption that average job retention duration is shorter for physicians in rural health professional shortage areas (HPSAs) than for physicians in rural non-HPSAs. Methods. In 1991, we surveyed nationally representative samples of primary care physicians who recently had moved to rural HPSAs and non-HPSAs who were without service obligations. We resurveyed these physicians in 1996 and 1997 to learn of any job changes. Results. Physicians in rural HPSAs (n = 308) demonstrated retention similar to that of the non-HPSA cohort (n = 197) (hazard ratio for leaving=1.28; 95% confidence interval = 0.97, 1.69; P = .08), even with adjustments for group demographic differences (P = .24). Conclusions. Average retention duration for generalist physicians in rural HPSAs is identical to or slightly shorter than for those in rural non-HPSAs. Poor recruitment is likely to be the principal dynamic underlying local rural shortages.

Purpose: The goals of this study are to describe the current state of residential care/assisted living (RC/ AL) care and residents in comparison with nursing home (NH) care and residents, identify different types of RC/AL care and residents, and consider how variation in RC/AL case-mix reflects differences in care provision and/or consumer preference. Design and Methods: Data were derived from the Collaborative Studies of Long-Term Care, a four-state study of 193 RC/AL facilities and 40 NHs. Multivariate analyses examined differences in ten process of care measures between RC/AL facilities with less than 16 beds; traditional RC/AL with 16 or more beds; new-model RC/AL; and NHs. Generalized estimating equation models determined differences in resident case-mix across RC/AL facilities using data for 2,078 residents. Results: NHs report provision of significantly more health services and have significantly more lenient admission policies than RC/AL facilities, but provide less privacy. They do not differ from larger RC/AL facilities in policy clarity or resident control. Differences within RC/AL types are evident, with smaller and for-profit facilities scoring lower than other facilities across multiple process measures, including those related to individual freedom and institutional order. Resident impairment is substantial in both NHs and RC/AL settings, but differs by RC/AL facility characteristics. Implications: Differences in process of care and resident characteristics by facility type highlight the importance of considering: (1) the adequacy of existing process measures for evaluating smaller facilities; (2) resident case-mix when comparing facility types and outcomes; and (3) the complexity of understanding the implication of the process of care, given the importance of person-environment fit. Work is continuing to clarify the role of RC/AL vis-a-vis NHs in our nation's system of residential long-term care. Key Words: Residential care, Process of care, Resident case-mix

The authors examined how racial matching between older patients and physicians relates to effectiveness of care, use of services, and satisfaction with care. In this cross-sectional, community-based cohort study, 2,867 elderly African American and White North Carolina residents with regular physicians were interviewed and screened for hypertension (HBP). African Americans were more likely than Whites to be told they had HBP, to receive HBP medication, and to take it regardless of their physician's race. White elders with African American physicians were more likely to report that they delayed care quite often. African American elders were less likely to delay care quite often, regardless of their physicians' race. These results did not support the position that African Americans require treatment by African American physicians to achieve better care. Although elders of both races who had African American physicians were less satisfied with care received, interpretation of this finding is difficult without better measurement of patient satisfaction.