Community APGAR Program: A Tool for Improving the
Recruitment and Retention of Rural Communities An Assets and Capabilities Assessment:
Experiences from Maine and Review of National Data
Presented by:
David Schmitz, MD, FAAFP
Associate Director of Rural Family Medicine
Family Medicine Residency of Idaho
Ed Baker, PhD
Director, Center for Health Policy
Boise State University
Presented at:
Arizona Recruitment and Retention Forum 2013
Phoenix, Arizona
Date: January 15, 2013
Presentation Overview
 Background/Purpose/Development
 Using the Community Health Center

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Community Apgar Questionnaire (CHC CAQ)
Maine Comparative Database Results
Examples from Facility Level Report
Next Steps
Findings from the National Apgar Database
Questions/Comments for Discussion
Acknowledgements
 Funding provided by



Office of Rural Health and Primary Care, Division of Local Public
Health, Maine Center for Disease Control & Prevention, Maine
Department of Health and Human Services
Maine Primary Care Association
Bureau of Primary Health Care, Health Resources and Services
Administration, U.S. Department of Health & Human Services
 Boise State University Center for Health Policy Research
Staff



Sean Wasden, MHS, Research Assistant
Lisa MacKenzie, Graduate Research Assistant
Bradley Morris, Undergraduate Research Assistant
Background
 How did we get here – Why research?




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


Boise State University: Ed Baker, PhD
Family Medicine Residency of Idaho: Dave Schmitz, MD
Office of Rural Health and Primary Care: Mary Sheridan
An intersection of workforce, education and advocacy
Practical knowledge, relationships, experience and
investment
Answering needs and necessary questions
Applied research: Development of tools
Partnerships with those with “skin in the game”
Apgar Score for Newborns
 Devised in 1952 by Virginia Apgar,
an anesthesiologist, as a simple
and repeatable method to quickly
and summarily assess the health
of newborn children immediately
after birth
 Determined by evaluating the newborn baby
on five simple criteria (Appearance, Pulse, Grimace,
Activity, Respiration) on a scale from zero to two,
then summing up the five values thus obtained
Mind Mapping
Apgar Scoring
How Ready is this Child?
A New Response
to the Same Old Problem…
What if there was a similar test for hospitals – quick
and repeatable with intervention measures on
standby – to assess readiness for recruiting
physicians?
• Something new
• Something based on quantifiable data
• Something that incorporates the whole community
• Something that shows people on graphs and charts
where they are and how to achieve their goals.
A History of Community Apgar
Year 3 (2009)
Year 1 (2007)
Idaho Family Physician
Rural Work Force
Assessment Pilot Study
[Published in the
Journal of Rural Health]
• Examining the Trait of Grit
and Satisfaction in Idaho
Physicians [Accepted for
publication in the Journal of the
American Board of Family
Medicine]
• Community Apgar Program
(CAP) Pilot for Critical Access
Hospitals in Idaho
• Nursing Community Apgar
Questionnaire (NCAQ)
Year 4 (2010)
Year 2 (2008)
Critical Access Hospital
Community Apgar
Questionnaire (CAH CAQ)
[Published in the Rural &
Remote Health Journal]
• Community Health Center
Community Apgar Questionnaire
(CHC CAQ) [Under review for
publication in the Rural and Remote
Health Journal]
• Community Apgar Program
(CAP) for Community Health
Centers in Idaho
• Community Apgar Solutions
Pilot Project
Years 5 & 6
(2011/2012)
• Expansion of the Community
Apgar Program (CAP) for
Critical Access Hospitals and
Community Health Centers
- Wyoming, North Dakota,
Wisconsin and Alaska
(CAHs)
- Maine (CHCs)
Purpose of the Community Health
Center CAQ (CHC CAQ)
 A validated tool used to assess an underserved
community’s assets and capabilities in
recruiting and retaining family physicians.
 This should accurately correlate to historical
community-specific workforce trends.
 Designed to be a real-time assessment tool
providing guidance for the most helpful
interventions at the present.
Purpose of the CHC CAQ (cont.)
 Presentation of individual CAQ scores
facilitating discussions with key decision
makers in each community for specific strategic
planning and improvements.
 The CHC CAQ can also be used to track a
community’s progress over time, similar to the
clinical use of Apgar scores in newborns.
CHC CAQ Development
 The CHC CAQ
 Questions aggregated into 5 Classes
 Geographic
 Economic
 Scope


of Practice
 Medical Support
 Facility and Community Support
Each Class contains 10 factors for a total of 50
factors/questions representing specific elements
related to recruitment and retention of physicians in
underserved areas.
Three open-ended questions
CHC CAQ Development:
Class/Factor Examples
Geographic
Economic
• Schools
• Climate
• Perception of
Community
• Spousal
Satisfaction
• Loan
Repayment
• Competition
• Part-time
Opportunities
• Signing Bonus
Scope of
Practice
Medical
support
• Mental Health
• Emergency
Care
• Inpatient Care
• Administration
Duties
• Nursing
Workforce
• Call/practice
Coverage
• Perception of
Quality
• Specialist
Availability
Facility and
Community
Support
• EMR
• Welcome &
Recruitment
• Televideo
Support
• Plan for
Capital
Investment
Community Apgar Project
Timeline for Maine’s CHCs
May – Dec. 2011
May – Oct. 2012
Two Rounds of Structured Interviews
Two Rounds of Community Presentations
Jan. – May 2012
Dec. 2012 – May 2013
CHC CAQ Development:
Maine Sample and Administration
 CHC CAQ Target Communities in Maine
 13 CHCs and 14 sites (one CHC had two sites that
participated)
 14 facility administrators and 14 clinicians (8
physicians, 5 nurse practitioners and 1 physician
assistant) for a total sample of 28
 CHC CAQ Administration


Participants mailed the CHC CAQ survey in advance with
consent form [IRB approval from Boise State University]
and one hour interviews scheduled
Separate structured one hour interviews for each participant
where consent form was reviewed and executed and CAQ
completed
Community Apgar
Participating Sites
Use of the CHC CAQ
 This assessment allows for identification of both
modifiable and non-modifiable factors and also
may suggest which factors are most important
for a community to address with limited
available resources.
 The CHC CAQ may be used by communities to
assess their relative strengths and challenges,
the relative importance of CAQ factors, and to
gain a better understanding of which CAQ
factors are seen as most important from the
physician point-of-view.
Making the most of the CHC CAQ
Recruiting and Retaining Family
Physicians:
 community self-evaluation
 prioritizing improvement plans
 advertising and interviewing
 negotiation strategies and contract
construction
The CAQ Value Proposition
 Beyond “Expert Opinion”
 A new approach to the old problem of
physician recruiting
 Self-empowering for the community:
knowledge as power, not an outside
“headhunter”
 Beyond physician recruitment to
community improvement
Future of the CHC CAQ
 With further research and collaboration, this tool
could also be used to share successful
strategies communities have used to overcome
challenges which may be difficult or impossible
to modify.
 CHC CAQ surveys may be useful in identifying
trends and overarching themes which can be
further addressed at state or national levels.
Maine Comparative Database Results
Class CHC Community Advantages and Challenges Cumulative Score
Overall
12.00
Administrator
11.00
10.00
9.00
Cumulative Score
8.00
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Scope of Practice
Facility and Community
Support
Economic
Community Advantages and Challenges Class
Medical Support
Geographic
Physician
Summary Class CHC Community Advantages and Challenges Mean Score
"Overall"
40
35
Cumulative Score
30
25
20
15
10
5
0
Respondent
Administrator
Physician
Top 10 CHC Community Advantages Mean Score
Overall
2.00
Mean Score
1.50
1.00
0.50
0.00
Recreational
opportunities
Loan repayment Community
need, physician
support
Inpatient care
Obstetrics:
deliveries, Csection
Obstetrics:
parental care
Top 10 Factors- Advantages
Mid-level
provider
workforce
CHC leadership
Perception of
quality
Call, practice
coverage
Top 10 CHC Community Advantages Mean Score (Continued)
Overall
2.00
Mean Score
1.50
1.00
0.50
0.00
Physical plant
and equipment
Office GYN
procedures
Top 10 Factors- Advantages
Top 10 CHC Community Challenges Mean Score
Overall
2.00
1.50
1.00
Mean Score
0.50
0.00
-0.50
-1.00
-1.50
-2.00
Spousal
satisfaction
Social
networking
Access to larger Salary (amount) Shopping, other
community
services
Specialist
availability
Top 10 Factors- Challenges
Mental health
Televideo
support
Production
incentive
Physician
workforce
stability
Class CHC Community Importance Cumulative Score
Overall
35.00
Administrator
Physician
30.00
Cumulative Score
25.00
20.00
15.00
10.00
5.00
0.00
Medical Support
Economic
Geographic
Community Importance Class
Scope of Practice
Facility and Community
Support
Summary Class CHC Community Importance Mean Score
Overall
180
160
140
Cumulative Score
120
100
80
60
40
20
0
Respondent
Administrator
Physician
Top 10 CHC Community Importance Mean Score
Overall
4.00
3.50
3.00
Mean Score
2.50
2.00
1.50
1.00
0.50
0.00
Call, practice
coverage
Administration Loan repayment
Spousal
satisfaction
Perception of
quality
Schools
Top 10 Factors- Importance
Competition
Nursing
workforce
Salary (amount) Electronic
medical records
Top 10 CHC Community Importance Mean Score (Continued)
Overall
4.00
3.50
3.00
Mean Score
2.50
2.00
1.50
1.00
0.50
0.00
Physician
workforce
stability
Top 10 Factors- Importance
Class CHC Community Apgar Cumulative Score
Overall
40.00
Administrator
35.00
Cumulative Score
30.00
25.00
20.00
15.00
10.00
5.00
0.00
Scope of Practice
Facility and Community
Support
Economic
Community Apgar Class
Medical Support
Geographic
Physician
Summary Class CHC Community Apgar Mean Score
Overall
140
120
Cumulative Score
100
80
60
40
20
0
Respondent
Administrator
Physician
Geographic Class CHC Community Apgar Mean Score
8.00
Overall
Administrator
Physician
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Recreational
opportunities
Housing
Schools
Perception of
community
Demographics:
underserved,
payor mix
Climate
Geographic Factor
Shopping, other Access to larger
services
community
Social
networking
Spousal
satisfaction
Economic Class CHC Community Apgar Mean Score
8.00
Overall
Administrator
Physician
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Loan repayment
Competition
CME benefit
Length of
contract
flexibility
Perceived fiscal Signing bonus,
stability
moving
allowance
Economic Factor
Part-time
opportunities
Retirement
package
Production
incentive
Salary (amount)
Scope of Practice Class CHC Community Apgar Mean Score
8.00
Overall
Administrator
Physician
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Inpatient care
Obstetrics:
parental care
Obstetrics:
deliveries, Csection
Administration
Office GYN
procedures
Mid-level
supervision
Scope of Practice
Minor trauma
Teaching
Emergency,
Mental health
stabilization care
Medical Support Class CHC Community Apgar Mean Score
8.00
Overall
Administrator
Physician
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Mid-level
provider
workforce
Perception of
quality
Call, practice
coverage
Nursing
workforce
Allied mental
Ancillary staff Language
health workforce workforce
services support
Medical Support
Pharmacy
services
Physician
workforce
stability
Specialist
availability
Facility and Community Support Class CHC Community Apgar Mean Score
8.00
Overall
Administrator
Physician
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Community
CHC leadership Physical plant Plans for capital
need, physician
and equipment investment
support
Moonlighting
opportunities
Welcome,
recruitment
program
Medical
reference
resources
Facility and Community Support
Electronic
Delegated
medical records physician patient
services
Televideo
support
Top 10 CHC Community Apgar Mean Score
Overall
8.00
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Loan repayment
Recreational
opportunities
Community
need, physician
support
Inpatient care
Mid-level
provider
workforce
Obstetrics:
parental care
Top 10 Factors- Apgar
Perception of
quality
Obstetrics:
deliveries, Csection
Call, practice
coverage
CHC leadership
Bottom 10 CHC Community Apgar Mean Score
Overall
8.00
6.00
4.00
Mean Score
2.00
0.00
-2.00
-4.00
-6.00
-8.00
Spousal
satisfaction
Social
networking
Access to larger Salary (amount) Shopping, other
community
services
Specialist
availability
Bottom 10 Factors- Apgar
Mental health
Televideo
support
Physician
workforce
stability
Production
incentive
Cumulative CHC Community Apgar Score – Maine Facilities
525
475
425
Cumulative CHC Apgar Score
375
325
275
225
Apgar Score
Apgar Average
175
125
75
25
-25
-75
9
12
1
3
5
10
4
14
13
Community Health Center Code
2
8
11
6
7
Examples from Facility Level
Reports
Facility X
Comparative Cumulative Apgar Score
Baseline Mean
York County Community Health Care
250.00
Cumulative Apgar Score
200.00
150.00
100.00
50.00
0.00
-50.00
Overall Apgar
Geographic
Economic
Scope of Practice
Community Apgar Class
Medical Support
Facility and Community
Support
Facility X
Comparative Cumulative Apgar Score for Geographic Class
Baseline Mean
Fish River Rural Health
20.00
15.00
Cumulative Apgar Score
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
Access to larger Demographics:
community
underserved,
payor mix
Housing
Schools
Social
networking
Recreational
opportunities
Geographic Factors
Spousal
satisfaction
Shopping, other
services
Climate
Perception of
community
Facility X
Comparative Cumulative Apgar Score for Economic Class
Baseline Mean
Eastport Health Care Inc
20.00
15.00
Cumulative Apgar Score
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
Part-time
Loan repayment Salary (amount) Signing bonus,
opportunities
moving
allowance
Length of
contract
flexibility
Perceived fiscal
stability
Economic Factors
Production
incentive
Retirement
package
CME benefit
Competition
Facility X
Comparative Cumulative Apgar Score for Facility and Community Support
Baseline Mean
Healthreach Community Health Centers Madison
20.00
15.00
Cumulative Apgar Score
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
Physical plant Plans for capital Electronic
CHC leadership
and equipment investment
medical records
Televideo
support
Community
need, physician
support
Welcome,
recruitment
program
Facility and Community Support Factors
Medical
reference
resources
Delegated
Moonlighting
physician
opportunities
patient services
Facility X
Comparative Cumulative Apgar Score for Medical Support
Islands Community Medical Services
Baseline Mean
20.00
15.00
Cumulative Apgar Score
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
Perception of
quality
Physician
workforce
stability
Specialist
availability
Nursing
workforce
Mid-level
provider
workforce
Ancillary staff
workforce
Medical Support Factors
Pharmacy
services
Allied mental Language
Call, practice
health
services support coverage
workforce
Facility X
Comparative Cumulative Apgar Score for Facility and Community Support
Baseline Mean
Harrington Family Health Center
20.00
15.00
Cumulative Apgar Score
10.00
5.00
0.00
-5.00
-10.00
-15.00
-20.00
Physical plant Plans for capital Electronic
CHC leadership
and equipment investment
medical records
Televideo
support
Community
need, physician
support
Welcome,
recruitment
program
Facility and Community Support Factors
Medical
reference
resources
Delegated
Moonlighting
physician
opportunities
patient services
Facility X
Top 10 Apgar Factors across All 50 Factors
Overall
8.00
7.00
6.00
Mean Score
5.00
4.00
3.00
2.00
1.00
0.00
Physician
workforce
stability
Community
Administration
need, physician
support
Schools
Obstetrics:
parental care
Perceived fiscal Perception of
stability
quality
Top 10 Apgar
Housing
Physical plant
and equipment
Recreational
opportunities
Facility X
Bottom 10 Apgar Factors across All 50 Factors
Overall
1.00
Mean Score
0.00
-1.00
-2.00
-3.00
-4.00
Physician
workforce
stability
Pharmacy
services
Production
incentive
Housing
Language
services support
Climate
Bottom 10 Apgar
Teaching
Welcome,
recruitment
program
Social
networking
Physical plant
and equipment
Facility X
Top 10 Cumulative Apgar Variance Factors across All 50 Factors
16.00
14.00
Cumulative Apgar Score
12.00
10.00
8.00
6.00
4.00
2.00
0.00
Social
networking
Spousal
satisfaction
Administration
Competition
Welcome,
recruitment
program
Mid-level
provider
workforce
Top 10 Apgar Variance Factors
Shopping, other Part-time
services
opportunities
Signing bonus,
moving
allowance
Housing
Facility X
Bottom 10 Cumulative Apgar Variance Factors across All 50 Factors
0.00
-2.00
Cumulative Apgar Score
-4.00
-6.00
-8.00
-10.00
-12.00
-14.00
-16.00
-18.00
-20.00
Part-time
opportunities
Physician
workforce
stability
Length of
contract
flexibility
Perception of
community
Specialist
availability
Allied mental
health
workforce
Administration Shopping, other
services
Bottom 10 Apgar Variance Factors
Spousal
satisfaction
Ancillary staff
workforce
Next Steps
 Return in Fall 2012 to re-assess using CHC
CAQ at original 14 CHCs
 Develop Year 2 Maine state comparative
database
 Develop reports for 14 individual CHCs using
updated Year 2 Maine comparative database
 Present individual reports to 14 CHCs
highlighting progress towards action plan goals
Findings from the National
Apgar Database
•States Participating in the CAP
•States Interested in Implementing the CAP
Top 10 Advantages - CHC
Idaho
(2010)
Maine
(2012)
• Recreational opportunities
• Recreational opportunities
• Loan repayment
• Loan repayment
• Retirement package
• Community need/physician support
• Perception of quality
• Inpatient care
• Mid-level provider workforce
• Obstetrics: deliveries, C-section
• Perceived fiscal stability
• Obstetrics: prenatal care
• CME benefit
• Mid-level provider workforce
• Minor trauma (casting/suturing)
• CHC leadership
• Community need/physician support
• Perception of quality
• Schools (tie for 10th)
• Call/practice coverage (tie for 10th)
• Teaching (tie for 10th)
• Physical plant and equipment (tie for 10th)
• Ancillary staff workforce (tie for 10th)
• Office GYN procedures (tie for 10th)
Top 10 Challenges - CHC
Idaho
(2010)
Maine
(2012)
• Televideo support
• Spousal satisfaction
• Mental health
• Social networking
• Spousal satisfaction
• Access to larger community
• Production incentive
• Salary (amount)
• Perception of community
• Shopping/other services
• Salary (amount)
• Specialist availability
• Nursing workforce
• Mental health
• Demographic: underserved/payor mix (tie for 7th)
• Televideo support
• Obstetrics: parental care (tie for 7th)
• Production incentive
• Specialist availability (tie for 7th)
• Physician workforce stability
Top 10 Importance - CHC
Idaho
(2010)
Maine
(2012)
• Call/practice coverage
• Call/practice coverage
• Salary (amount)
• Administration
• Spousal satisfaction
• Loan repayment
• Obstetrics: deliveries/C-section
• Spousal satisfaction
• Recreational opportunities
• Perception of quality
• Obstetrics: prenatal care
• Schools
• Loan repayment
• Competition
• Competition
• Nursing workforce (tie for 8th)
• Allied mental health workforce
• Salary (amount) (tie for 8th)
• Schools (tie for 10th)
• Electronic medical records (tie for 8th)
• Perception of quality (tie for 10th)
• Physician workforce stability (tie for 8th)
• Physician workforce stability (tie for 10th)
Top 10 Apgar Factors - CHC
Idaho
(2010)
Maine
(2012)
• Recreational opportunities
• Loan repayment
• Loan repayment
• Recreational opportunities
• Perception of quality
• Community need/physician support
• Schools
• Inpatient care
• Retirement package
• Mid-level provider workforce
• CME benefits
• Obstetrics: prenatal care
• Community need/physician support
• Perception of quality
• Mid-level provider workforce
• Obstetrics: deliveries/C-section
• Minor trauma (casting/surturing) (tie for 9th)
• Call/practice coverage
• Call/practice coverage (tie for 9th)
• CHC leadership
Bottom 10 Apgar Factors - CHC
Idaho
(2010)
Maine
(2012)
• Mental Health
• Spousal satisfaction
• Televideo support
• Social networking
• Spousal satisfaction
• Access to larger community
• Perception of community
• Salary (amount)
• Salary (amount)
• Shopping/other services
• Production incentive
• Specialist availability
• Nursing workforce
• Mental health
• Demographic: underserved/payor mix
• Obstetrics: parental care (tied for 9th)
• Administration (tied for
9th)
• Specialist availability(tied for
• Televideo support
• Physician workforce stability
• Production incentive
9th)
• Welcome/recruitment program (tied for 9th)
Cumulative CHC Community Apgar Score by Facility – Across Two States
Cumulative CHC Community Apgar Score by Facility – Across Two States
Top 10 Challenges - CAH
Idaho
(2012)
Wyoming
(2011)
North Dakota
(2011)
Wisconsin
(2012)
Alaska
(2012)
•Shopping/other
services
• Spousal
satisfaction
• Climate
• Spousal
satisfaction
• Spousal
satisfaction
•Spousal
satisfaction
• Shopping/other
services
• Spousal
satisfaction
• Televideo support
• Shopping/other
services
•Mental health
• Access to larger
community
• Shopping/other
services
• Inpatient care
• Mental health
• Mental health
• Shopping/other
services
• C-section
•Access to larger
community
• Social networking
• Access to larger
community
• Social networking
• Access to larger
community
•Allied mental
health workforce
• Allied mental
health workforce
• Allied mental
health workforce
•C-section
• Climate
• Emergency room
coverage
•Schools
•Electronic
medical records
•Obstetrics
•Religious/cultural
opportunities
• Religious/cultural
opportunities
• Social networking
• Electronic
medical records
• Demographic/pati
ent mix
• Nursing home
• Call/practice
coverage (tie for
10th)
• Electronic
medical records
(tie for 10th)
• Electronic
medical records
• Mental health
• Climate
• Climate
• Part-time
opportunities
• Endoscopy,
surgery
• C-section
• Employment
status
• Obstetrics
• Electronic
medical records
• Social networking
Top 10 Importance - CAH
Idaho
(2012)
Wyoming
(2011)
•Spousal
satisfaction
• Revenue flow
•Loan repayment
• Spousal
satisfaction
•Income
guarantee
• Competition
•Call/practice
coverage
• Income
guarantee
•Recreational
opportunities
• Physician
workforce stability
•Revenue flow
• Call/practice
coverage
•Schools
•Perception of
quality
• Perception of
quality
•C-section
• C-section
•Obstetrics
• Employment
status
• Loan repayment
(tie for 10th)
• Obstetrics (tie for
10th)
North Dakota
(2011)
• Spousal
satisfaction
• Perception of
quality
• Call/practice
coverage
• Physician
workforce stability
Wisconsin
(2012)
• Schools
• Employment
status
• Perception of
quality
• Physical
plant/equipment
• Loan repayment
• Spousal
satisfaction
• Physical
plant/equipment
• Revenue flow
• Transfer
arrangement
• Emergency room
coverage
• Employment
status
• Income
guarantee
• Physician
workforce stability
• Obstetrics
• Emergency room
coverage
• Call/practice
coverage
Alaska
(2012)
• Spousal
satisfaction
• Physician
workforce stability
• Call/practice
coverage
• Schools
• Perception of
quality
• Loan repayment
• Moving allowance
• Recreational
opportunities
• Nursing
workforce
• Income
guarantee
Top 10 Advantages - CAH
Idaho
(2012)
• Recreational
opportunities
• Internet access
• Community need/
physician support
• Loan repayment
Wyoming
(2011)
North Dakota
(2011)
• Employment status
• Internet access
• Community
need/physician
support
• Perception of
quality
• Loan repayment
• Transfer
arrangements
Wisconsin
(2012)
• Recreational
opportunities
• Employment status
• Income guarantee
• Nursing workforce
Alaska
(2012)
• Moving allowance
• Income guarantee
• Emergency medical
services
• Recreational
opportunities
• Recreational
opportunities
• Income guarantee
• Loan repayment
• Religious/cultural
opportunities
• Income guarantee
• Ancillary staff
workforce
• Community
need/physician
support
• Community
volunteer
opportunities
• Community
volunteer
opportunities
• Revenue flow
• Ancillary staff
workforce
• Ancillary staff
workforce
• Competition
• Transfer
arrangements
• Hospital leadership
• Perception of
quality
• Community
need/physician
support
• Ancillary staff
workforce
• Start-up/marketing
costs
• Employment status
• Moving allowance
• Community
volunteer
opportunities
• Income guarantee
• Perception of
quality
• Schools
• Start-up/marketing
costs (tie for 10th)
• Recreational
opportunities (tie for
10th)
• Part-time
opportunities (tie for
10th)
• Moving allowance
(tie for 10th)
• Inpatient care
• Payor mix
• Transfer
arrangements
• Perception of
quality
• Mid-level provider
workforce
• Perception of
community
• Community
need/physician
support (tie for 10th)
Top 10 Apgar Factors - CAH
Idaho
(2012)
• Recreational
opportunities
• Internet access
• Community need/
physician support
• Loan repayment
• Income guarantee
• Perception of
quality
• Competition
• Stability of
physician workforce
• Employment status
• Call/ practice
coverage
Wyoming
(2011)
North Dakota
(2011)
• Employment status
• Perception of
Quality
• Loan repayment
• Transfer
arrangements
• Income guarantee
• Community
need/physician
support
• Recreational
opportunities
Wisconsin
(2012)
• Moving allowance
• Recreational
opportunities
• Recreational
opportunities
• Perception of
quality
• Income guarantee
• Income guarantee
• Emergency medical
services
• Loan repayment
• Nursing workforce
• Inpatient care
• Income guarantee
• Religious/cultural
opportunities
• Community
need/physician
support
• Internet access
• Revenue flow
• Competition
• Ancillary staff
workforce
• Transfer
arrangement
• Ancillary staff
workforce
• Employment status
• Ancillary staff
workforce
• Moving allowance
(2012)
• Employment status
• Community
need/physician
support
• Transfer
arrangements
Alaska
• Moving allowance
• Schools
• Physician
workforce stability
• Community
volunteer
opportunities (tie
for 10th)
• Revenue flow (tie
for 10th)
• Perception of
quality
• Community
volunteer
opportunities
• Physical plant and
equipment
• Welcome and
recruitment (tie for
10th)
• Perception of
community (tie for
10th)
Bottom 10 Apgar Factors - CAH
Idaho
(2012)
Wyoming
(2011)
• Spousal
satisfaction
• Spousal
satisfaction
• Shopping/other
services
• Shopping/other
services
• Schools
• Access to larger
community
• Mental health
• Allied mental
health workforce
• C-section
• Access to larger
community
• Electronic medical
records
• Obstetrics
• Religious/ Cultural
opportunities
• Mental health
North Dakota
(2011)
Wisconsin
(2012)
Alaska
(2012)
• Climate
• Spousal
satisfaction
• Spousal
satisfaction
• Spousal
satisfaction
• Televideo support
• Shopping/other
services
• Shopping/other
services
• Mental health
• Inpatient care
• Climate
• Shopping/other
services
• Access to larger
community
• Mental health
• Part-time
opportunities
• Social networking
• Access to larger
community
• Allied mental
health workforce
• Emergency room
coverage
• Religious/cultural
opportunities
• Demographic/pati
ent mix
• Electronic medical
records
• Climate
• Social networking
• Perception of
community
• Electronic medical
records
• Allied mental
health workforce
• Mid-level
supervision
• Nursing home
• Electronic medical
records
• Social networking
• Climate
• C-section
• Endoscopy,
surgery
• Employment
status
• Electronic medical
records
• Social networking
Cumulative CAH Community Apgar Score by Hospital – Across Five States
Cumulative CAH Community Apgar Score by Hospital - Across Five States
Questions/Comments for
Discussion