7 Questions With Dr. Kim Stokes: How ECU Will Boost Rural Health Care with $1.2M
A new grant award will be put to work placing more medical providers into the rural areas in which they’re needed.
The United States Health Resources and Services Administration (HRSA) recently awarded ECU’s Department of Physician Assistant Studies $1.2 million for the Physician Assistant Program Primary Care Training Enhancement grant.
Dr. Kim Stokes, director of clinical education for the College of Allied Health Sciences’ Department of Physician Assistant Studies, is the principle investigator for a new grant that will work to seed more medical providers into the rural communities where they’re most needed. (Contributed photos taken pre-COVID-19)
Dr. Kim Stokes, director of clinical education for the department, is the principle investigator of the interdisciplinary project that includes faculty from other departments within the College of Allied Health Sciences, as well as the Brody School of Medicine, and emphasizes interprofessional collaboration among health care students to achieve better patient outcomes.
The project is one of many ongoing within ECU’s Division of Health Sciences working to increase the number of health care providers in rural, underserved areas and to provide interprofessional experience to students from a vast array of health care fields.
“We are all a team with a common goal: positive patient outcomes. The more our learners can practice working as a team before they get to clinics, the more impact they can have in the clinical learning and practice environment,” Stokes said. “When the Interprofessional Education Collaborative (IPEC) came together in 2011, they envisioned that graduates trained in interprofessional principles would encourage the changes needed in the clinical learning/practice environment needed for collaborative, patient-centered care.”
The four-year project aims to:
- Expand rural training sites to retain rural medical providers
- Provide interprofessional learning opportunities between medicine and behavioral health students
- Provide medication assisted-treatment (MAT) training for graduates
- Provide training and continuing medical education (CME) related to resilience and decrease burnout of students, preceptors and faculty.
- Create an admissions pipeline for military veterans into the program.
As director of clinical education for PA learners, Stokes will be working on the rural health expansion portion of the grant and will work on continuing education related to burnout and resilience as well as interprofessional education. Other ECU faculty partners working on the project include Dr. Alan Gindoff and Jane Trapp, also of PA Studies, Dr. Paul Toriello from the Department of Addictions and Rehabilitation Studies, Dr. Rob Carels, professor in the Departments of Psychology and Family Medicine and Dr. Molly Jacobs, assistant professor in the Department of Health Services and Information Management.
Dr. Kim Stokes works with PA students in one of the simulation labs prior to COVID-19.
You’re in the first year of this four-year grant. What are you currently working on with respect to the grant and how do you see the timeline developing in the next three years?
“We are currently trying to work through the hoops associated with hiring a grant manager during a pandemic. This is a struggle to say the least,” Stokes said, adding that a grant manager is key to operationalizing funds, but the COVID-19 pandemic has caused the hiring process to be delayed. “In the next two to three years, I anticipate securing relationships with local preceptors to help generate rural health tracks with integrated behavioral health. We also plan to quickly integrate medication assisted treatment training for opioid use disorders into our curriculum for all graduating PA students in an effort to increase the number of MAT trained and registered providers in eastern NC. Ultimately, we plan to have additional modules for students and preceptors, including modules related to screening, brief intervention, and referral to treatment, interprofessional collaboration, resiliency, and burnout.”
What’s your strategy for expanding rural training sites and why is it important to retain more medical experts in rural areas?
“Rural areas need quality primary care providers. This is about more than just ‘access’ to a provider. Primary care addresses preventable diseases/illnesses from ensuring patients get screening exam and immunizations. But, more importantly, a good primary care provider develops an ongoing relationship with their patient. There’s trust and rapport. There’s stability. High quality primary care is evidence-based and rooted in collaboration with patients, families, specialists, allied health, and other resources. The strategy in the grant to expand rural health training sites involves engagement with rural health sites and health systems to create training experiences for PA learners (and also counseling learners) that allow students to live in these areas for more than a four-week rotation. By allowing the students to immerse in the communities, we hope they will decide to stay in these areas. We plan to partner with these sites and their providers, offering CME to the providers as well. Additionally, we are exploring pipeline opportunities to recruit students from rural areas who plan to return to these areas after graduation to practice. ECU Pirate PA alumni are a force and if their sites allow them to precept students, they commonly do. This would increase our rural training sites as well.”
What kinds of interprofessional learning opportunities are you planning for medical and behavioral health students?
“The plan is to have up to four collaborative learning environments included in the
grant. These will be the rural health sites we partner with, who allow an integrated behavioral health student in the site at the same time a PA learner is assigned to the site. At least one day per week, the PA student and the behavioral health student can see patients together, learn from each other. An additional thought is to have behavioral health learners teach our students the concepts related to SBIRT as it relates to substance use disorders.”
What kind of medication assistance training will be involved and why is it important for graduates? Will it be only for PA graduates or will graduates of other programs receive it as well?
“The Substance Abuse and Mental Health Services Administration (SAMHSA) has a Medication-Assisted Treatment (MAT) waiver certification for opioid use disorder treatment. After connecting this waiver to their DEA certification, this allows the provider to prescribe medications to patients who are known to use opioids that may be life saving,” Stokes said. “Currently, rural and underserved areas are highly affected by the opioid epidemic, yet few MAT waiver certifications are registered in SAMHSA for eastern NC or other rural areas. The training is available (currently) for free for physicians, physician assistants, nurse practitioners and nurse midwives. When our students graduate, they can take the exam and register. Currently practicing providers can do that now.”
Stokes added that clinical year curriculum changes due to COVID-19 provided an opportunity add MAT training to the program’s current clinical practicum.
“It was easier than anticipated to add the MAT training to our current clinical practicum and we will continue to offer it this way. As the training is free, it is available to any person who wishes to take it. I do anticipate creating clinical cases related to MAT as we progress through the grant to allow learners to practice these conversations and prescribing before they get into clinics. I hope to do some as part of their course assessments and then some interprofessional immersion that is related to research. When the modules and cases are generated for the standardized patients, I plan to make them readily available for physician and/or other advanced practice providers. We should all have a chance to learn. This could also be adapted into continuing education as well.”
What made you want to include resilience training and decreasing burnout as part of this project? Are there common causes of burnout that you’ve observed from students, preceptors and faculty?
“Burnout in rural health is abundant due to the lack of providers and the high volume of patients. There are two important factors that contribute to this: 1. A lower number of providers seeking to practice rural primary care and 2. A broken healthcare system that relies on third-party payers including Medicaid and Medicare. Population data shows that young, healthy adults are moving out of rural areas an into more population dense (urban or suburban areas). Reimbursement from Medicaid and Medicare are lower than typical private insurance. To make up for the financial imposition, more patients are booked into the system. Thus, the provider is seeing more patients in an already busy day. To boot, the population is aging. This has been anticipated as the baby boomers become Medicare eligible. People are living longer these days, but with more chronic disease burden. This means that same rural health provider is seeing more patients who are also sicker and more complicated. There is no reprieve, no break from the cycle. In my opinion, healthcare providers are generally altruistic, putting the needs of the patient above their own. They will do this until they are stressed, chronically, to the point of burnout. Chronic stress is no joke. We see what it does to our patients regularly: hypertension, diabetes, strokes, coronary artery disease, depression, anxiety, even suicide. Healthcare providers are not immune.
“The primary way to combat burnout is through resilience. A lot of people think ‘Resilience? Do you mean yoga and meditation?’ Sure, resilience can include yoga and meditation. But it can also include self-awareness, knowing when you need to take a break, scheduling time to be truly away, recognizing when to ask for help, gratitude practice, a girls’ night, a Bible study or even just getting a timely breath of fresh air or some exercise. Sharing the load of responsibility for the patients and practice can also help to decrease burnout and stress. The interprofessional nature of this grant will allow us to introduce integrated behavioral health and physician assistants into practices that may not have had these exposures before. Having someone as your ally can help alleviate stress. This is an additional value of interprofessional clinical practice.”
How do you envision creating a military veteran pipeline for admission into the PA program? Will it be just for the PA program or is it for others as well?
“We have currently written a military veteran pipeline into the grant that would allow for a 6% increase in matriculated military veterans starting in year three. This is roughly 2 students per our 36-person cohort. We have been developing relationships with Camp Lejeune over the past few years related to clinical training sites. We hope to further explore potential in this area. Additionally, the ECU PA admissions team has already relaxed admissions related to military veterans (as it pertains to residency) to increase the applicant pool. The verbiage at this time is related to only the PA program, but I would love to see more military veterans in our clinical counseling programs. I think that could be highly impactful here in Eastern NC where we have four military bases (Fort Bragg, Goldsboro, Jacksonville, and Havelock) and three VA centers (Greenville, Jacksonville, Goldsboro and Morehead City) and a mental health provider shortage.”
What makes interprofessional projects like these important to the College of Allied Health Sciences and the Division of Health Sciences? How have they supported this type of collaboration?
“Interprofessional education and collaborative practice (IPECP) is vital to ensuring healthy patient populations. We are all a team with a common goal: positive patient outcomes. The more our learners can practice working as a team before they get to clinics, the more impact they can have in the clinical learning and practice environment. When the Interprofessional Education Collaborative (IPEC) came together in 2011, they envisioned that graduates trained in interprofessional principles would encourage the changes needed in the clinical learning/practice environment needed for collaborative, patient-centered care.
“Both DHS and CAHS have been very supportive of our efforts to obtain grant funding. I thank (vice chancellor for the Division of Health Sciences) Dr. Stacy for hearing ideas related to IPECP and supporting them when possible. Additionally, (College of Allied Health Sciences dean) Dr. Orlikoff has been instrumental to advancing IPECP within CAHS and beyond. This support has come through development of a task force to address IPECP needs within the college as well as supporting professional development to spur innovation and research opportunities within the college.”