FRANKLIN, Va. — On a sunny Tuesday in July, the blue door of Old Dominion University’s Medical Mobile Clinic opened onto a parking lot in Franklin, and a teenage boy went quickly down the steps.
“Have a great day!” Tammy Speerhas, director of ODU’s Community Care program, called after him. “Have a great football season!”
The city of Franklin, which is surrounded by Southampton County in Virginia’s Southside region, is one of the state’s most underserved areas when it comes to health care. According to the Virginia Health Workforce Development Authority, Southside has one of the state’s highest concentrations of counties designated as shortage areas for primary care, mental health, and other medical services. That data is borne out on the ground: Speerhas said this summer that Franklin’s only two pediatricians were booked through the fall. The alternative for residents was to drive a half-hour to an urgent care facility in Suffolk, where routine check-ups are not covered by most insurance.
That’s where the mobile clinic came in. Operating in Franklin starting this year, the clinic is treating K-12 students in need of back-to-school and sports physicals and then continuing to operate for other care.
“A lot of these kids aren’t playing sports because they can’t get their physicals,” said Speerhas, who was overseeing the team of nurses, medical professionals, students and volunteers staffing the clinic. With the mobile unit, “we’re able to do these free sports physicals, and it also allows us to identify any other needs that they might have.”
Food insecurity, dental issues and conditions like asthma and scoliosis are just some examples of additional needs discovered by medical workers during these physicals. Doing check-ups on the children has also helped build trust with parents, who have then followed up for treatment themselves, Speerhas said.
“It’s amazingly fulfilling and rewarding to not only be able to give pre-care to a community that is so appreciative, but to teach and educate students and have them see this population through a different lens,” Speerhas said.
The ODU mobile clinic is modeled after St. Mary’s Health Wagon, a remote area medical clinic that visits several sites in Southwest Virginia annually to provide services to residents who might otherwise have no place to go for health care. The projects are just two of numerous donation-driven and grant-funded initiatives across the state that seek to address the health care disparities found throughout rural Virginia.
But despite these efforts, gaps in health care access continue to widen. An analysis of July 2023 data by the Center for Healthcare Quality and Payment Reform, a national policy center advocating for improved health care payment systems, found nine rural hospitals are currently at risk of closing in the state.
“Even before COVID, there were many hospitals — including rural hospitals, but not exclusively rural hospitals — that had negative operating margins,” said Julian Walker, vice president of communications for the Virginia Hospital and Healthcare Association.
There are numerous reasons why health care providers struggle in rural areas, but one of the key factors has been their failure to recruit and retain sufficient medical staff. Walker said that shortages existed before the pandemic, but the outbreak exacerbated them as contract labor costs spiked.
Last year, the General Assembly tasked the Virginia Healthcare Workforce Development Authority with examining how to reverse staff shortages in the state’s health care industry. Published in September, the group’s final report said a series of interventions was necessary to correct a downward trajectory.
“If current trends persist, nursing, primary care, and behavioral health workforce shortages will increase across Virginia,” the report found.
Data shows 102 of Virginia’s 133 counties and cities, accounting for 29% of the state’s population, meet federal criteria to be designated as Health Professional Shortage Areas (HPSAs) for primary care. Many of these are in rural regions, which present other unique challenges such as lack of infrastructure and cultural differences.
Additionally, while Virginia trains many health care workers at schools such as ODU, Virginia Commonwealth University and the University of Virginia, many also leave: According to the authority’s report, 40% of graduates from four-year nursing programs in Virginia go on to jobs in other parts of the country.
State investments
Based on those findings, VHWDA requested over $14.7 million from the state over the next two years to fund measures to support retention, recruitment and structural efficiency in the workforce. Whether that happens will be up to Gov. Glenn Youngkin, who will present his budget proposal to lawmakers this December, and the General Assembly, which is responsible for crafting the state’s biennial spending plans.
“Virginia hasn’t dedicated a lot of operational dollars to support health workforce development initiatives,” said Harrison Hayes, the authority’s executive director.
The General Assembly’s Joint Commission on Health Care said in a report last year that the state ranked 38th in the country on public health spending. Hayes said the authority received funding from the state for the first time last year: $600,000 for operational costs and $600,000 for the workforce study. Although the authority had been created in 2010, it previously had been federally funded.
That lack of investment has forced rural providers like the Northern Neck Middlesex Free Health Clinic to come up with creative ways to keep their boat afloat. CEO Jean Nelson said balancing the checkbook has turned into a complicated game of searching for funding from alternative sources like private donors.
“We get probably about $170,000 from the state,” Nelson said. “170,000 is nothing. Our budget is $2 million.”
One of the main missed opportunities by the state government, said Hayes, is not providing supplemental funding to Area Health Education Centers. These federally funded facilities serve as conduits for local health care workers, connecting medical students with jobs and internships as well as sponsoring continuing education. There are eight AHEC regions in Virginia.
“North Carolina provides a significant amount, over $56 million” to its AHEC program, Hayes said. “Maryland provides nearly a million, Georgia $6 million. And then when you look at Virginia, we don’t provide any funding to ours.”
Part of the authority’s funding request is for roughly $1.1 million to go toward matching grants for the program over the next two years.
The state could also provide more incentives for young medical professionals like loan repayment offers, said Nelson. A preliminary VHWDA study published earlier this year touted Virginia as having one of the top loan repayment programs among peer states, but also said it could be expanded further.
That study said that in 2022, the Virginia Department of Health allotted $6.8 million for student financial assistance, while the state currently has $3.3 million dedicated to its loan repayment program. However, some of the repayment awards are as low as $1,000 — a drop in the bucket for the average medical student’s total debt.
Attracting medical professionals to rural areas — and keeping them there
Even with incentives, it can be difficult to attract young medical professionals to work in rural areas, said Tracy Douglas, CEO of the Virginia Community Healthcare Association.
“A lot of folks are focused on quality of life, and that means access to activities and events,” Douglas said. “Many of these rural communities don’t have those kind of activities available.”
While they may not be as exciting as metropolitan areas, Douglas said rural communities still have a lot to offer, and her team has put together online profiles to help market them to aspiring medical professionals as places to both work and live.
The VHWDA report notes that when it comes to rural investments, Virginia has made progress in areas like broadband, but still faces shortfalls in housing, transportation and child care. The General Assembly passed legislation in 2020 to develop a statewide telehealth plan that has seen great success in extending care to rural areas, and this year’s long-awaited budget deal included $10 million for mobile behavioral health crisis services in underserved areas. But Hayes said medical staff wanted modern conveniences other than just internet access.
“Some nurses would love to practice in rural settings but oftentimes go to an urban setting to do a travel contract because everything that they need is right in that area and they don’t have to travel far distances in order to get the services that they need for their family, themselves or their kids,” Hayes said.
One possible solution: recruit more professionals from their rural hometowns. ODU Associate Chair of Nursing Carolyn Rutledge, who grew up in a rural area herself, said her program does just that.
“If you recruit them from there, you keep them there,” Rutledge said. “Then they’re likely to stay there.”
An additional barrier to getting health professionals into rural settings has been Virginia’s strict scope of practice laws, which limit what advanced nurse practitioners, physician assistants, dental hygienists and other medical staff can do on their own without supervision.
In 2018, Virginia passed legislation that allowed nurse practitioners to operate their own standalone practices, but only after five years of full clinical experience. That restriction was temporarily lowered further to two years during the pandemic, but it has since been brought back up to five.
Today, Virginia is one of 10 states that still have restricted-practice authority laws for nurse practitioners. Many physicians say the limits are needed to protect patients, arguing nurse practitioners don’t have sufficient training or education to operate practices without a doctor’s oversight. But other groups say the system needs to be changed.
“A nurse practitioner should be able to do everything they were trained to do instead of having these artificial restrictions placed on them,” said Beth O’Connor, executive director of the Virginia Rural Health Association. “Scope of practice could be a major issue for Virginia going forward.”
Burnout
One problem rural health care workers share with their urban and suburban counterparts: burnout. It’s an issue that only became more pressing with the COVID-19 pandemic.
“They’re burnt out,” Hayes said. “There’s an opportunity to ensure that we prevent burnout but also that we have a strong pipeline of nurses and healthcare professionals that get into the profession and actually enjoy being in the profession and staying in the profession.”
On top of the stress that comes with understaffing, many health care workers interviewed in the VHWDA report cited concerns related to safety, reporting a spike in workplace violence since COVID. Walker said that health care providers are five times more likely to be victims of workplace violence than workers in any other industry.
One person quoted in the final report said that as an emergency room nurse in Virginia, they had been “punched, slapped, bit, kicked, spit on,” and “confronted multiple knives and guns.”
“With every one of these situations, although hospital leadership preached a zero-tolerance policy to workplace violence, I was discouraged,” they said. “Nursing retention is difficult if the threat of physical harm is present every day.”
Facing so many challenges, the Virginia Healthcare Workforce Development Authority is putting together a coalition of health care professionals, schools, employers and government agencies to try to reverse the more worrying workforce trends. While the General Assembly has passed roughly 60 bills in the past 10 years related to health care workforce development, steep problems remain. Among the goals VHWDA hopes the coalition will tackle are raising wages, reducing workplace violence and stress, offering more financial assistance to students and making it easier for young professionals to find jobs.
Despite all of the obstacles facing rural health care workers, professionals like Speerhas and those at the ODU mobile clinic continue their work, many motivated by a simple desire to serve the community.
“I know it’s cliche, but we’re truly making a difference and making an impact,” Speerhas said. “To wake up everyday and be able to do that, why would you not?”
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