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Plugging holes in rural health care

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Copyright © 2014 Albuquerque Journal

DaVon and Shirley Knackstedt are husband and wife nurse practitioners who work at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla, south of Chama, in northern New Mexico. The couple commute to their home in Albuquerque on the weekends. Attracting health professionals to rural areas and retaining them can be difficult in rural New Mexico because of the isolation of some small communities, say recruiters. (Roberto E. Rosales/Albuquerque Journal)

DaVon and Shirley Knackstedt are husband and wife nurse practitioners who work at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla, south of Chama, in northern New Mexico. The couple commute to their home in Albuquerque on the weekends. Attracting health professionals to rural areas and retaining them can be difficult in rural New Mexico because of the isolation of some small communities, say recruiters. (Roberto E. Rosales/Albuquerque Journal)

TIERRA AMARILLA – More than 7,500 feet above sea level, and 75 miles from the nearest hospital emergency room, the quiet town of Tierra Amarilla isn’t just isolated.

“We’re the frontier,” says Darren DeYapp, executive director of La Clinica del Pueblo de Rio Arriba off U.S. 84.

The clinic is the hub for medical, dental and behavioral health care in this sparsely populated area and served 2,405 patients last year, according to federal data.

For more than three years, the clinic has been without a physician. But that’s nothing new.

In its 43 years of existence, DeYapp said, “we’ve had more time without a doctor than we’ve had with a doctor.”

This area south of the Colorado border is lush in the spring and summer but can turn brutal in the winter cold.

“It’s a hard sell. We do not have all the creature comforts people are looking for. There’s not a Starbucks here; there’s not a Whole Foods store here,” DeYapp said.

Chronic turnover among the clinic’s health professionals can be rough on patients.

La Clinica del Pueblo de Rio Arriba hasn't had a staff physician for three years, but relies on four so-called midlevel health professionals to serve a sparsely populated area of 15 communities. A disproportionate majority of New Mexico's health care workforce is concentrated in urban areas, leaving rural communities underserved, according to state data. (Roberto E. Rosales/Albuquerque Journal)

La Clinica del Pueblo de Rio Arriba hasn’t had a staff physician for three years, but relies on four so-called midlevel health professionals to serve a sparsely populated area of 15 communities. A disproportionate majority of New Mexico’s health care workforce is concentrated in urban areas, leaving rural communities underserved, according to state data. (Roberto E. Rosales/Albuquerque Journal)

“The community is hypersensitive; they see the changing of the guard,” he said. “But they start to lose confidence in you, like ‘here I am again having to rehash my medical information.’ You develop these very strong relationships with your provider, and then they leave.”

DeYapp said personnel rules prevent him from explaining to patients why their health provider has resigned.

“But I tell them the world is about change, and we have to embrace it and do what we can do,” he said.

Here in the Chama River Valley north of Española, and elsewhere in rural New Mexico, so-called midlevel health professionals will increasingly be called on to plug the holes in community safety nets.

La Clinica’s medical team is made up of two physician assistants and a husband-and-wife team of nurse practitioners. “They can do 90 percent of what a doctor can do,” DeYapp said.

Patients from the 15 communities served by the clinic are referred to Santa Fe or Española if they need to be seen by physicians or specialists.

Nurse practitioners and physician assistants are the new hope for New Mexico’s strained health care system, because they can be trained more quickly and cheaply than doctors, according to a state Legislative Finance Committee report.

Shirley Knackstedt is a nurse practitioner at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla, north of Española. The clinic is the only place in the area that some people can get their medications. Finding health professionals in rural areas like Tierra Amarilla is becoming increasingly challenging, recruiters say. (Roberto E. Rosales/Albuquerque Journal)

Shirley Knackstedt is a nurse practitioner at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla, north of Española. The clinic is the only place in the area that some people can get their medications. Finding health professionals in rural areas like Tierra Amarilla is becoming increasingly challenging, recruiters say. (Roberto E. Rosales/Albuquerque Journal)

Yet New Mexico’s production of those two so-called “midlevel” professionals lags behind that of primary care physicians, the report says.

While the state needs an additional 219 primary care physicians to keep up with its population, there’s a shortage of more than 280 nurse practitioners, according to the New Mexico Health Workforce Committee’s report for 2013. The study didn’t examine the physician assistant workforce.

New Mexico has about 577 licensed physician assistants who work as “workforce extenders” in primary care, but the LFC report says they must be overseen by physicians and tend to work in hospital settings, often as part of a surgical team.

The availability of both nurse practitioners and physician assistants practicing in urban areas of New Mexico is about twice that of rural areas, according to a 2006 report cited by the LFC report.

Gov. Susana Martinez and the LFC are endorsing initiatives to be introduced during the upcoming legislative session that would increase health professional rolls. The proposals were spurred in part by the fact that an estimated 160,000 new Medicaid recipients are expected beginning this year, and thousands of previously uninsured people will be obtaining coverage under the federal Affordable Care Act.

The LFC is recommending more than $5 million in new money to increase nursing capacity at the associate’s, bachelor’s and graduate levels.

Jessica Wise from El Vado get into her truck to head home after a dental appointment at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla. The clinic offers dental care, but is lacking a primary care physician. Other rural areas of the state are having trouble attracting dentists, forcing residents to drive long distances for care. (Roberto E. Rosales/Albuquerque Journal)

Jessica Wise from El Vado get into her truck to head home after a dental appointment at La Clinica del Pueblo de Rio Arriba in Tierra Amarilla. The clinic offers dental care, but is lacking a primary care physician. Other rural areas of the state are having trouble attracting dentists, forcing residents to drive long distances for care. (Roberto E. Rosales/Albuquerque Journal)

At the top of Martinez’s health workforce spending proposals is money for additional nurse practitioners to be trained at the University of New Mexico College of Nursing. The number of graduates would be increased from 16 a year to about 40, with most of the funding helping to increase salaries to attract qualified instructors.

Martinez is also asking the Legislature for funding to help recruit nurse practitioners from other states “because we have such a good practice environment we should take advantage of it,” said Nancy Ridenour, dean of the University of New Mexico College of Nursing.

“I know Texas and Oklahoma already are a little upset with us because those two states don’t have as open a practice law and some practitioners are thinking about moving,” Ridenour said.

Ridenour got her start as a nurse practitioner in Colorado.

“In my experience, if a person has seen a nurse practitioner, they ask to see us again and, in fact, when I was in Colorado … a pediatrician called me and said I don’t know what a nurse practitioner is but my patients say I need one.”

The education of a primary care physician typically takes at least 11 years, compared with a total of six years for nurse practitioners.

Because the nurse practitioner program takes a registered nurse with a bachelor’s degree two years to complete, that initiative is considered one of the quicker ways to shore up the supply of providers in New Mexico.

DeYapp said he hopes to work with UNM to attract new recruits. During interviews with prospective health professionals, he said, salary can be an issue but so can concerns about housing and schools. Then, there’s the lack of privacy.

“You never disconnect in a rural community,” he said. “You’re at the grocery store and see your patients. You’re at the basketball game. Many health professionals just want to get away (when they’re not at work).”

Shirley Knackstedt and her husband, DaVon Knackstedt, are former Kansas farmers turned nurse practitioners.

For the past three years, the couple have worked in Tierra Amarilla during the week and commuted to their home in Albuquerque on the weekends. They live in an apartment above the clinic with their small dog during the work week.

“We have the fresh air and the people of northern New Mexico during the week, and when we go home, we have the big city. It really is the best of both worlds,” Shirley Knackstedt said.

Clinic physician assistant James Derrick also commutes to his home in Rio Rancho on weekends. He is supervised by a physician in Española, whom he talks to a few times a month.

DeYapp said many patients don’t distinguish between midlevel practitioners and physicians when they need care. But some “are adamant about wanting to see a doctor. And you can’t blame them.”

Shirley Knackstedt said the issue sometimes arises.

If a patient says he or she would rather be seeing a physician? She laughs. “I’d tell them, go ahead; try to find one. Good luck.”

Most patients are happy to see her, she added.

“A lot of people say, ‘I like you better than a physician because you spend time with me and you listen to what I say.’ With a nursing background, we are trained to listen.

“Nurses are very much patient advocates.”

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