FNU Footprints: Eastern Kentucky Impact Report

FNU Impact Report:

Eastern Kentucky

IMPACT Report: Eastern Kentucky

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Appalachia: Beautiful Barriers 2

Dear Friends: There is no denying the beauty and splendor of the Appalachian region of eastern Kentucky. The picturesque hills and mountains, vibrant colors, and rural settings are the subject of calendars and postcards. However, those hills and rural settings also contribute to a significant problem in many parts of the region -- the availability of and access to adequate healthcare.

Mary Breckinridge recognized the difficulty of providing healthcare to people in these rural areas and founded the Frontier Nursing Service (FNS) in Hyden, Ky., in 1925. FNS introduced the first nursemidwives to the U.S. Riding horses up mountains, through fog, flood or snow, the FNS nurses brought modern healthcare to one of the poorest and most inaccessible areas in the U.S. Mary Breckinridge demonstrated that care provided by nurse-midwives acting as nurses to the family would drastically cut infant and maternal mortality, as well as morbidity and mortality in the community. The impact of FNS led to the founding of Frontier Nursing University as the Frontier Graduate School of Midwifery in 1939 as part of FNS’ demonstration project in the care of the mother and child in rural areas of Kentucky. The model of care brought forth by Mary Breckinridge so many decades ago continues today through the work of FNU faculty, students, and graduates across the nation.

At Frontier Nursing University, we work every day to address healthcare shortages, particularly in rural and underserved populations. Today, our unique distance-learning model allows and, in fact, encourages students to continue their education in the same communities where they practice. Our students aren’t pulled to larger cities to be able to attend classes. They can remain in their local communities, and continue to work and serve there while attending classes on a flexible schedule.

As a result, our graduates are practicing in rural and underserved communities across the country.

For example, just since 2010, FNU has graduated 188 new nurse practitioners and nursemidwives who serve in eastern Kentucky. Nearly 150 FNU graduates are currently practicing in Alaska, many in extremely remote and rural areas with limited healthcare providers. Similar examples of our presence are felt across the United States. Our enrollment has grown to more than 2,000 students and our faculty consists of over 100 faculty members who guide the student through the process and visit their clinical sites.

We are extremely proud of the ever-growing impact of FNU graduates in these rural and underserved communities, including our birthplace in eastern Kentucky. In this report, we want to share with you the challenges represented in that region and how FNU graduates are filling in the gaps to provide outstanding healthcare in the area. The data is eye-opening and the stories are compelling. We appreciate your time to read this report. We welcome your input and thank you for your support of healthcare in our country.

Sincerely,

Susan Stone, CNM, DNSc, FAAN, FACNM Susan Stone, DNSc., President, Frontier NursingCNM, University President, American College of Nurse-Midwives

IMPACT Report: Eastern Kentucky

FACNM, FAAN

The Problem More than 58 million Americans reside in geographic areas or belong to groups that are considered primary care shortage areas. Alarmingly, 54% of rural counties across the United States are without maternity care.

Maternal mortality rates have climbed 40% in the last 20 years. Over 90 million adults live in areas where shortages of mental health professionals make obtaining treatment difficult.

These problems are particularly prevalent in rural Kentucky. As illustrated in the map below, the vast majority of counties in southeastern Kentucky are

designated as medically underserved. This lack of care contributes to the high rates of obesity and diabetes in the region. Even in counties that are not designated as underserved, a high percentage of residents have significantly poor health. In Johnson County, for example, 43 percent of its nearly 23,000 residents are considered to be in “Less than good health”*. Despite its beauty, the region’s remote locations and rural clinics and hospitals struggle to attract healthcare providers from larger cities and communities. *Source: KentuckyHealthFacts.org

Commonwealth of Kentucky Medically Underserved Counties in Kentucky Medically underserved counties.

Partially medically underserved counties.

County where a Nurse Practitioner is the only full-time healthcare provider.

Community where a Nurse Practitioner is the only full-time healthcare provider.

Source: The Kentucky Coalition of Nurse Practitioners & Nurse-Midwives

Poverty, 2016-Kentucky 0%-7%

7%-14% 14%-21% 21%-28%

>28%

Source: U.S. Census Small Area Income and Poverty Estimates, 2009-2016

IMPACT Report: Eastern Kentucky

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The Model FNU’s distance-learning model addresses many of the issues at the core of poor healthcare in rural and underserved areas. It does so by educating and training nurse practitioners and nurse-midwives in the same communities in which they live and practice. The Frontier model of educating advanced practice nurses and midwives in their own communities is a critical part of the solution. Frontier graduates are increasing access to quality healthcare across the nation.

More than 180 FNU graduates practice in southeastern Kentucky. In many of these counties FNU graduates make up 50 percent or more of the total number of Family Nurse Practitioners in the county. That doesn’t fix all the healthcare gaps and disparities all at once, but it does add stability to the infrastructure and provides the basis for improved outcomes in the future.

Clay County

McCreary County

FNU Grads ............................ 8 Total NPs ............................. 17

FNU Grads ............................ 3 Total NPs .............................. 9

Floyd County

Perry County

FNU Grads ............................ 5 total NPs ............................. 25

FNU Grads ........................... 13 Total NPs ............................ 39

Johnson County

Pike County

FNU Grads ............................ 2 Total NPs .............................. 4

FNU Grads ........................... 16 Total NPs ............................ 35

Leslie County FNU Grads ............................ 9 Total NPs .............................. 9

In just an eight-county region, Frontier graduates comprise 42% of the advanced nursing providers in the area.

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IMPACT Report: Eastern Kentucky

FNU Graduates Address the Problem

PROFILE

Mission in Action In the following pages, you will read about five Frontier graduates who are making a difference in healthcare in eastern Kentucky. You will see the health data for their counties in which they work. You will learn about the challenges they face in their daily practice and the gaps they help fill for the people they serve. As you read these, please remember that these are just five stories. There are 180 more stories of Frontier graduates who are currently performing the same kind of work in these rural eastern Kentucky counties. Each and every one of these graduates are making a difference in the communities they serve.

Carolyn Compton, MSN, CFNP Carolyn Compton has been at the HomePlace Clinic of the Mountain Comprehensive Care Center since 2016.

The clinic operates in Pikeville, Prestonsburg, Paintsville, Louisa and Belfry, meaning that Compton practices in Floyd, Johnson and Pike counties.

She says that much of her practice involves treating high blood pressure, diabetes and high cholesterol.

“The main part of my care is providing a lot of education,” Compton says. “I talk to patients about how to help with cholesterol -- exercising at least three times a week for at least 20 minutes, eating better, things like that. There’s a lack of knowledge of health in this community and a lack of education that contributes to the healthcare issues.”

“There’s a lack of knowledge of health in this community and a lack of education that contributes to the healthcares issues.”

Carolyn Compton Pike County:

Floyd County:

Johnson County:

Population...........................60,555

Population............................ 37,110

Population...........................22,978

Less than good health............ 37%

Less than good health............ 36%

Less than good health............ 43%

FNU Alumni................................ 16

FNU Alumni.................................. 5

FNU Alumni..................................2

Physicians.................................197

Physicians.................................. 82

Physicians.................................. 37

NPs............................................35

NPs ............................................ 25

NPs..............................................4

OBGYN.........................................8

OBGYN.........................................6

OBGYN.........................................2

Pediatricians............................... 15

Pediatricians................................. 5

Pediatricians................................. 3

Prenatal Care Adequacy.......... 69%

Prenatal Care Adequacy...........58%

Prenatal Care Adequacy...........58%

IMPACT Report: Eastern Kentucky

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PROFILE

James Corder, DNP, APRN, FNP-C McCreary County, Ky., is home to 25 waterfalls, 40 natural arches and 640,000 acres of timberland. What it is not home to is a hospital.

The nearest hospital -- Lake Cumberland Regional Hospital -- is about 30 miles away. For patients seeking care, it’s a scenic but not necessarily easy commute on narrow roads through hills and forests. Nearly half of the county’s population is considered to be in less than good health. Chronic diseases such as diabetes and respiratory diseases plague its residents. Further, McCreary County ranks among the poorest counties in the United States.

“There are three nurse practitioners where I practice, and no medical doctors,” Corder says. “There are four practices that have no medical doctors at all. Because there’s no hospital, we have to treat more aggressively and do more than one would normally do in traditional primary care settings.”

Corder says that not only is attracting physicians to the area challenging, but it’s also not financially appealing to the clinics.

“A nurse practitioner (NP) is reimbursed by Medicare 85% of what they reimburse an MD,” Corder says. “They don’t want to hire an MD and pay them that much. So, it’s a lot more feasible to hire an NP. I’m seeing a lot more NPs coming into the rural workforce. I can see NPs filling the positions once occupied by MDs. The rural community is very much dependent on NPs.” For that reason, Corder says NPs in McCreary County are relied upon to do more.

“In general, we are forced to do more than what an NP would do in traditional primary care practice. We must rely more on our clinical skills than a clinic where we might have access to a hospital,” Corder says. “When Frontier students go to clinical they are prepared to see whoever the provider is seeing. Frontier prepares students to begin clinical. Early in the NP program of a lot of schools, students are limited to seeing whatever they are studying in class. For example, they may show up for a clinical rotation only able to do patient history and physical assessments. At Frontier, students are ready to just dive in and see whatever the preceptor is seeing because they have completed their didactic coursework up front—this works great.”

Part of diving in is understanding the residents and culture of the area. That comes naturally to Corder, whose father was a coal miner in Hyden, Ky., and died in a mining accident shortly after leaving the area.

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IMPACT Report: Eastern Kentucky

FNU Graduates Address the Problem

“A lot of places are just prepping them to take patient history and physical assessment. A Frontier student is ready to just dive in.”

James Corder

Corder’s mother took him to the hospital that sat on the mountainside in Hyden and she received prenatal care there while she was pregnant with his younger brother.

The medical card with his mother’s blood type on it says “FNS.” When he was choosing his NP program, he took that as a sign and enrolled at Frontier.

Corder’s family moved back to the foothills of the Appalachians to McCreary County. Practicing where he grew up helps him understand his patients and how to communicate with them.

“You don’t tell them they can’t eat biscuits and gravy,” Corder says. “You just tell them to eat it once every few weeks. I have to do more patient teaching than one might do in an urban area, where an NP could refer to a dietitian. We don’t have that available in this town, but a provider can do a lot of teaching with them in five to 10 minutes—ease them into small changes.”

“Understanding the culture and population is very important,” Corder continues. “Understanding the community where you practice is critical. The kind of disease processes that an NP repeatedly treats here might be much different than in, say, Florida. The mindset of the patients is different in different areas. FNU’s community assessment makes students really think about where they live, what kind of diseases and conditions are common in that area, and understanding the average education level of the patients.”

In addition to his work in McCreary County, James Corder recently went on a medical mission trip to Africa.

McCreary County: Population............................. 17,511 Less than good health............ 46% FNU Alumni..................................3 Physicians.................................. 12 NPs..............................................9 OBGYN........................................ 0 Pediatricians................................ 0 Prenatal Care Adequacy.......... 72%

IMPACT Report: Eastern Kentucky

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FNU Graduates Address the Problem

PROFILE

Denise Kilburn, CFNP Denise Kilburn’s ties to Frontier Nursing University not only include being a graduate, but she also worked at the Mary Breckinridge Hospital from 1995-2001.

Previously affiliated with Mountain Clinic in Hazard, Ky., as well as Pikeville Medical Center, she recently joined Correct Care Solutions working at Eastern Kentucky Correctional Complex in Morgan County. She also recently joined Schumacher Clinical Partners where she works in the Appalachian Regional Healthcare emergency departments throughout eastern and southern Kentucky.

“There are enough providers in the area, but they migrate to the hospitals,” Kilburn says. “There’s a lack of care out in the rural areas. It’s so far for people to get to primary care facilities.”

how to relate to them. She says that patients in the area respond better to less aggressive approaches.

“People in rural areas are more receptive to a low and slow approach,” she says. “Don’t start with all the bloodwork and tests. Sometimes patients don’t have the funds for all that or the will to follow up. You have to fix what you can while you have them there.”

Among the common conditions she treats are high blood pressure and other conditions related to obesity and poor diet.

“We have to be less aggressive with medications and more helpful with education,” she says. “Patients would do more to help themselves if they knew changing their lifestyle could help them take less pills.”

It can be difficult for someone who has only practiced in a larger cities or medical complexes to understand the mindset of those in rural eastern Kentucky.

Understanding what patients will and will not embrace in terms of lifestyle changes or medical treatments is vital to earning their trust.

“Having precepted a lot of students from other programs, I can say FNU’s approach is so much more holistic and with a broader spectrum,” Kilburn says. “There’s a better outlook on how to treat patients, family and Kilburn says that the Frontier model of educating community. Plus, Frontier has a stipulation that you have students in the communities in which they practice is to practice for a certain amount of time before you enter highly effective in helping understand the patients and the program. That makes a big difference, rather than just going from program to program with Perry County: Clay County: no nursing experience at all. In Population...........................27,343 Population.......................... 20,766 clinicals, FNU students must see Less than good health............ 37% Less than good health............ 36% a certain number of various types of patients. There’s just a huge FNU Alumni................................ 13 FNU Alumni..................................8 difference in FNU’s model that sets Physicians..................................97 Physicians..................................23 them apart from other programs.”

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NPs............................................39

NPs............................................ 17

OBGYN......................................... 1

OBGYN.........................................2

Pediatricians.................................6

Pediatricians................................. 1

Prenatal Care Adequacy.......... 64%

Prenatal Care Adequacy...........61%

IMPACT Report: Eastern Kentucky

FNU Graduates Address the Problem

PROFILE

Carrie Lee Hall, MSN, WHNP, FNP, SANE, CNM Hall continues to thrive in her field at Mountain Comprehensive Health Corporation, a facility which has approximately 500 births per year. She is always seeking new ways to improve health care in rural areas and was even featured in The American Nurse Project in recognition of her many accomplishments in the field.

As an alumnus, Hall gives back by serving as a preceptor for other FNU students who share her same concern for women and families.

“My passion is practicing in a rural area,” Hall says. “I would love to help promote breastfeeding, decrease smoking and other negative health habits, and bring greater awareness to the negative effects of drug abuse in Eastern Kentucky.”

A passion for mothers and babies runs through Carrie Lee Hall’s family, going back to her great-grandmother who practiced as a lay midwife. Her great-grandmother’s stories had a tremendous influence on Hall, and led to her pursuing a career in nurse-midwifery via Frontier Nursing University. At FNU, she found more inspiration through the story of Mary Breckinridge and credits the school with preparing her for a successful career.

In addition to nurse-midwifery, Hall returned to FNU for both a Women’s Health Care Nurse Practitioner degree and a Family Nurse Practitioner degree so that she can treat families as a whole. She is also a sexual assault nurse.

Letcher County: Population. . . . . . . . . . . . . . . 22,773 Less than good health. . . . . . . 38% FNU Alumni . . . . . . . . . . . . . . . . . 9 Physicians. . . . . . . . . . . . . . . . . . 39 NPs . . . . . . . . . . . . . . . . . . . . . . . . 9 OBGYN. . . . . . . . . . . . . . . . . . . . . . . 1 Pediatricians . . . . . . . . . . . . . . . . . 4 Prenatal Care Adequacy . . . . . . 71%

“My passion is practicing in a rural area.”

Carrie Lee Hall

IMPACT Report: Eastern Kentucky

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PROFILE

Cynthia Maggard, MSN, CFNP Cynthia Maggard credits her training at FNU for preparing her to better relate to and treat those in her community.

“How Frontier educates is to lean toward intervention rather than going straight to medication, which is different from what a lot of other schools teach,” she says.

“It works because a lot of patients here don’t want to take a pill or an insulin shot. If we can give them alternatives, they are more apt to try them.”

Maggard’s work includes practicing at Glendale Medical Center, a part of Manchester Memorial Hospital; the Willowbrook Women’s Center in Manchester, Ky., where she treats pregnant women who are addicted to drugs; a nursing home in Hyden where she treats acute and chronic patients; and a privately owned clinic where she provides addiction care. In each case, she finds employing the Frontier model helps her relate to her patients.

“I think how Frontier originated, starting in rural areas, actively outreaching and helping people who don’t have access to healthcare is reflected in their education today.”

“I think how Frontier originated, starting in rural areas, actively outreaching and helping people who don’t have access to healthcare is reflected in their education today,” Maggard says. “Not every school does that. It’s all about getting to know your patients and their lifestyle so you can develop individualized treatment and look at all aspects that could be keeping them from being as healthy as they can be.”

Maggard says drug abuse, black lung disease, diabetes, and COPD are the primary health issues she sees in her

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Clay County:

Leslie County:

Population.......................... 20,766

Population........................... 10,538

Less than good health............ 36%

Less than good health............ 38%

FNU Alumni..................................8

FNU Alumni..................................9

Physicians..................................23

Physicians.................................. 10

NPs............................................ 17

NPs............................................ 17

OBGYN.........................................2

OBGYN.........................................2

Pediatricians................................. 1

Pediatricians................................ 0

Prenatal Care Adequacy...........61%

Prenatal Care Adequacy.......... 65%

IMPACT Report: Eastern Kentucky

Cynthia Maggard

FNU Graduates Address the Problem

The Future

FNU's model will continue to address healthcare shortage issues across the country. In the last ten years, Frontier has graduated nearly 3,500 primary care providers with the majority living in federally designated rural areas and in medically underserved areas. patients. “Drug abuse bleeds into everything,” she says.

“Even with diabetes and COPD, there are a lot of chronic opioid abusers.”

There are also those unable to get to their appointments because of adequate travel options. The hospital does offer free transportation to and from the hospital for appointments, but Maggard says there’s a lack of awareness about the program.

Similarly, she says that lack of understanding of insurance and what providers are accepted where is a significant hurdle to many of her prospective patients.

“People pick their insurance not knowing that no one in the area is going to accept it,” she says. “If we tried as a community to educate people about what insurances are accepted, that would help. In general, there’s a lack of communication between all the disciplines -- the pharmacies, medical providers and insurance. I have to jump through a million hoops just to get a CT scan approved.”

Understanding that issue and the potential barrier to care that it represents, Maggard helped implement a strategy to assist patients know where to go for care.

More than 70% of those graduates completed the program in the last five years alone. Most recent graduate employment data verified that 56% of prior years’ graduates were working in rural counties, health professional shortage areas, or medically underserved areas.

More than 600 new advanced practice nurses and midwives graduate from Frontier annually and this number continues to grow. We estimate graduating 7,000 new advanced practice nurses and midwives over the next 10 years.

Frontier graduates are taking their places in communities across the country and improving healthcare one family at a time.

“When we have a patient leave, we make a list of clinics they can transfer to and what insurances they accept,” she says. The hope is that one less barrier will be enough for more patients to make and keep their appointments for ongoing care and better overall health.

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Campus: 195 School Street P.O. Box 528 Hyden, KY 41749 FNU@frontier.edu 606.672.2312 Frontier.edu

Our mission is to provide accessible nurse-midwifery and nurse practitioner education to prepare competent, entrepreneurial, ethical, and compassionate leaders in primary care to serve all individuals with an emphasis on women and families in diverse, rural, and underserved populations.

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IMPACT Report: Eastern Kentucky