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JANUARY / FEBRUARY 2014 :: 75(1)
Education of Health Professionals

The policy forum in this issue focuses on how innovative educational programs are training tomorrow’s physicians, nurses, pharmacists, dentists, physician assistants, allied health providers, and other health care professionals so that they will be prepared to meet North Carolina’s changing health care needs. Original articles address the epidemiology of traumatic brain injuries treated in emergency departments in North Carolina and medical students’ knowledge of patient safety and quality improvement.

INVITED COMMENTARY

New Initiatives in Allied Health in North Carolina

Stephen W. Thomas

N C Med J. 2014;75(1):45-47.PDF | TABLE OF CONTENTS



In addition to providing a well-prepared and diverse workforce of allied health professionals, North Carolina universities are helping to improve access to care and outreach to underserved communities. This commentary will discuss workforce preparation initiatives and innovations that help all North Carolinians access timely and high-quality services.

The myriad disciplines that constitute allied health have become an integral part of health care, health promotion, disease prevention, and wellness services. With an aging population and the advent of the Patient Protection and Affordable Care Act, an expanded allied health workforce is needed to ensure timely access to care. Most allied health professionals are cost-effective frontline health care providers who are currently in high demand as important members of interdisciplinary health care teams.

This commentary will highlight the increased emphasis on preparation of the allied health workforce and will describe the university-based allied health education programs that have implemented innovative approaches to meeting the challenges of patient access and outreach. The anticipated increase in the number of new patients accessing health care may put additional strain on an already overburdened health care system, which will require a larger well-prepared workforce. Also, the difficulty of providing high-quality health care services to underserved populations in rural and urban areas of the state is a continuing concern that must be addressed.

Workforce Preparation
Workforce preparation and expansion is currently one of the greatest needs in the allied health professions in North Carolina. A 2012 report from the Cecil G. Sheps Center for Health Services Research of the University of North Carolina at Chapel Hill (UNC-CH) found that allied health graduates from universities and community colleges make up roughly 34% of the health care workforce in the state, holding 129,920 out of 376,930 jobs; registered nurses make up 24% of the state’s health care workforce, and physicians comprise only 5% of this workforce [1]. (There is debate about which professions should be included in allied health, but the report defined allied health professionals as “all health professionals with the exception of physicians, nurses, chiropractors, dentists, optometrists, pharmacists, podiatrists, nurse aides, orderlies and attendants.”) Since 2000 the number of allied health jobs has grown at a fast pace—increasing by 61% versus 54% for the health care sector overall [1]—which indicates potential for increased future growth in the number of allied health positions.

This increasing demand for allied health professionals has resulted in the expansion of existing allied health degree programs, departments, schools, and colleges in public and private universities across North Carolina, and in the development of new degree programs. East Carolina University (ECU), UNC-CH, UNC Greensboro (UNCG), Western Carolina University, and Winston-Salem State University (WSSU) have long been recognized as offering a variety of allied health degree programs. Allied health education at these 5 universities has seen an expansion in enrollment, the development of new degree programs, and the merger of related degree programs and departments into existing allied health units. Allied health deans at these institutions communicate regularly and attend meetings sponsored by the Council for Allied Health in North Carolina [2].

Several universities in the UNC system have begun to establish and expand allied health degree programs. For example, Appalachian State University (ASU), UNC Charlotte, and UNC Wilmington have created allied health academic units (colleges, schools, or departments) on their campuses, and ASU, ECU, and UNCG have relocated degree programs from other colleges or schools to their allied health units. In 2012 ASU opened a College of Health Sciences, and they are partnering with Wake Forest University School of Medicine to create a master of physician assistant studies degree program. ECU College of Allied Health Sciences has opened a new program offering a master of science degree in health informatics and information management, and ECU is in the early stages of getting approval to relocate the Department of Nutrition Science into the College of Allied Health Sciences. The physician assistant degree program that was recently established by the UNC School of Medicine to provide an educational pathway for US Army Special Forces Medical Sergeants has been relocated to the school’s Department of Allied Health Sciences; plans are for the first class to be accepted as early as 2015. Finally, some universities in the UNC system already offer an allied health degree in an academic unit that is unrelated to allied health; for example, the School of Education at North Carolina Central University offers a master’s in education degree in speech-language pathology.

In the fall of 2011, Northeastern University opened a campus in Charlotte, where it currently offers 2 graduate programs in allied health: a master of science degree in health informatics, and the Transitional Doctor of Physical Therapy (t-DPT) degree for individuals who hold a master’s degree in physical therapy. On December 2, 2011, Lenoir-Rhyne University’s School of Occupational Therapy was accredited to offer a master of science degree in occupational therapy; it had provisionally offered graduate courses in occupational therapy prior to that date. Degree programs at the graduate level in health informatics and bioinformatics are also available at a growing number of North Carolina universities, including Duke, ECU, Northeastern, UNC-CH, and UNC Charlotte. Finally, although physician assistant studies are not considered to be an allied health program under the definition of allied health provided in the Code of Laws of the United States [3], physician assistant programs often exist outside of medical schools. In recent years, Campbell University, High Point University, Wingate University, and Gardner-Webb University have opened, or are preparing to open, graduate programs in physician assistant studies and/or physical therapy.

Access, Outreach, and Community Engagement
In underserved communities, lack of transportation prevents some patients from accessing health services, so more innovative forms of outreach are required. Mobile units and telemedicine are 2 approaches that are being applied in a growing number of university-based allied health programs and clinics.

Mobile units. One example of successful mobile outreach to underserved intercity areas is the RAMS Know H.O.W. (Healthcare on Wheels) mobile clinic run by WSSU School of Health Sciences [4]. The mobile unit offers free, convenient, preventive health services to residents in the community who are uninsured or underinsured. The mobile clinic operates 3–4 days a week, including Saturday, and provides high-quality, accessible, integrated wellness services to help reduce health disparities. The mobile clinic team—which consists of health sciences faculty members, staff, and students from allied health and nursing—creates an excellent environment in which to engage in interprofessional education and practice. This mobile team measures blood pressure, determines serum levels of glucose and cholesterol, and provides health education and referrals to local providers when needed. Over the past 3 years, the clinic has served more than 4,000 people; more than 80% of these individuals were African Americans, 70% were overweight or obese, 30% had diabetes (many without realizing it), more than 30% had hyperlipidemia, and 70% had prehypertension or hypertension (oral communication with Peggy Valentine, dean of WSSU School of Health Sciences; October 3, 2013).

Another mobile unit that deserves mention is run by ECU College of Allied Health Sciences. ECU’s Department of Addictions and Rehabilitation Studies recently received a 3-year continuation grant totaling $828,956 from the Substance Abuse and Mental Health Services Administration of the US Department of Health & Human Services to fund Operation Reentry North Carolina: Veteran Resiliency and Reintegration through Technology. The project will send a clinical team in a technology-equipped van through rural Eastern North Carolina to conduct mobile outreach to veterans who are homeless or underserved and will provide state-of-the-art, evidence-based interventions. The service area includes Craven, Cumberland, Onslow, and Wayne counties; together with surrounding counties, this area is home to an estimated 125,000 veterans [5]. Using telehealth technology, team members in the mobile clinic will be able to access the services of ECU’s Navigate Counseling Clinic, Family Therapy Clinic, Psychophysiology Lab and Biofeedback Clinic, and Psychiatric Outpatient Clinic (written communication from Paul Toriello, professor and chair of the Department of Addictions and Rehabilitation Studies at ECU College of Allied Health Sciences; September 28, 2013). Services will be provided face-to-face by team members in the mobile clinic, including students, or will be delivered via telecounseling, with clients in the van being counseled by a team member at ECU Brody School of Medicine’s Telemedicine Center. The project will commence service at the beginning of 2014.

Telemedicine. Another innovation designed to increase access to allied health services is telemedicine, also referred to as telehealth, telepractice, or telerehabilitation. A telepractice application began to be evaluated in 2008 in the Department of Communication Sciences and Disorders in the School of Health and Human Sciences at UNCG. A successful 2008 pilot project involved the delivery of speech-language pathology services to 4 public school districts and 200 students in grades prekindergarten through middle school. Later, speech-language services were delivered to public schools in a remote mountain area in Yancy County. Over several years, UNCG telepractice speech-language evaluations and treatments were expanded to include school systems in rural Eastern North Carolina, including Washington County, where speech-language pathologists were not available. Assessment and treatment services were offered 2 days per week to 12–15 students with articulation and fluency difficulties, aphasia, hearing impairment, autism, traumatic brain injury, and other difficulties. These services were funded through a local physician’s telehealth practice grant and public school contracts. Although the telepractice service was considered to be a success, lack of sustainable funding limited further delivery of services.

Another telehealth program began in 1992 when the Department of Physical Therapy in the College of Allied Health Sciences at ECU entered into an arrangement with the North Carolina Department of Corrections to offer evaluation and treatment services to inmates at a medium-security prison. Prisoners were evaluated by a nurse under the guidance of a state-licensed physical therapy faculty member, and consultation was ordered by an onsite physician through telerehabilitation. Follow-up revealed physical improvement among inmates who were motivated to attend the physical therapy sessions and to perform their home exercise programs. Today, the telerehabilitation physical therapy services are offered to inmates at Maury Prison, where some prisoners are transported for physical therapy evaluations, and at Central Prison in Raleigh, where this service is used to lessen the caseload of the onsite physical therapist or to provide a second opinion.

Another example of telemedicine aims to improve hearing screenings for newborns. Legislation establishing North Carolina’s Early Hearing Detection and Intervention Program was formally adopted in July 2000 [6], and administrative rules were put into effect governing newborn hearing screening [7]. In September 2009 the North Carolina Department of Health and Human Services received “lost to follow-up” funding from the Health Resources and Services Administration. As a result of this legislation and funding, a teleaudiology project developed by the North Carolina Division of Public Health and the ECU Department of Communication Sciences and Disorders in 2011 provided diagnostic evaluations of infants living in 36 rural northeastern North Carolina counties where access to such services is very limited. Audiology faculty members and doctoral students at ECU provide teleaudiology diagnostic evaluations to 19 birthing centers in the catchment area. Over a 1-year period (from June 2011 to June 2012), 41 infants received diagnostic evaluations after rescreening warranted the service. Eleven of those infants (3 females and 8 males) were referred to the teleaudiology project, and services were rendered and reported within the required 90-day period [8]. This teleaudiology service is ongoing.

An audiology professor in the Department of Communication Sciences and Disorders and a professor in the Department of Engineering at ECU have obtained 5 patents for a hearing evaluation system consisting of a device and software. The system makes it possible for audiology evaluations to be conducted over a broadband network between any 2 locations. The system is currently being tested in a pilot study at the Veterans Affairs hospital in Los Angeles and at another satellite Veterans Affairs office in California. This system makes it possible to offer teleaudiology evaluations to individuals in rural and underserved areas at any local physician office, health center, or clinic where the device is installed. Telehealth services continue to collect research data on the effectiveness of the system and to expose students to its potential as a platform for evaluation and treatment.

Conclusion
Allied health innovations at North Carolina universities will continue to be stimulated by the quest to improve the efficiency and effectiveness of interprofessional services through education, research, and engagement. Opportunities for community engagement are available to universities that are committed to clinical research, community improvement, student involvement, and delivery of innovative, high-quality, state-of-the-art allied health services.

Acknowledgments
The author wishes to thank the deans, department chairs, faculty, and clinical staff at the participating universities for providing information on their programs for this article.

Potential conflicts of interest. S.W.T. is an employee of East Carolina University.

References
1. Alcorn E, Gaul K, Fraher E. Allied Health Job Vacancy Tracking Report. Chapel Hill, NC: Cecil G. Sheps Center for Health Services Research; March 2012. http://www.shepscenter.unc.edu/hp/publications/AHvacancy_fall2011.pdf. Accessed November 13, 2013.

2. Council for Allied Health in North Carolina (CAHNC). Presentations and publications. CAHNC Web site. http://www.med.unc.edu/ahs/cahnc/presentations-and-reports. Accessed November 14, 2013.

3. 42 USC §295p (2010).

4. RAMS Know H.O.W. Mobile Clinic. Winston-Salem State University School of Health Sciences Web site. http://www.wssu.edu/school-health-sciences/mobile-clinic/default.aspx. Accessed November 15, 2013.

5. N.C. Rural Economic Development Center, Inc. Rural Data Bank. North Carolina Rural Economic Development Center Web site. http://www.ncruralcenter.org/index.php?option=com_wrapper&view=wrapper&Itemid=121. Accessed March 21, 2013.

6. NCGS 130A-125, SL2000 CH67 S11.31a5.

7. 10A NCAC 43F.1201-1204.

8. Stuart A, Jones G, Watts K, Butler AK. Diagnostic evaluation of infants in rural eastern North Carolina via teleaudiology. Poster presented at the American Speech-Language-Hearing Association 2012 Annual Convention; November 16, 2012; Atlanta, GA.


Stephen W. Thomas, MS, EdD professor and dean, College of Allied Health Sciences, East Carolina University, Greenville, North Carolina, and immediate past chair, Council for Allied Health in North Carolina, Chapel Hill, North Carolina.

Address correspondence to Dr. Stephen W. Thomas, College of Allied Health Sciences, Mail Stop 668, Health Sciences Bldg 3206H, East Carolina University, Greenville, NC 27858-4353 (thomass@ecu.edu).