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Table of Contents for Program Narrative Table of Contents (not counted in page limit) . 1 INTRODUCTION . 2 NEEDS ASSESSMENT AND RATIONALE . 2 Demographics . 2 Infant Mortality and Low Birth Weight . 3 Heart Disease . 4 Suicide . 5 Summary . 6 Rationale Discussion . 6 Certified Nurse-Midwives . 7 The Midwifery Initiative . 7 Family and Psychiatric Mental Health Nurse Practitioners . 9 Relationship: HRSA BHPr Goals, Project Objectives and Activities . 9 Project Objectives and Linkages to National and State Goals . 11 METHODOLOGY AND WORKPLAN . 12 CURRICULUM . 16 Overview . 16 Plan of Study: Core and Each Specialty . 18 Course Information . 21 Clinical Experience . 21 Electronic Distance Learning Methodologies . 22 Education Program . 22 Equipment and Technical Support . 22 Experience and Financing . 23 Competencies . 24 Certification . 24 Program Accreditation and Approval . 24 DIVERSITY AND CULTURAL COMPETENCE . 24 FUNDING FACTOR – STATUTORY FUNDING PREFERENCE . 26 RESOLUTION OF CHALLENGES . 26 EVALUATION AND TECHNICAL SUPPORT CAPACITY . 27 ORGANIZATIONAL INFORMATION . 27 Project Management, Resources, and Capabilities . 27 Project Personnel . 27 Faculty Recruitment Plan . 28 Capabilities of Applicant Organization . 29 Institutional Resources . 29 Linkages and Community Support . 30 SUSTAINABILITY . 30 Challenges . 31 REPLICABILITY . 31 SUMMARY . 31 End Notes . 32 Shenandoah University – Program Narrative – Page 1 (Table of Contents) Program Narrative: INTRODUCTION: The legislative purpose of Health Resources and Services Administration (HRSA) Bureau of Health Professions (BHPR) – to “prepare advanced education nurses through the enhancement of advanced nursing education and practice” – guides the objectives of this project, “Improving Access to Health Care in Rural and Medically Underserved Areas of Virginia with Advanced Practice Nurses.” To further the accomplishment of this purpose, Shenandoah University Division of Nursing (SUDON) will use its Family Nurse Practitioner (FNP), Psychiatric Mental Health Nurse Practitioner (PMHNP) and Nurse-Midwifery (NM) graduate program tracks to: (1) increase recruitment and retention of NM students willing to enter practice in rural underserved areas of Virginia by making the NM curriculum accessible through collaborative agreements with universities in these areas (BHPR Goal One: Eliminate Health Barriers), (2) promote training in cultural competence skills for faculty, preceptors, and all advanced practice nursing (APN) students in the NM, FNP, and PMHNP tracks (BHPr Goal Two: Eliminate Health Disparities), (3) use informatics technology to enhance dissemination of current information to preceptors and NM, FNP, and PMHNP students in rural underserved areas, and to disseminate curricula to these areas via distance learning (BHPR Goal Three: Assure Quality of Care). The project’s activities that are directed to these goals will increase the supply of advanced practice nurses in Virginia’s predominantly rural communities in order to decrease the health disparities these populations bear due to the lack of access to an adequate supply of culturally competent health care providers. By doing so, this project will also honor Goal One of the Health and Human Services (HHS) Rural Task Force: Improving rural communities’ access to quality 1 health and human services. NEEDS ASSESSMENT AND RATIONALE Demographics Five regions are the focus of this project: Blue Ridge, Central, Hampton Roads, Roanoke, and Southwest regions. They are home to 70% of Virginia’s population.2 All have many rural jurisdictions and are predominantly medically underserved areas (MUAs). The urban Northern Virginia Region is not included. See Attachment 4 for schematic representations of these regions, their rural and MUA designations, and their poverty rates in Figures 1-5. Table One below displays the percentages of MUA and rural jurisdictions in the five focus regions. Table 1 Number and percentage of MUAs Counties and Cities in Each Focus Region Region* % Jurisdictions MUA * % Jurisdictions with Rural (%Partial/%Full) Designations** Blue Ridge 52 (14/38) 48 Central 85 (9/76) 50 Hampton Roads 95 (43/52) 28 Roanoke 58 (15/43) 48 Southwest 93 (29/64) 79 *Data Avail from Virginia Center for Healthy Communities, http://67.92.69.86/southwest.pdf , http://67.92.69.86/blueridge.pdf , http://67.92.69.86/roanoke.pdf , http://67.92.69.86/central.pdf , http://67.92.69.86/hamptonroads.pdf , Accessed 10/19/06 accessed November 18, 2006. **Office of Management and Budget: Rural Designations in Virginia Shenandoah University – Program Narrative – Page 2 The poverty rate in rural Virginia in 2003 was 13.9% and in urban areas was 9.3%.3 The map in Attachment 5, Figure 5 shows that the Southwest and Central Regions consist of many counties with poverty levels greater than 15% and as high as 21%. The rural poverty rate is compounded by minorities who are more vulnerable to factors contributing to poor health. Nationally, in 2004, those who defined themselves as black or another race than white had the highest poverty rates of about 24%. Among those of Hispanic origin (any race), the poverty rate was 21.4%.4 In Virginia, 20.4% of the population is black, 4.5% Asian, .5% Native American, and 5.3% Hispanic. The Hispanic population is the fastest growing minority group in Virginia and continues with substantial growth.5 Nationally, the population growth in rural areas from 2000 to 2005 was higher among Hispanics than non- Hispanic whites. The rural population under age 20 has declined for whites and blacks, but has increased for Asians and Hispanics, reflecting recent immigration of young Asian and Hispanic 6 families. This indicates a high level of future growth. The rural Hispanic population in the U.S. 7 has doubled and is now the most rapidly growing demographic group in rural America. According to Virginia Center for Health Communities (VCHC), Virginia’s overall health status has continuously declined since the late 1990’s: In 1996 Virginia ranked as the healthiest state in the nation, but in 2001 it ranked the 18th.8 Increases in heart disease, obesity, and diabetes contribute to Virginia’s declining health status. This Needs Assessment relates infant mortality, low birth rate, heart disease, and suicide to the need for the project’s activities. These indices were chosen because they are associated with factors that are more prevalent in rural areas such as poverty, lack of access, and unhealthy lifestyles.9 It has been shown that many of these contributing factors can be relieved by NP and CNM care through health promotion, disease prevention, health protection, anticipatory guidance and counseling.10 Therefore, this project is designed to increase NP and CNM numbers in rural, underserved areas. Infant Mortality and Low Birth Weight (LBW): Table 2 displays each region’s infant mortality rate and the percent MUA/rural designations obtained from Table 1. Table 3 shows the percent LBW in each region by race compared to Virginia’s rate and the Healthy People (HP)2010 Goal. Table 2: Infant Mortality: Regions’ ranges* Compared with State rate & HP2010 Goal** HP2010 Goal: 4.5 per 1,000 live births Virginia Rate: 7.3 per 1,000 live births Region Blue Ridge Central Hampton Roads Roanoke Southwest Range Low: 0 Low: 0 Low: 0 Low: 0 Low: 0 Median: 6.5 Median: 8.5 Median: 10 Median: 5.4 Median: 3.7 High: 16.2 High: 30.3 High: 23.4 High: 16.4 High: 16.1 Total %MUA 52 (14/38) 85 (9/76) 95 (43/52) 58 (15/43) 93 (29/64) (%Partial/%Full) % Rural 48 50 29 48 79 *Virginia Department of Health (VDH) (2004). Table 2: Resident Total Pregnancy Terminations, Live Births, Induced Termination of Pregnancy, and Natural Fetal Deaths, Infant Deaths under One Year of Age, and Total Deaths rates for 1,000 Females Ages 15-44, Live Births, and Total Population by Planning Districts and City or County and Virginia Center for Health Communities: Virginia Atlas of Community Health Avail: http://67.92.69.86/southwest.pdf , http://67.92.69.86/blueridge.pdf , http://67.92.69.86/roanoke.pdf , http://67.92.69.86/central.pdf , http://67.92.69.86/hamptonroads.pdf , Accessed 10/19/06 ** U.S. Department of Health and Human Services (DHHS) HP2010, ed Shenandoah University – Program Narrative – Page 3 Table 3: LBW Rate by Region and Race,* compared to State & HP2010 Goal** HP2010 Goal: 5% of all births Region Total % % LBW % LBW % LBW Total % MUA LBW White Black Other (% Partial/% Full) Virginia 8.4 7.0 12.9 8.1 Blue Ridge 7.7 7.4 14.7 13.3 52 (14/38) Central 10.1 7.4 16.2 18.7 85 (9/76) Hampton Roads 8.8 7.7 11.5 13.7 95 (43/52) Roanoke 8.1 7.5 14.8 25.9 58 (15/43) Southwest 9.7 9.3 31.5 16.7 93 (29/64) *VDH, (2004). Table 10: Resident Low Weight Live Births & Very Low Weight Births by Race with % of Resident Total Live Births by Planning District and City or County. ** U.S. Department of Health and Human Services (DHHS) HP2010, ed The infant mortality rate is a sensitive indicator often used as a reference point for defining a community’s quality of life and the quality and accessibility of prenatal care.11 12 See Attachment 4 for a schematic representation of the adequacy of prenatal care in the State. Socioeconomic factors that influence higher infant mortality rates are poverty, exposure to alcohol and other substances, cigarette smoking, short gestation, and LBW.13 According to “Healthy Rural People 2010,” there are increased rates of infant mortality among rural residents with evidence suggesting that the rates result from a disproportionate distribution of poverty, race/ethnicity disparities, age, education, and access to care.14 As shown in Table 2, all of the regions had areas with high infant mortality rates that were often more than twice the state’s rate. LBW is among four causes of more than half of all infant deaths, and the cost of LBW babies is more than half the health care costs of all newborns combined.

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