For primary medical care providers and primary oral care providers, retention in NHSC was evaluated under different criteria in the currently available studies. Table A.1 below summarizes the retention metrics that were previously used in the literature.
In 2008 and 2012, extensive retention surveys were administered to NHSC providers. The 2012 survey commissioned by BCRS assessed retention in the short-term (1 month to 1 year after service terms are completed), mid-term (2-5 years), and long-term (7-12 years) (Pathman et al, 2012(a)). By contrast, NHSC employs slightly different criteria in its assessment of primary mental and behavioral health care providers. Retention for these groups of clinicians is measured as the percent continuing to practice in a HPSA four years after completion of the service term (National Health Services Corps, 2012).
In the BCRS survey, retention was assessed with respect to remaining within the same practice where the clinician served during his or her NHSC contract term, but also with respect to working in other practices that focus on serving underserved populations. This is similar to the approach taken by Holmes (2004) who, instead of defining retention solely on the basis of index site retention, as was common and remains a widespread practice, used a holistic definition of retention in underserved locations by studying both index site retention and retention in any underserved location after leaving the original service practice.
In the 2012 BCRS survey, “remaining within the last NHSC service site” was calculated as the number of months from the self-reported date of service completion until the date the clinician reported leaving the site at which he or she last served when completing the last NHSC service contract. “Working in practices that were focused on care for the underserved” was calculated from alumni’s self-reported information of working in practices that focused on care for the underserved at a given point in time. Those who reported working in non-clinical positions, were in training positions, were not working at the point in time, were not working in a practice that they indicated as focused on providing care for the underserved, and were not still working at their last NHSC service site, were considered to be not working in a “practice that focused on care for the underserved (Pathman et al., 2012(a)).”
The researchers who led the BCRS survey suggest that future studies of retention of NHSC clinicians would benefit from a more “clearly and consistently defined measure of the location of sites that qualify as successful retention outcomes (e.g., same site, any underserved site, any rural site, any ‘safety net’ employer, high reliance on Medicaid, etc.) as well as more focus on a consistent and meaningful measure of duration of retention.” Further, the researchers suggested that more attention be given to the definition and benchmarking of “success,” as well as the suitability of using various comparison groups (e.g., health professionals recruited to communities of similar circumstances but without a service obligation, or those working in similar settings under a state-based or other type of service obligation) (Pathman et al., 2012(b)).
In response to suggestions from the early 1990s that NHSC could enhance retention if it accepted only applicants from primary care-oriented schools, a research team led by Donald Pathman sought to determine, separately for NHSC scholars and physicians not affiliated with NHSC, whether retention in rural practice may be longer for physicians who graduated from public medical schools, were trained in a community hospital-based residences, or participated in rural training programs as medical students or residents. The indices of retention were percentage of physicians who continued working in nonmetropolitan areas, and the percentage of physicians who remained in their index practices (Pathman et al., 1992).
A distinction between retention at primary sites versus secondary sites has yet to be studied. Satellite clinical practice locations are generally located in areas apart from the main clinic in an effort to expand clinical access to patients in more remote areas. Typically, these sites have less patient volume than the main practice site, which is ultimately reflected in staffing. Retention at original service site or within the same geographic region is not known to take into account this distinction.