Evaluating rural healthcare workforce programs: Applying modified whole‐of‐person retention improvement framework in VHA programs

Abstract

Purpose

Healthcare workforce shortages are acute in rural areas. Using a holistic workforce retention framework, we examined evidence and identified gaps in recruitment and retention programs, using the Veterans Health Administration as a case study.

Methods

Rural workforce recruitment and retention initiatives were identified using VHA's 2023 Rural Recruitment and Hiring plan, and classified by rural focus, recruitment or retention, and strength of evidence. Initiatives were then mapped to a modified whole‐of‐person retention improvement framework (WoP‐RIF) to assess coverage of domains: workplace/organizational, role/career, community/place, and financial.

Findings

Of 31 VHA initiatives, 19% exclusively focused on the rural workforce, 35% included rural, and 45% had no specific geographic target. One third (32%) focused on recruitment only, 48% focused on recruitment and retention, and 19% focused on retention only. Nearly three‐quarters (71%) lacked sufficient evidence or were too early in implementation to assess effectiveness or ineffectiveness of the initiative. The strongest evidence existed for education loan repayment and nursing residency programs. For modified WoP‐RIF domains, about half of initiatives focused on financial incentives (52%) or workplace/organizational programs (42%); 35% focused on role/career opportunities; and only three (10%) focused on community/place.

Conclusion

While initiatives exist to address workforce shortages in rural areas, using the VHA as a case study, these are more focused on recruitment than retention, and few address important aspects of retention outside of financial or workplace domains. More rigorous and holistic evaluations of workforce initiatives using the modified WoP‐RIF framework would bolster evidence across the span of recruitment to retention for rural workforce development.

BACKGROUND

By 2036, the United States will be short nearly 90,000 physicians due to an aging population and reduced physician supply. ¹ , ² , ³ , ⁴ , ⁵ This impact may be more pronounced in rural communities. ⁶ , ⁷ , ⁸ Currently, 40% of rural counties are located in health professional shortage areas (HPSAs) ⁷ , ⁸ and experience reduced access to primary care and behavioral health compared to urban counties. ⁹ , ¹⁰ Lack of access to adequate provider supply exacerbates existing health disparities, contributing to higher rates of morbidity and mortality among rural‐residing populations. ⁶ , ¹¹ , ¹²

Understanding rural practice patterns, including strategies for recruiting and retaining rural providers, is critical to mitigating workforce shortages. Existing evidence suggests that financial incentive programs are effective in recruiting providers to rural areas, but less so in retaining them. ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ Rural upbringing and rural residency location may predict rural practice. ²² , ²³ , ²⁴ A limitation of prior literature is the lack of conceptual frameworks to interpret barriers and facilitators to rural practice location holistically, which could better identify gaps in strategies to increase rural workforce capacity.

Cosgrave's Whole‐of‐Person Retention Improvement Framework (WoP‐RIF) was developed specifically to understand rural healthcare workforce retention challenges and to promote “place‐based strategic actions” designed to improve workforce capacity. ²⁵ The model addresses facilitators and barriers in three domains: workplace/ organizational (e.g., characteristics of the workplace setting that support a positive, inclusive environment), role/career (e.g., access to professional development networks and pathways), and community/place (e.g., characteristics of the rural community setting that foster a sense of integration and belonging). ²⁵ It is a parsimonious and highly flexible framework that can be applied to a variety of rural healthcare landscapes.

The Veterans Health Administration (VHA) offers a useful case to examine the breadth and depth of workforce strategies to increase provider supply in rural areas. VHA provides health care for over nine million Veterans annually, nearly one‐quarter of whom live in rural HPSAs. ²⁶ Although the number of veterans living in rural areas has declined from 1992–2018, the 2.7 million rural and highly rural veterans, defined by the VA Office of Rural Health as Rural‐Urban Commuting Area (RUCA) codes 2–9 and code 10 respectively, currently enrolled in the VA health care system experience a high incidence of disabilities and medically complex health. ²⁷ , ²⁸ In 2022, driven by COVID‐related stressors, VHA reported a 12.1% employee loss rate and a nearly 20% employee vacancy rate at rural facilities, with an average employee hire rate of only 2.8%. ²⁹ , ³⁰

VHA has made considerable financial contributions to rural workforce initiatives. These include the Veterans Access, Choice, and Accountability Act (VACAA) of 2014, which funded expansion of GME residency positions and prioritized institutions in rural areas ³¹ ; and the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act in 2018, which expanded community care programs for veterans and included directives to expand services through workforce recruitment and redistribution in rural and underserved. ³² , ³³ More recently and in response to workforce concerns exacerbated by COVID‐19, the 2022 PACT Act (Section 901) included substantial investment in provider recruitment and retention across VHA sites and included a mandate to launch a national recruitment and hiring plan for rural and highly rural VA medical centers (VAMC) and community‐based outpatient clinics (CBOC). ³⁴ The FY2023 VHA Rural Recruitment & Hiring Plan, developed by the VHA Office of Workforce Management and Consulting, outlined a set of strategies to invest in rural VHA employee growth, including retention bonuses, enhanced schedule flexibility, and expanded staffing for improved onboarding. ³⁰ , ³⁵

While initiatives exist to address rural workforce challenges, including in the VHA, there has not been a holistic examination of strategies focused on both recruitment and retention. The objective of this study, using the VHA as a case study, was to assess the strength of evidence for rural workforce programs and use a modified version of Cosgrave's WoP‐RIF to evaluate comprehensiveness and gaps in strategies.

METHODS

We conducted a landscape scan using Cosgrave's WoP‐RIF, to examine the VHA's strategic plan to address rural workforce capacity. ³⁶ Based on prior literature demonstrating the role of financial rewards, particularly in recruitment efforts to incentivize rural workforce hiring, we amended Cosgrave's framework to include a “financial” domain to encompass programs which offer financial benefits to practice in a rural area, and refer to this four‐domain model as “modified WoP‐RIF”. ¹³ , ¹⁴

To identify a comprehensive list of VHA recruitment and retention strategies, we used the VHA's FY2023 Rural Recruitment and Hiring Plan, which described their approach to improving workforce capacity in rural and highly rural VAMCs and CBOCs. ³⁰ The plan includes wide‐ranging “flexibilities, authorities, and incentives” to enhance sustainable rural workforce capacity, such as expanded physician/nurse recruiter staff, maximizing education loan repayment programs, and streamlining hiring from VHA scholarship programs. We then conducted an extensive review of published and gray literature to identify research or evaluations that had been conducted related to each initiative. Specifically, we focused on whether there was evidence for the VHA initiative related to recruitment or retention; if VHA evidence was not available, we looked for evidence based on a comparable, non‐VHA program (e.g., loan repayment programs outside of the VHA). We searched PubMed and Google Scholar and entered search terms related to specific VHA programs into these databases to elicit the broadest search of existing, publicly accessible information about each program. We included literature meeting the following inclusion criteria: published in the past 10 years, published in English‐language, and article types inclusive of peer‐reviewed manuscripts or reports published by a governmental entity (e.g., congressional reports). The list of initiatives was also reviewed by collaborators at the VA's Office of Rural Health to ensure that no key initiatives were missing.

We reviewed and classified key features of each initiative. First, we classified whether the initiative was focused specifically on the workforce in rural areas. Our categories included: (1) exclusive to rural geographic areas, where the initiative was focused only on recruitment and/or retention in rural or highly rural VAMC or CBOC locations; (2) inclusive of rural areas, where the initiative focused on VHA locations with workforce shortages in both rural and non‐rural areas; and (3) general initiatives where geography was not a specific focus of the program. Of note, while the literature specific to VHA strategies references a common definition for rurality (RUCA 2 and higher), definitions used in other literature varied across sources, although no definition was broader than that used by the VHA.

Next, we classified whether the initiative was designed to address recruitment, retention, or both. We then assessed whether the initiative focused on the modified four WoP‐RIF domains; multiple WoP‐RIF domains could apply to an initiative. We also categorized evidence for recruitment and/or retention related to each initiative or a comparable, non‐VHA initiative as strong/moderate or weak. Evidence was categorized as strong/moderate if it demonstrated efficacy or lack of efficacy in recruitment/retention with an adequate sample size and longitudinal design. Evidence was categorized as weak if the results only focused on program processes (e.g., individuals completing the program), self‐reported program perceptions (e.g., satisfaction), or did not include longitudinal efficacy data. If no research was available, we categorized these as having no evidence of effectiveness or ineffectiveness. Two authors independently reviewed and classified the initiatives. Consensus discussions were held to resolve differences in classifications.

RESULTS

The VHA plan outlined 31 specific initiatives (Table 1). Of these, 19.4% (n = 6) were designated as workforce initiatives exclusive to rural geographic areas; 35.5% (n = 11) were inclusive of rural areas (i.e., the initiative could include rural or non‐rural areas), and 45.2% (n = 14) were not geographic‐specific (i.e., general initiatives where geography was not a focus of the program). One third (32.3%, n = 10) focused on recruitment only, 48.4% (n = 15) focused on recruitment and retention, and 19.4% (n = 6) focused on retention only.

TABLE 1.

VHA workforce initiatives by focus and modified WoP‐RIF domains.

Initiative	Rural focus a	Workforce strategy focus		Modified whole‐of‐person retention improvement framework domains				Evidence b
		Recruitment	Retention	Community/place	Role/career	Workplace/organizational	Financial	Strength & efficacy
VA Rural Scholars Fellowship	ER		X		X	X		SM c , f
Rural Health Career Development Award	ER		X		X		X	N
Rural Interprofessional Faculty Development Initiative	ER		X		X	X		W e
Rural Recruitment Search Assessments and VA Careers	ER	X		X	X			N
VHA National Sourcing Office g	ER	X						N
Provider Contract Buy‐Out Program	ER	X	X				X	N
Physician Provider Recruiters/Nurse Recruiters	IR	X	X	X		X		N
3 Rs (recruitment/ relocation/ retention) and Permanent Change of Station	IR	X	X				X	N
Appointment Above Minimum Rate of Grade	IR	X					X	SM c , f
Critical Skills Incentives	IR	X					X	N
Special Salary Rates (SSR) under USC 7455	IR	X					X	N
Hire Right Hire Fast	NG	X				X		N
Title 38 Enhanced Recruitment Onboarding Model	NG	X	X			X		N
Direct Hire Authority g	IR	X						N
Consider Non‐Citizens (i.e., Visa Holders)	IR	X	X				X	SM d , f
VAMC Referral Awards Program	IR	X		X				N
Creditable Service for Annual Leave Accrual	NG	X					X	N
VHA Optimal Recruitment to Onboarding Surge Events	NG	X				X		N
Education Debt Reduction Program	IR	X	X				X	SM c , f
Student Loan Repayment Program	IR	X	X				X	SM c , f
Employee Incentive Scholarship Program—Includes National Nursing Education Initiative and VA National Education for Employees Program	NG	X	X		X		X	SM c , e
VA Trainee Recruitment Events	NG	X	X			X		N
VA Student Trainee Experience Program	NG	X	X		X	X		N
Health Professions Scholarship Program	NG	X	X		X		X	N
Specialty Education Loan Repayment Program	IR	X	X				X	N
RN Transition to Practice Program	NG	X	X		X	X	X	N
Post Baccalaureate Registered Nurse Residency	NG		X		X	X	X	SM c , e
Nurse practitioner residency	NG		X		X	X		W c , e , f
Alternate work schedules	NG	X	X			X		N
Total rewards of a VA career	NG	X	X				X	N
Stay in VA initiative	NG		X		X	X		N

^a Rural focus: ER: exclusive to rural geographic areas; IR: inclusive of rural geographic areas; NG: no geographic focus.

^b Evidence strength & efficacy: SM, Strong/Moderate: Evidence that program is effective or ineffective in recruitment/retention with an adequate sample size and longitudinal design; W, Weak: Evidence at the program evaluation level, not focused on recruitment/retention, or does not include information of retention over a period of time; N, No Evidence: Evidence not found or may be too early in program implementation to determine whether the program is effective or ineffective.

^c Evidence that this initiative has efficacy on recruitment/retention over a period of time.

^d Evidence that this program lacks efficacy on recruitment/retention over a period of time.

^e Evidence from evaluation of VHA initiative.

^f Evidence from comparable program outside VHA.

^g Initiative does not address any of the modified WoP‐RIF domains.

We identified 23 unique published articles and gray literature that included research or evaluations that had been conducted related to our identified initiatives (see Appendix for list of resources found per initiative). We found no available evidence of effectiveness or ineffectiveness for most programs (71%, n = 22) due to no available evaluations for established programs or no available assessments because the initiative is too early in implementation to expect to see evidence (e.g., Provider Contract Buy‐Out Program). ³⁷ Only 19.4% (n = 6) of initiatives (e.g., education loan repayment and nursing residency) had strong/moderate positive impacts for recruitment or retention, while 3% (n = 1) had strong/moderate negative evidence. Of the six initiatives with strong/moderate evidence of efficacy, four had evidence from comparable programs outside the VHA, and two had evidence from evaluation of the VHA program (e.g., National Nursing Education Initiative and Post Baccalaureate RN Residency).

When assessing coverage of modified WoP‐RIF domains, more initiatives focused on financial incentives (51.6%, n = 16) or workplace/organizational programs (41.9%, n = 13), with fewer focused on role/career opportunities (35.5%, n = 11). Only three (9.7%) included at least some focus on the community/place domain, and of those, only one specifically targeted rural locales. In addition, 11 initiatives (35.5%) focused exclusively on financial incentives. Combining the framework domains and evidence, all three community/place initiatives lacked evaluation. Of the six exclusively rural initiatives, four addressed role/career domains, one addressed the community/place domain, and one has strong/moderate evidence of efficacy. Of the 11 initiatives that could include the rural workforce, eight addressed the financial domain only, and over half (n = 6) focused on recruitment only.

DISCUSSION

Examining rural‐focused workforce initiatives at VHA, we found that more programs focused on recruitment than retention, few had sufficient evidence to demonstrate effectiveness or ineffectiveness of the program, one‐third focused exclusively on financial strategies, and only 1 in 5 were explicitly created to target rural and highly rural hiring and retention. While there is existing evidence to suggest that debt reduction strategies (e.g., loan repayment) and non‐physician residency programs can be effective, many other VHA recruitment and retention strategies have not yet been evaluated for reach or impact.

When considering the modified WoP‐RIF framework domains, we found a notable gap in initiatives to include community/place strategies, such as ways to enhance employee integration into rural community life. The three VHA initiatives under community/place included strategies such as purposeful recruiter outreach to providers who might be interested in working/living in a rural area; and a referral rewards program to identify and recruit candidates who already live in the community. While these initiatives lacked evaluation, studies suggest that integration into the community and a sense of belonging are important factors in rural physician retention. ¹⁵ , ²² , ³⁸ , ³⁹ In addition, preferences and employment prospects for significant others and their receptivity to a rural lifestyle were also found to be factors associated with practicing in a rural area. ³⁸ , ³⁹ In a systematic review of 30 qualitative studies of early career clinician experiences working in rural or remote areas, clinician concern with the needs of their partner and children, and feeling supported when their family lived in the same location were significant factors in the decision to stay in a rural area. ¹⁵ In a recent study, the Center for Rural Health at the University of North Dakota published further findings from the Community Apgar Project (CAP), designed to understand workforce recruitment and retention factors at rural healthcare facilities. The CAP survey found that facility and community support factors (e.g., leadership, community need/support) as well as geographic factors (e.g., spousal satisfaction, housing, schools) were perceived by providers as important retention factors to rural healthcare employment. ⁴⁰ We identified no VHA initiatives that explicitly addressed supportive integration of physicians and their families into rural communities.

The one initiative that showed strong/moderate negative evidence (i.e., ineffectiveness) on retention over time was visa waivers (e.g., Conrad 30 waiver program) for international physicians completing US‐based residencies to practice in rural and/or underserved areas for a prespecified time period (typically three years). ¹⁸ , ¹⁹ , ²⁰ Although visa waivers appear effective at attracting international providers to rural locales, frequently these providers leave the rural area after the required service years. ¹⁹ , ²¹ Survey data from a recent study of physicians participating in the Conrad 30 waiver program demonstrate barriers to rural retention related to the community/place domain, including challenges obtaining spousal employment and gaps in community‐level characteristics of value to them and their families. ²⁰

Role/career opportunities were a focus of one‐third of the VHA initiatives. Most of these initiatives were nursing education and residency programs in the VHA (e.g., Registered Nurse Transition‐to‐Practice programs) and were not exclusive to rural areas. ⁴¹ , ⁴² Systematic reviews on interventions to retain healthcare workers in rural areas have shown that providing educational and skills opportunities to physicians practicing in rural areas was associated with increased retention. ²³ , ⁴³ One initiative, the Rural Interprofessional Faculty Development Initiative, provides training for residency proctors to train and mentor residents serving in rural areas. ⁴⁴ Since 2018, the VA Rural Scholars Fellowship has provided a small number of participants with a two‐year fellowship which includes protected research time to support their professional growth. ⁴⁵ Although systematic reviews have demonstrated that providing educational and skills opportunities to physicians practicing in rural areas was associated with increased retention, ²³ , ⁴³ there is a need to expand professional development opportunities that are specifically designed to support physicians working in rural and highly rural facilities who may have unique barriers to career growth.

One limitation of our approach is that the original Cosgrave model focuses primarily on retention. We added the financial domain to broaden its applicability for recruitment programs. Our choice of a landscape analysis rather than a systematic review was based on the recency of VHA efforts to address workforce shortages post‐COVID and the likelihood of gaps in peer‐reviewed evidence. Though this choice broadened our evidence search, it limited our ability to assess evidence quality. Nonetheless, the available literature evaluating recruitment and retention programs is small, and thus, conclusions should be considered preliminary. An additional limitation is that while the VHA strategies and literature reference a common definition for rurality, definitions used in other literature varied across sources. However, these definitions were usually more restrictive than the VHA's definition of what was considered rural, so they could potentially be more applicable to rural contexts. Finally, because our selection of recruitment and retention strategies was selected from one source, we may have failed to capture other VHA strategies that were smaller in scope, older, or regionally based.

CONCLUSION

While initiatives exist to address VHA workforce shortages in rural areas, this study suggests that future targeted efforts should focus on improved assessment of the effectiveness or ineffectiveness of existing programs, explicitly designing programs to support recruitment and retention efforts in rural and highly rural areas informed by the modified WoP‐RIF framework, increasing programming specific to provider retention, and expanding efforts addressing important predictors of retention outside of the workplace setting. More rigorous and holistic evaluations of workforce programs using the modified WoP‐RIF framework would assist in creating evidence across the span of rural workforce development.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Appendix Table. Initiative Resources.

Longacre MR, Kinney LM, Carluzzo KL, Watts BV, Schifferdecker KE. Evaluating rural healthcare workforce programs: Applying modified whole‐of‐person retention improvement framework in VHA programs. J Rural Health. 2026;42:e70115. 10.1111/jrh.70115