Health Care Access in the Heartland - Appendices

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APPENDIX 1

A data-dependent identification process was implemented to select the 12 locations in which to hold focus groups. Since the project is focused on underserved rural populations, only counties designated as a geographic health care professional shortage area (HPSA) by the Health Resources and Services Administration were considered. Ultimately, four criteria were utilized to identify target counties:

  1. Classified as a geographic health professional shortage area for primary, dental and mental health care
  1. Classified as a nonmetro county by the United States Department of Agriculture rural-urban continuum codes 4 through 92
  1. Sufficient population density to allow for focus group participation and partner organization
  1. Large number of HPSA access risk factors relative to other counties in the state.

When multiple counties within a state were similar on the above criteria, we prioritized counties where the team had established relationships to help identify focus group members and nonadjacent counties that would provide as much geographic diversity within each state. Unsurprisingly, counties with the greatest health care shortages also had the lowest population densities. Therefore, there were no counties that met all established criteria. In these areas, we chose an adjacent county as a focus group site and prioritized identifying participants from neighboring counties.

Focus groups were semistructured, consisting of a mix of open-ended and survey questions. A separate member of the team took notes via Zoom teleconferencing for each focus group. Focus groups were also recorded and transcribed using Zoom’s embedded transcription service to help research team members with the final coding process. Survey responses were collected using the Plickers system. Focus group notes were coded using a rubric and reviewed for consistency by members of the research team. Coding of the focus group notes allowed for the development of themes, which were grouped and modified to establish key issue areas.

Focus group questions centered on the accessibility and affordability of rural health care services—primarily preventive care and chronic disease management, including vision, dental and behavioral/mental health—and workforce challenges associated with each. Participants also were asked about the role of telehealth and local, innovative service-delivery strategies providers had implemented to support health care access, including supportive services.

APPENDIX 2: OCCUPATIONAL LICENSING REQUIREMENTS FOR SELECTED OCCUPATIONS AND STATES

FIGURE A1. LICENSING REQUIREMENTS FOR DENTISTS, SELECTED STATES (2022)

Education RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Additional Required ExamsCost of Initial Licensure (in dollars)Cost of License Renewal (in dollars)Reciprocity or EndorsementGood Moral Character Requirement
ArkansasCODA-accredited Dental SchoolCDCA, CITA, CRDTS, SRTA, WREB250AR Jurisprudence Exam$150 by exam
$1,000 by credential
$300NoNo
KansasCODA-accredited Dental SchoolCDCA, CITA, CRDTS, SRTA, WREB260KS Jurisprudence Exam$200 by exam
$300 by credential
$275NoYes
KentuckyCODA-accredited Dental SchoolCDCA, CITA, CRDTS, SRTA, WREB230KY Jurisprudence Exam$325 by exam
$325 by credential
$295NoNo
MissouriCODA-accredited Dental SchoolCDCA, CITA, CRDTS, SRTA, WREB250MO Jurisprudence Exam$150 by exam
$150 by credential
$150YesYes
OklahomaCODA-accredited Dental SchoolCDCA, CITA, CRDTS, SRTA, WREB140OK Jurisprudence Exam$200 by exam
$500 by credential
$200NoYes

Note: Certification requirements for other occupations mentioned in this study are included in Appendix 3.

Figure A2. Licensing requirements for psychologists, selected states (2022)

Education RequiredExperience Required / Training Required Professional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Additional Required ExamsCost of Initial Licensure*Cost of License Renewal Reciprocity or Endorse-mentGood Moral Character Require-ment
ArkansasDoctorate2 years (incl. 1 postdoctoral) / 2,000 hours internshipASPPB exam120$400$300ReciprocityYes
KansasDoctorate2 years supervised work experienceEPPP exam250$775$150ReciprocityYes
KentuckyDoctorate2 years supervised work experienceEPPP exam339KY Jurisprudence Exam$450$450ReciprocityYes
MissouriDoctorate1 years supervised work experienceEPPP exam215MO Jurisprudence exam$150$300ReciprocityNo
OklahomaDoctorate2 years supervised work experienceEPPP exam120OK Jurisprudence Exam$400$200ReciprocityNo
TennesseeGraduate2 years postgrad supervised work experienceNational Counselor Examination; National Clinical Mental Health Counseling Examination220$600$225YesYes

*Initial Licensure may include exam, application and licensing fees.

Figure A3. Licensing requirements for pharmacy technicians, selected states (2022)

Education Required / Training RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial LicensureCost of License Renewal Reciprocity or EndorsementGood Moral Character RequirementBlanket Ban for Ex-Offenders
ArkansasNoneYes20$145$35YesYesYes
KansasNoneYes220$67$20YesNoNo
KentuckyNone10$25$25NoYesNo
MissouriNoneNo10$75.3$35NoNoNo
OklahomaNone10$75$75YesYesNo
Tennessee480 hours of training required (non-degree)No20$95$95NoYesYes

Note: No experience or additional exams required

Figure A4. Licensing requirements for occupational therapy assistants, selected states (2022)

Education RequiredExperience RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)
ArkansasAssociates2 monthsYes110$605 / $50YesYes
KansasAssociates0Yes240$635 / $75YesYes
KentuckyAssociates16 weeksYes112$590 / $35YesYes
MissouriAssociatesFieldwork prescribed by accredited institutionYes224$585 / $10YesYes
OklahomaAssociates2 monthsYes220$605 / $20YesYes
TennesseeAssociatesFieldwork prescribed by accredited institutionYes224$585 / $80YesYes

Note: No hours of training required, no additional exams required, no blanket ban for ex-offenders.

Figure A5: Licensing requirements for occupational therapists, selected states (2022).

Education Required Training Required (in hours) / Experience Required (in hours)Professional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)Reciprocity or Endorsement
ArkansasMaster’s or Doctoral from an ACOTE®-accredited program0 / 0Yes (Board for Certification in Occupational Therapy)110$75 / $55Yes
KansasMaster’s or Doctoral from an ACOTE®-accredited program0 / 0Yes140 for the preceding two-year period, reported during the odd-numbered years$80 / $80NoNo
KentuckyMaster’s or Doctoral from an ACOTE®-accredited program0 / 24 hoursNBCOT certification exam112$50 / $50YesYes
MissouriMaster’s or Doctoral from an ACOTE®-accredited program1,000 hours fieldwork / 0Yes224$30 / $30YesNo
OklahomaMaster’s or Doctoral from an ACOTE®-accredited program0 / 0NBCOT certification exam120$120 / $100YesYes
TennesseeMaster’s or Doctoral from an ACOTE®-accredited program10 hours / 0NBCOT certification exam224$100 / $85NoYes

Note: No hours of experience required, no additional exams required, no blanket ban for ex-offenders ACOTE® – Accreditation Council for Occupational Therapy Education

Figure A6: Licensing requirements for social workers, selected states (2022)

Education RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)Reciprocity or EndorsementGood Moral Character RequirementBlanket Ban for Ex-Offenders
ArkansasBachelor’sYes230$100 / $80YesNoYes
KansasBachelor’sYes26$150 / $150YesYesNo
KentuckyBachelor’sYes315; 3-year period$25 / $75NoNoNo
MissouriBachelor’sYes215$70 / $65YesYesNo
OklahomaBachelor’sYes216 per 2-year period$150 / $100YesYesNo
TennesseeBachelor’sYes29$75 / $45YesNoNo

Note: No hours of training required, no hours of experience required, no additional exams required

Figure A7: Licensing requirements for pharmacy technicians, selected states (2022).

Training requiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)Reciprocity or Endorsement
ArkansasYes20$145 / $35YesYesYes
KansasYes220$67 / $20YesNoNo
Kentucky10$25 / $25NoYesNo
MissouriNo10$75.3 / $35NoNoNo
Oklahoma10$75 / $75YesYesNo
Tennessee480 hours (non-degree)No20$95 / $95NoYesYes

Note: No education required, no experience required, no additional exams

Figure A8: Licensing requirements for dietician nutritionist, selected states (2022).

Education RequiredExperience RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)Reciprocity or EndorsementGood Moral Character Requirement
ArkansasBaccalaureateAmerican Dietetic Association approved pre-professional experienceCommission on Dietetic Registration exam112$110 / $50YesNo
KansasBaccalaureate900 hours of planned continuous pre-professional experienceCommission on Dietetic Registration exam115$140 / $135YesNo
KentuckyBaccalaureateCommission on Dietetic Registration exam115$50 / $50YesNo
MissouriBaccalaureateCommission on Dietetic Registration exam275 (every 5 years)$50 / $20YesNo
OklahomaBaccalaureateInternship or preplanned professional experienceCommission on Dietetic Registration exam10$120 / $100YesNo
TennesseeBaccalaureate900 hours of planned continuous pre-professional experienceCommission on Dietetic Registration exam20$130 / $70YesYes

Note: No training hours required, no additional exams, no blanket ban on ex-offenders

Figure A9: Licensing requirements for optometrist, selected states (2022)

Education RequiredProfessional ExamRequired Time of License Renewal (in Years)Continuing Education Requirement (in hours)Additional Required ExamsCost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars)Reciprocity or Endorsement / CostGood Moral Character RequirementBlanket Ban for Ex-Offenders
ArkansasDoctorateEntrance exam112$450* / $150Yes / $438.50NoYes
KansasDoctorateEntrance exam248$180** / $450Yes / $150YesNo
KentuckyDoctorateEntrance exam112$525 / $250Yes /$725YesNo
MissouriDoctorateEntrance exam232Law exam$275*** / $150Yes / $225YesNo
OklahomaDoctorateEntrance exam125$200 / $300NoYesNo
TennesseeDoctorateEntrance exam240Jurisprudence exam$250 / $275YesYesNo

Note: No training required, no experience required, no blanket ban for ex-offenders
* includes $400 entrance exam fee; **includes $150 for entrance exam fee; ***includes $50 law exam fee