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:
- Classified as a geographic health professional shortage area for primary, dental and mental health care
- Classified as a nonmetro county by the United States Department of Agriculture rural-urban continuum codes 4 through 92
- Sufficient population density to allow for focus group participation and partner organization
- 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 Required | Professional Exam | Required Time of License Renewal (in Years) | Continuing Education Requirement (in hours) | Additional Required Exams | Cost of Initial Licensure (in dollars) | Cost of License Renewal (in dollars) | Reciprocity or Endorsement | Good Moral Character Requirement | |
|---|---|---|---|---|---|---|---|---|---|
| Arkansas | CODA-accredited Dental School | CDCA, CITA, CRDTS, SRTA, WREB | 2 | 50 | AR Jurisprudence Exam | $150 by exam $1,000 by credential | $300 | No | No |
| Kansas | CODA-accredited Dental School | CDCA, CITA, CRDTS, SRTA, WREB | 2 | 60 | KS Jurisprudence Exam | $200 by exam $300 by credential | $275 | No | Yes |
| Kentucky | CODA-accredited Dental School | CDCA, CITA, CRDTS, SRTA, WREB | 2 | 30 | KY Jurisprudence Exam | $325 by exam $325 by credential | $295 | No | No |
| Missouri | CODA-accredited Dental School | CDCA, CITA, CRDTS, SRTA, WREB | 2 | 50 | MO Jurisprudence Exam | $150 by exam $150 by credential | $150 | Yes | Yes |
| Oklahoma | CODA-accredited Dental School | CDCA, CITA, CRDTS, SRTA, WREB | 1 | 40 | OK Jurisprudence Exam | $200 by exam $500 by credential | $200 | No | Yes |
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 Required | Experience Required / Training Required | Professional Exam | Required Time of License Renewal (in Years) | Continuing Education Requirement (in hours) | Additional Required Exams | Cost of Initial Licensure* | Cost of License Renewal | Reciprocity or Endorse-ment | Good Moral Character Require-ment | |
|---|---|---|---|---|---|---|---|---|---|---|
| Arkansas | Doctorate | 2 years (incl. 1 postdoctoral) / 2,000 hours internship | ASPPB exam | 1 | 20 | $400 | $300 | Reciprocity | Yes | |
| Kansas | Doctorate | 2 years supervised work experience | EPPP exam | 2 | 50 | $775 | $150 | Reciprocity | Yes | |
| Kentucky | Doctorate | 2 years supervised work experience | EPPP exam | 3 | 39 | KY Jurisprudence Exam | $450 | $450 | Reciprocity | Yes |
| Missouri | Doctorate | 1 years supervised work experience | EPPP exam | 2 | 15 | MO Jurisprudence exam | $150 | $300 | Reciprocity | No |
| Oklahoma | Doctorate | 2 years supervised work experience | EPPP exam | 1 | 20 | OK Jurisprudence Exam | $400 | $200 | Reciprocity | No |
| Tennessee | Graduate | 2 years postgrad supervised work experience | National Counselor Examination; National Clinical Mental Health Counseling Examination | 2 | 20 | $600 | $225 | Yes | Yes |
*Initial Licensure may include exam, application and licensing fees.
Figure A3. Licensing requirements for pharmacy technicians, selected states (2022)
| Education Required / Training Required | Professional Exam | Required Time of License Renewal (in Years) | Continuing Education Requirement (in hours) | Cost of Initial Licensure | Cost of License Renewal | Reciprocity or Endorsement | Good Moral Character Requirement | Blanket Ban for Ex-Offenders | |
|---|---|---|---|---|---|---|---|---|---|
| Arkansas | None | Yes | 2 | 0 | $145 | $35 | Yes | Yes | Yes |
| Kansas | None | Yes | 2 | 20 | $67 | $20 | Yes | No | No |
| Kentucky | None | 1 | 0 | $25 | $25 | No | Yes | No | |
| Missouri | None | No | 1 | 0 | $75.3 | $35 | No | No | No |
| Oklahoma | None | 1 | 0 | $75 | $75 | Yes | Yes | No | |
| Tennessee | 480 hours of training required (non-degree) | No | 2 | 0 | $95 | $95 | No | Yes | Yes |
Note: No experience or additional exams required
Figure A4. Licensing requirements for occupational therapy assistants, selected states (2022)
| Education Required | Experience Required | Professional Exam | Required Time of License Renewal (in Years) | Continuing Education Requirement (in hours) | Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars) | |||
|---|---|---|---|---|---|---|---|---|
| Arkansas | Associates | 2 months | Yes | 1 | 10 | $605 / $50 | Yes | Yes |
| Kansas | Associates | 0 | Yes | 2 | 40 | $635 / $75 | Yes | Yes |
| Kentucky | Associates | 16 weeks | Yes | 1 | 12 | $590 / $35 | Yes | Yes |
| Missouri | Associates | Fieldwork prescribed by accredited institution | Yes | 2 | 24 | $585 / $10 | Yes | Yes |
| Oklahoma | Associates | 2 months | Yes | 2 | 20 | $605 / $20 | Yes | Yes |
| Tennessee | Associates | Fieldwork prescribed by accredited institution | Yes | 2 | 24 | $585 / $80 | Yes | Yes |
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 Exam | Required 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 | ||
|---|---|---|---|---|---|---|---|---|
| Arkansas | Master’s or Doctoral from an ACOTE®-accredited program | 0 / 0 | Yes (Board for Certification in Occupational Therapy) | 1 | 10 | $75 / $55 | Yes | |
| Kansas | Master’s or Doctoral from an ACOTE®-accredited program | 0 / 0 | Yes | 1 | 40 for the preceding two-year period, reported during the odd-numbered years | $80 / $80 | No | No |
| Kentucky | Master’s or Doctoral from an ACOTE®-accredited program | 0 / 24 hours | NBCOT certification exam | 1 | 12 | $50 / $50 | Yes | Yes |
| Missouri | Master’s or Doctoral from an ACOTE®-accredited program | 1,000 hours fieldwork / 0 | Yes | 2 | 24 | $30 / $30 | Yes | No |
| Oklahoma | Master’s or Doctoral from an ACOTE®-accredited program | 0 / 0 | NBCOT certification exam | 1 | 20 | $120 / $100 | Yes | Yes |
| Tennessee | Master’s or Doctoral from an ACOTE®-accredited program | 10 hours / 0 | NBCOT certification exam | 2 | 24 | $100 / $85 | No | Yes |
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 Required | Professional Exam | Required 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 | Good Moral Character Requirement | Blanket Ban for Ex-Offenders | |
|---|---|---|---|---|---|---|---|---|
| Arkansas | Bachelor’s | Yes | 2 | 30 | $100 / $80 | Yes | No | Yes |
| Kansas | Bachelor’s | Yes | 2 | 6 | $150 / $150 | Yes | Yes | No |
| Kentucky | Bachelor’s | Yes | 3 | 15; 3-year period | $25 / $75 | No | No | No |
| Missouri | Bachelor’s | Yes | 2 | 15 | $70 / $65 | Yes | Yes | No |
| Oklahoma | Bachelor’s | Yes | 2 | 16 per 2-year period | $150 / $100 | Yes | Yes | No |
| Tennessee | Bachelor’s | Yes | 2 | 9 | $75 / $45 | Yes | No | No |
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 required | Professional Exam | Required 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 | |||
|---|---|---|---|---|---|---|---|---|
| Arkansas | Yes | 2 | 0 | $145 / $35 | Yes | Yes | Yes | |
| Kansas | Yes | 2 | 20 | $67 / $20 | Yes | No | No | |
| Kentucky | 1 | 0 | $25 / $25 | No | Yes | No | ||
| Missouri | No | 1 | 0 | $75.3 / $35 | No | No | No | |
| Oklahoma | 1 | 0 | $75 / $75 | Yes | Yes | No | ||
| Tennessee | 480 hours (non-degree) | No | 2 | 0 | $95 / $95 | No | Yes | Yes |
Note: No education required, no experience required, no additional exams
Figure A8: Licensing requirements for dietician nutritionist, selected states (2022).
| Education Required | Experience Required | Professional Exam | Required 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 | Good Moral Character Requirement | |
|---|---|---|---|---|---|---|---|---|
| Arkansas | Baccalaureate | American Dietetic Association approved pre-professional experience | Commission on Dietetic Registration exam | 1 | 12 | $110 / $50 | Yes | No |
| Kansas | Baccalaureate | 900 hours of planned continuous pre-professional experience | Commission on Dietetic Registration exam | 1 | 15 | $140 / $135 | Yes | No |
| Kentucky | Baccalaureate | Commission on Dietetic Registration exam | 1 | 15 | $50 / $50 | Yes | No | |
| Missouri | Baccalaureate | Commission on Dietetic Registration exam | 2 | 75 (every 5 years) | $50 / $20 | Yes | No | |
| Oklahoma | Baccalaureate | Internship or preplanned professional experience | Commission on Dietetic Registration exam | 1 | 0 | $120 / $100 | Yes | No |
| Tennessee | Baccalaureate | 900 hours of planned continuous pre-professional experience | Commission on Dietetic Registration exam | 2 | 0 | $130 / $70 | Yes | Yes |
Note: No training hours required, no additional exams, no blanket ban on ex-offenders
Figure A9: Licensing requirements for optometrist, selected states (2022)
| Education Required | Professional Exam | Required Time of License Renewal (in Years) | Continuing Education Requirement (in hours) | Additional Required Exams | Cost of Initial Licensure (in dollars) / Cost of License Renewal (in dollars) | Reciprocity or Endorsement / Cost | Good Moral Character Requirement | Blanket Ban for Ex-Offenders | |
|---|---|---|---|---|---|---|---|---|---|
| Arkansas | Doctorate | Entrance exam | 1 | 12 | $450* / $150 | Yes / $438.50 | No | Yes | |
| Kansas | Doctorate | Entrance exam | 2 | 48 | $180** / $450 | Yes / $150 | Yes | No | |
| Kentucky | Doctorate | Entrance exam | 1 | 12 | $525 / $250 | Yes /$725 | Yes | No | |
| Missouri | Doctorate | Entrance exam | 2 | 32 | Law exam | $275*** / $150 | Yes / $225 | Yes | No |
| Oklahoma | Doctorate | Entrance exam | 1 | 25 | $200 / $300 | No | Yes | No | |
| Tennessee | Doctorate | Entrance exam | 2 | 40 | Jurisprudence exam | $250 / $275 | Yes | Yes | No |
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