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Increasing in number, advanced practice providers fill critical role in rural health care

If not for these professionals, access to health care in many rural communities would be severely diminished or non-existent, health system executives say

Christina Brooks, a physician assistant at the Nelson County Health System in McVille, ND, said achieving good work-life balance was an important part of her career decision-making process. Photo by Eric Hylden/Grand Forks Herald
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GRAND FORKS -- As a pre-med student in college, Christina Brooks was heading for a career as a physician and gaining practical experience as a certified nurse assistant at Altru Health System.

Along the way, she began to consider another route that would require fewer years of training and provide personal and professional advantages.

Brooks decided to pursue a career as a physician assistant and enrolled in the two-year University of North Dakota physician assistant studies program.

As part of her degree requirements in the program, which emphasizes family medicine and rural health care, Brooks completed a two-month rotation at Nelson County Health System in McVille, N.D. She earned a master’s degree in 2018 and joined that health system in July that year.

“I really like the flexibility associated with being a PA,” she said. “PAs have this great capability of having the flexibility of going into any specialty they desire. ... That was something that was very important to me.”


And there are benefits in terms of her family life, said Brooks. She and her husband welcomed their first children, twin girls, in February.

“I like the flexibility too in the sense that I’m able to have a family and be present at home, but also have a full-time career at the same time.”

She is among three advanced practice providers who work with the sole physician, Dr. Erling Martinson, at the Nelson County Health System, based in McVille, N.D. The health system includes a clinic, hospital, ER, and long-term care facilities, and operates a satellite clinic in Michigan, N.D.

Growing field

Brooks is among an increasing number of health care professionals who are joining the ranks of physician assistants and nurse practitioners in North Dakota and Minnesota.

These professionals -- generally referred to as “advanced practice providers” -- are filling an important need in health care, many of them in rural locations where it is often difficult or impossible to attract and retain physicians.

In North Dakota, to date, 890 physician assistant licenses have been issued, according to the state’s Board of Medicine. The board cannot report the number of active licenses at certain points in time, said Sandra DePountis, executive director, and the number of licenses issued does not equate to the number of licensees who are actively practicing in the state. By the end of 2001, a total of 274 had been issued, and at the end of 2011, 472 were issued.

Also, in North Dakota, the number of licensed nurse practitioners stands at 1,464, according to the North Dakota Board of Nursing. This compares to 812 listed in the board’s 2019-20 annual report and 329 in 2006-07, said Stacey Pfenning, executive director.

According to the Minnesota Department of Health, the number of health professionals licensed as advanced practice registered nurses has more than doubled since 2010 -- from 4,846 to 10,312 today. These health care professionals are licensed as certified nurse midwives, certified nurse practitioners, certified registered nurse anesthetists and clinic nurse specialists.


The number of licensed nurse practitioners in Minnesota has grown from 2,682 in 2010 to 6,061 in 2020, according to the Minnesota Board of Nursing.
The number of licensed PAs in Minnesota has jumped from 305 in 2000 to 1,209 in 2010. Today, that total is 3,682, according to the Minnesota Board of Medical Practice.

This growing pool of advanced practice providers is a trend that rural healthcare leaders are pleased to see.

“The pool of candidates has greatly increased,” said Gabriel Mooney, CEO, Kittson Health Care in Hallock, Minn. Four years ago, when he was an Altru employee, “we were begging for PAs and NPs and then, about the time of COVID, things changed; now there are some who are looking for jobs. The field has changed. I attribute most of that to schooling; there are more schools (and they) are pushing out more providers than they used to.”

The Kittson Health Care system serves all of Kittson County. Its service area has a population of about 4,300 people, including some from outside the county, Mooney said.

Kittson Health Care employs five advanced practice providers -- two nurse practitioners and two physician assistants who provide care in family practice and a nurse practitioner in psychiatry, whose practice is focused solely on behavioral health in areas such anxiety, depression and bipolar disorder.

To employ a behavioral health professional “has been a great addition for us,” Mooney said.

The primary role of these advanced practice health professionals is in clinical practice, he said, and, as “physician extenders, they can do so much of what a physician can do.”

The system employs a physician 24/7 for oversight of the emergency room and another full-time physician for the clinic.


The advanced practice providers, who offer “a great opportunity to be able to see someone quicker than a physician, and (can take care of) some of those lower-acuity, lower-complex patients than a physician would see,” Mooney said.

They fill the role of primary care provider -- the patient’s first contact with the system -- so the more complex cases would flow to the physician, Mooney said. “And we just don’t have the physicians like a larger system would.”

While their knowledge base, education, training and scope of service are similar, NPs can act more independently than PAs, Mooney said. “It’s really ballooned in the last several years that I’ve seen, in a positive way, (and PAs) can act more independently, which really takes some weight and stress off the physicians.”

In Minnesota, PAs and NPS are now able to practice independently, without physician supervision, and may be lead practitioners in a clinical practice, according to a Minnesota health department spokesperson.

Recent changes in North Dakota law have also permitted more independence in the way a PA practices.

Motivated to ‘give back’

At the Nelson County Health System, which serves a population of nearly 3,000, advanced practice providers are motivated by a desire “to give back to the community,” said Chris Haseleu, CEO. “There’s a lot more personal involvement with (health care). The people who work here want (to ensure) that the people they know around here are cared for properly.”

The system operates the only hospital -- a level 5 trauma hospital -- in Nelson County; the closest others are in Northwood and Cooperstown.

Advanced practice providers “really enhance the health care status and quality of life for the people in the community we serve here,” Haseleu said, “and having that commitment to individuals, they are advancing medical services and are aware of (new medical development and technology).”

Having these providers on the front lines of health care delivery has proven to be vital for many small and rural communities.

“Without advanced practice providers, the landscape of rural health care would greatly change for the negative, and it would impact patient care -- and that’s where my focus is and my role is: what’s best for our patients and the care they receive. We need to have those mid-levels there,” Mooney said.

Christina Brooks, a PA at the Nelson County Health System in McVille, ND. visits with one of her patients, David Aaser, July 8, 2021. Photo by Eric Hylden/Grand Forks Herald

Christina Brooks, a PA at the Nelson County Health System in McVille, ND. visits with one of her patients, David Aaser, July 8, 2021. Photo by Eric Hylden/Grand Forks Herald

Pamela Knudson is a features and arts/entertainment writer for the Grand Forks Herald.

She has worked for the Herald since 2011 and has covered a wide variety of topics, including the latest performances in the region and health topics.

Pamela can be reached at pknudson@gfherald.com or (701) 780-1107.
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