Dan Keuning, Pagosa Springs, Colo.

    • October 8, 2004

The remote Rocky Mountain town of Pagosa Springs, Colo., has more than enough of certain things—like snow, up to 600 inches a year—and not enough of others, like health care. The nearest hospital, for example, is 60 miles away. Both aspects of the town—its superb skiing, hunting, fishing and mountain biking, as well as the underserved medical needs of its 12,000 year-round residents—appealed to Dan Keuning when he honeymooned in Pagosa Springs in 1993.

A Southern Californian, he had just graduated from college in Michigan, where he had met his wife and became a registered nurse (RN). "We fell in love with the town and moved here three months after we got married," he recalls. By 1998 he was working as an RN in the Mary Fisher Clinic, a family-focused primary care facility in town. Now the father of a two-year-old boy, he realized that in order to provide for a growing family and be of greater service to his community he would have to get his master's degree and become a nurse practitioner. (Nurse practitioners are registered nurses with advanced training who provide primary care services—such as performing physical examinations and diagnostic testing, interpreting findings, prescribing medications, and conducting patient education and counseling—often working in collaboration with physicians.)

Getting the necessary training didn't seem possible in Pagosa Springs, and Denver was a six-hour drive. "I didn't want to leave town for three years to go to school," he says. "I was thinking we would have to move somewhere where I had family, like California or Michigan."

That's where matters stood until, in August of 1998, the solution to his dilemma literally walked through the door. A team from the University of Colorado Health Sciences Center in Denver visited the clinic that day. They were part of the Mountain and Plains Partnership (MAPP), a distance-learning project supported by RWJF through Partnerships for Training: Regional Education Systems for Nurse Practitioners, Certified Nurse-Midwives and Physician Assistants, a national program to develop regional models for the education of mid-level practitioners to increase their numbers in underserved areas.

"They asked if I was interested in continuing my schooling," recalls Keuning, who was 28. "I said, 'Sure, but I'm not moving to Denver.' They said, 'Well, we have a grant that will help you continue schooling in your own community.' That was on a Thursday. By Monday I was signed on and had started taking my first classes."

For the next three years, Keuning cut back his hours at Mary Fisher to 24 a week and put about 40 hours a week into classes and homework—both in front of a computer screen. "MAPP sent someone to my house to set me up with a new computer," he relates. "The guy drove from Grand Junction, which is about 150 miles from my house." Through a dial-up modem, Keuning downloaded study materials and assignments, and took online exams.

Once a week, he would drive 90 miles to Alamosa, over a 10,800-foot mountain pass, for a live video feed from the classroom in Denver. Seated at a camera-equipped computer, Keuning could be seen by the instructor in Denver and the 30 or so students in the classroom. They not only could see him, but also several other MAPP students remotely connected from other frontier locations.

"I had a microphone that I'd click and say, 'Excuse me, I have a question,'" Keuning says. "The instructor would look at her camera and say, 'Go ahead, Dan." The students would ask me questions, too. In Denver they never had to worry about being without an emergency room or an ambulance. But in a rural setting, it could take 40 minutes for the ambulance to get to me. They were amazed by that."

The class lasted three hours. The drive each way took two hours—time Keuning put to good use by studying Spanish on tape. "We have a lot of immigrants from northern Mexico here and a lot of descendants of the original Spaniards," he explains. "Now I'm fluent in Spanish because of my time on the road, and that helps a lot in a small community."

Since finishing the program in 2001, Keuning, now 34, has been enjoying the added duties of a nurse practitioner. "I got certified in trauma, I can diagnose and prescribe, suture, and do mole removals and things like that," he says. "I couldn't have done it without the assistance of the Mountain and Plains Partnership."