Retooling and Reconfiguring the US Health Workforce to Meet the Demands of Health Reform

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Retooling and Reconfiguring the US Health
Workforce to Meet the Demands of Health Reform

• Erin Fraher, PhD MPP
• Director, Program on Health Workforce Research
  Policy
• Cecil G. Sheps Center for Health Services
  Research, UNC-CH
• Duke-NUS Seminar, Singapore, June 20, 2013

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Presentation Overview

• Who am I?
• The Program on Health Workforce Research Policy
• Why we need to retool and reconfigure the
  workforce
• How do we transform the workforce to move toward
  a transformed health system?
• Innovative approaches from Canada, UK, Australia
  and NZ

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Who am I?

• Masters in Public Policy from UC Berkeley, 1993
• Worked for College of Nurses of Ontario, Canada
  developing Nurse Practitioner regulations,
  1994-1997
• Have worked at Cecil G. Sheps Center for Health
  Services Research at University of North Carolina
  at Chapel Hill since 1999
• Finished PhD in Health Policy and Management in
  2009
• Worked for National Health Service in England in
  2010
• Returned to Sheps with appointment as Assistant
  Professor in Depts of Family Medicine and Surgery

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Program on Health Workforce Research Policy
Mission

• MissionProvide policy makers with evidence-based
  workforce research and data to ensure workforce
  is in place to meet demands of health care
  system
• Build science of workforce policy by
• grounding it in better data, research and
  modeling techniques
• infusing it with interdisciplinary theory and
  methods
• conducting interprofessional workforce studies
• broadly disseminating, and applying, research to
  real world decisions affecting clinicians,
  employers, patients and policy makers

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Program on Health Workforce Research Policy 3
Service Lines

• Three main service lines
• Research Build science of workforce research
• Policy analysis Anticipate policy questions,
  inform policy with data-driven evidence,
  simulate effect of policy scenarios
• Service Provide rapid response to requests for
  data and research, serve on taskforces and
  committees, present to variety of state, national
  and international audiences
• We also teach and mentor

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Culture of Engaged ScholarshipState and
National Service

• Program as hub for reliable, trustworthy
  information. Dissemination efforts in the most
  recent five years include
• 27 fact sheets and reports
• 85 presentations to local, state, national and
  international audiences
• 830 responses to requests for informationdata,
  maps, information, quick turn-around
  analysesfrom national and state policymakers,
  researchers, educators, others
• 27 states requesting technical assistance (since
  2003) about building better health workforce
  planning systems

Note Figures current as of December 2012.
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Future Research

• Continue to develop workforce modeling
  capabilities
• Move away from silo-based modeling to better
  understand plasticity in portfolio of services
  offered by different skill mix configurations
• Apply comparative effectiveness methods to
  understanding cost/quality implications of
  workforce interventions
• Increase understanding (and action!) on workforce
  implications of health system reform

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With or without health reform, current system is
not sustainable

• Demand side aging population, increase in
  chronic disease, health system consolidation,
  payment policy changes
• Supply Side health workforce is growing,
  deployment is rigid, turf wars abound, and
  productivity is lagging
• Whether or not states implement health reform,
  pressure to reduce cost and improve quality and
  patient satisfaction are driving health system
  change

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Health care employment outpacing overall
employment allied health growing fastest
Data derived from US Bureau of Labor Statistics,
Occupational Employment Statistics, State
Cross-Industry Estimates 2000-2011. URL
http//www.bls.gov/oes/oes_dl.html. Accessed 21
Oct 2012.
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Therapies growing fastest within therapies,
assistant jobs growing most rapidly
Growth in Health Professionals per 10,000
Population Since 1981 North Carolina
PTs and PTAs grew much more rapidly relative to
docs, nurses and pharmacists
Sources NC Health Professions Data System with
data derived from the North Carolina Boards of
Physical Therapy Examiners, Medicine, Nursing and
Pharmacy.
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But more people are doing less

• Of 2.6 trillion spent nationally on healthcare,
  56 is wagesfor health workers
• Workforce is LESS productive now than it was 20
  years ago...

Kocher and Sahni, Rethinking Health Care Labor,
NEJM, October 13, 2011.
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Health reform and the new world of health
workforce planning

• All about the redesign of how health care is
  delivered less emphasis on who delivers care
• Patient Centered Medical Home
• Accountable Care Organizations
• Technology
• Shift will require more flexible workforce with
  new skills and competencies

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Accountable Care Organizations Patient Centered
Medical Homes

• Key characteristics
• Emphasis on primary and preventative care
• Health care is integrated across
• medical sub-specialties, home health agencies and
  nursing homes
• community- and home-based services
• Technology used to monitor health outcomes
• Payment incentives will promote accountability,
  moving toward risk-based and value-based
  models of care
• Designed to lower cost, increase quality, improve
  patient experience

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Different health system means different workers

• A transformed health care system will require a
  transformed workforce.
• The people who will support health system
  transformation for communities and populations
  will require different knowledge and skills.in
  prevention, care coordination, care process
  re-engineering, dissemination of best practices,
  team-based care, continuous quality improvement,
  and the use of data to support a transformed
  system

Source Centers for Medicare and Medicaid
Services, Health Care Innovation Challenge Grant,
Funding Opportunity Number CMS-1C1-12-001 ,
CFDA 93.610 , November 2011. http//www.innovatio
ns.cms.gov/Files/x/Health-Care-Innovation-Challeng
e-Funding-Opportunity-Announcement.pdf
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Flexible workforce, with new competencies, needed
in transformed system

• A more flexible use of workers will be needed to
  improve care delivery and efficiency that
  includes
• Existing workers taking on new roles in new
  models of care
• Existing workers shifting employment settings
• Existing workers moving between needed
  specialties and changing services they offer
• New types of health professionals performing new
  functions
• Broader implementation of true team-based models
  of care and education

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1. Existing workers will take on new roles in
new models of care

• To date, most policy discussion has focused on
• asking how many new health professionals will be
  needed
• Determining how to redesign educational
  curriculum for students in the pipeline
• But it is workers already in the system who will
  transform care
• Need more continuing education opportunities to
  allow workers to upgrade their skills and gain
  new competencies

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2. Existing workforce will shift from acute to
ambulatory, community- and home-based settings

• Changes in payment policy and health system
  organization
• Shift from fee-for-service toward bundled care
  payments, risk-and value-based models
• Fines that penalize hospitals for readmissions
• Rapid consolidation of care
• Will increasingly shift health careand the
  health care workforcefrom expensive inpatient
  settings to ambulatory, community and home-based
  settings
• Generally we dont train health professionals in
  these settings
• Current workforce not prepared to meet patient on
  their turf

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3. Existing workforce will need more career
flexibility

• Rapid and ongoing health system change will
  require a workforce with career flexibility
• Clinicians want well-defined career frameworks
  that provide flexibility to change roles and
  settings, develop new capabilities and alter
  their professional focus in response to the
  changing healthcare environment, the needs of
  patients and their own aspirations (NHS England)
• Need more generalists, fewer specialists
• Need better articulation agreements and career
  ladder opportunities to support continuous
  learning

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4. New types of health professional roles are
emerging in evolving system

• Patient navigators
• Nurse case managers
• Care coordinators
• Community health workers
• Care transition specialists
• Pharmacists
• Living skills specialists
• Patient Family Activator
• Medical Assistants
• Physicians
• Medical Directors

• Dental Hygienists
• Behavioral Health
• Social Workers
• Occupational Therapists
• Physical Therapists
• Grandaids
• Health Coaches
• Paramedics
• Home health aids
• Peer and Family Mentors

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5. Need to develop true team-based models of care
and education

• How do new roles fit with existing health
  professionals in team-based models of care?
• Chicken or egg what comes first team-based
  practice or team-based education?
• Significant professional resistance exists
• Need to identify new competencies, standardize
  and credential (?) new skills

Real and lasting change cannot happen without
simultaneously addressing payment, regulatory
and education policy
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Health Workforce Planning the Traditional Way
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Result is a Compromised Workforce Planning
System

• Resembles a version of Goldilocks written by
  Albert Camus with approaches that are either
  too hot, or too cold, but never just right
  (Grumbach, Health Affairs 2002 21(5) 13-27)
• Often lurches from oversupply to shortage
• Generates vigorous disagreements about what
  constitutes an adequate supply, distribution and
  right mix of health providers
• Data not linked to policy action

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How do we get there from here?Look
internationally for best practices
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What the US can, and should, learn from other
countries

• US workforce policy discussion positioned as
  false dichotomy centralized planning versus
  market rule
• Reality is more nuanced
• Despite different sizes, payment models, health
  care delivery models and education systems, UK,
  Canada, NZ, Australia (and Singapore?) face
  similar workforce challenges
• How do these countries determine the most
  effective shape of the future workforce?

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Encouraging collaborativeworkforce planning
approaches

• Health workforce policy is highly contested space
• Need to move from backroom planning to
  developing partnerships that
• engage coalitions of the willing to overcome
  professional resistance and tribalism
• test face validity of modelsneed boots on the
  ground perspective
• educate policy makers about difficulty and
  uncertainty in process
• Collaborative policy making and dialogue
  establishes new networks among the players in
  system, increases distribution of knowledge among
  these players(Hajer, Maarten, and Hendrik
  Wagenaar. 2003. Deliberative Policy Analysis
  Understanding Governance in the Network Society.
  Cambridge University Press)

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Developing workforce planning models that allow
for uncertainty and account for outcomes

• Considerable effort has been aimed at getting
  the right answer
• But in context of rapidly changing and evolving
  system, need to use workforce models to
• Simulate effect of different policy scenarios
• Reflect uncertainty in estimates (use of
  confidence intervals)
• Allow for different units of geography
• Account for how different scenarios affect cost,
  quality and access
• UK uses Christmas trees
• New Brunswick, Canada incorporating cost
• Other models?

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Engaging clinicians and patients in designing
new models of care (1)

• NZ doing innovative work engaging clinicians and
  patients in designing future health care system
• Transforming from ground up, rather than top down
• Constructing idealised patient journeys in
  mental health , aged care, primary care,
  maternity services, rehabilitation services, eye
  health and musculoskeletal health
• Asking clinicians to design ideal patient
  pathways by disease area and identify workforce
  changes that enable new models of care

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Engaging clinicians and patients in designing
new models of care (2)

• Identifying clinical vignettes that account for
  the majority of patient encounters in each
  service area
• Group of clinical leaders together with patients
  and health workforce experts describe a typical
  patient journey versus the ideal journey for
  each vignette
• Ideal journey must meet doubling of demand at
  cost lt 140 and no decrease in access or quality
• Result 1 identify what workers, IT and
  facilities enable those scenarios
• Result 2 develop implementation plan and
  identify barriers to implementing idealized
  journeys

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Building a workforce for health, not a health
workforce

• Increased focus on keeping people out of
  hospital, caring for patients in community and
  home
• Need to expand health workforce planning efforts
  to include workers in health, community and
  home-based settings
• Embrace role of social workers, patient
  navigators, community health workers, home health
  workers, therapists, dieticians and other allied
  health workers
• Need better integration with public health
• Plan for population health, not needs of
  professions

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Engaging employers in designing new models of
care (1)

• Employers under huge pressure to retool workforce
  
• Currently absorbing retraining costs but
  financial pressures may find them asking
  education system to partner
• Requires not only producing shiny new graduates
  but also upgrading skills of existing workforce
• Education system will need to work with employers
  to develop community- and home-based clinical
  placements
• Both educators and employers will need to
  identify and support innovative,
  interprofessional practices of future

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Engaging employers in designing new models of
care (2)

• Identify competencies needed to avoid
  readmissions and better integrate care
• More health educators, home health personnel,
  community health workers, care managers,
  transition specialists, nutrition services,
  medication management, rehabilitation and therapy
  services etc.
• Will need more generalists, fewer specialists
• Identify in what professions, and for areas of
  patient care, is the workforce over- and
  under-skilled?

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Under- and over-skilling among nurses and other
professionals is BIG issue

• Recent study in the Netherlands and US asked
  34,000 nurses
• Q1 What duties do you perform that you dont
  need to perform?
• Answer clearing trays, cleaning rooms, clerical
  duties, arranging transportation for discharge,
  other non-nursing tasks etc.
• Q2 What duties are you willing/able to perform
  but dont because you dont have time?
• Answer patient education, comforting and
  talking to patients and family, skin care,
  procedures and treatments, discharge prep, pain
  management, patient surveillance

Walter Sermueus, RN4CAST and possible skill
(mis)match of nurses. OECD Expert group on health
workforce planning and management,
http//www.oecd.org/els/healthpoliciesanddata/162
0RN4CAST_OECD_WS.pdf
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Engaging employers in designing new models of
care (3)

• Workforce demographics mean we need to pay more
  attention to retention
• Higher remuneration ? retention
• Health workers want career progression and job
  satisfaction
• Need to focus efforts on building meaningful,
  rewarding work environments and career ladders

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Using workforce data to shape policy

• Health workforce agencies created in NZ,
  Australia, UK and US to better integrate
  fragmented workforce planning efforts
• Roles are advisory to government
• Set strategic vision, dont dictate policy
• Efforts are national in scope but balanced with
  sub-national workforce planning needs
• Increased attention to link data to policy
  action
• we are drowning in data and free of
  intelligence

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Questions?

• Erin Fraher
• [phone]
• erin_fraher_at_unc.edu
• Program on Health Workforce Research Policy
• http//www.healthworkforce.unc.edu
• North Carolina Health Professions Data System
• http//www.shepscenter.unc.edu/hp