Title: Retooling and Reconfiguring the US Health Workforce to Meet the Demands of Health Reform
1Retooling 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
2Presentation 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
3Who 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
4Program 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
5Program 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
6Culture 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.
7Future 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
8With 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
9Health 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.
10Therapies 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.
11But 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.
12(No Transcript)
13Health 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
14Accountable 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
15Different 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
16Flexible 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
171. 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
182. 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
193. 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
204. 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
215. 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
22Health Workforce Planning the Traditional Way
23 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
24How do we get there from here?Look
internationally for best practices
25What 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?
26Encouraging 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)
27Developing 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?
28 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
29 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
30Building 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
31Engaging 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
32Engaging 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?
33Under- 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
34Engaging 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
35Using 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
36Questions?
- Erin Fraher
- (919) 966-5012
- 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