Retooling and Reconfiguring the US Health Workforce to Meet the Demands of Health Reform - PowerPoint PPT Presentation


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


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 – PowerPoint PPT presentation

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

Retooling and Reconfiguring the US Health
Workforce to Meet the Demands of Health Reform
  • Erin Fraher, PhD MPP
  • Director, Program on Health Workforce Research
  • Cecil G. Sheps Center for Health Services
    Research, UNC-CH
  • Duke-NUS Seminar, Singapore, June 20, 2013

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

Who am I?
  • Masters in Public Policy from UC Berkeley, 1993
  • Worked for College of Nurses of Ontario, Canada
    developing Nurse Practitioner regulations,
  • 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
  • Worked for National Health Service in England in
  • Returned to Sheps with appointment as Assistant
    Professor in Depts of Family Medicine and Surgery

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

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

Culture of Engaged Scholarship State 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.
Future Research
  • Continue to develop workforce modeling
  • 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

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

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// Accessed 21
Oct 2012.
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
But more people are doing less
  • Of 2.6 trillion spent nationally on health care,
    56 is wages for health workers
  • Workforce is LESS productive now than it was 20
    years ago...

Kocher and Sahni, Rethinking Health Care Labor,
NEJM, October 13, 2011.
(No Transcript)
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

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

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
    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

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
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
  • 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
  • Broader implementation of true team-based models
    of care and education

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
  • 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

2. Existing workforce will shift from acute to
ambulatory, community- and home-based settings
  • Changes in payment policy and health system
  • 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
  • Generally we dont train health professionals in
    these settings
  • Current workforce not prepared to meet patient on
    their turf

3. Existing workforce will need more career
  • 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

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

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
Health Workforce Planning the Traditional Way
Result is a Compromised Workforce Planning
  • 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

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

Encouraging collaborative workforce planning
  • 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)

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?

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

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

Building a workforce for health, not a health
  • Increased focus on keeping people out of
    hospital, caring for patients in community and
  • 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

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
  • Both educators and employers will need to
    identify and support innovative,
    interprofessional practices of future

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- 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,
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
  • Need to focus efforts on building meaningful,
    rewarding work environments and career ladders

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
  • we are drowning in data and free of

  • Erin Fraher
  • (919) 966-5012
  • Program on Health Workforce Research Policy
  • http//
  • North Carolina Health Professions Data System
  • http//