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

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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 information—data, maps, information, quick turn-around analyses—from 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.

7. 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

8. 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

9. 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.

10. 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.

11. 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.

13. 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

14. 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

15. 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.innovations.cms.gov/Files/x/Health-Care-Innovation-Challenge-Funding-Opportunity-Announcement.pdf

16. 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

17. 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

18. 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 care—and the health care workforce—from expensive inpatient settings to ambulatory, community and home-based settings • Generally we don’t train health professionals in these settings • Current workforce not prepared to meet patient on “their turf”

19. 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

20. 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

21. 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

22. Health 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

24. How do we get there from here?Look internationally for best practices

25. 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?

26. 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 models—need “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)

27. 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?

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 < 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

30. 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

31. 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

32. 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?

33. 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 don’t 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 don’t because you don’t 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/16%20RN4CAST_OECD_WS.pdf

34. 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

35. 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, don’t 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”

36. Erin Fraher (919) 966-5012 erin_fraher@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 Questions?