Transcript California's Health Care Workforce: Readiness for the ACA Era

Innovative Workforce
Models- Projects and
Research from the Center
for Health Professions
Susan A. Chapman
UCSF School of Nursing & Center for Health Professions
September 21, 2012
Health Workforce Initiative
Statewide Advisory Committee Meeting
What’s New at the UCSF Center for
Health Professions?
• Leadership transition- Sunita Mutha, acting
director
• Forming closer ties with other UCSF policy
centers
• Continuing focus on human capital &
leadership development
• Workforce in new models of care
• Lens of health reform
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Overview of today’s talk
• Looking through the lens of health reform
• Is California’s workforce adequate for health
reform?
• Examples of data available to assess
California’s health workforce
• What do key informants think
• How might new models of care be used in
health reform
– Example: enhanced roles for Medical Assistants
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Health Reform:
Can you explain it?
How will it work?
http://healthreform.kff.org/the-animation.aspx
9/12
UCSF-CHP
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Now we know that the ACA is here to
stay?
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What is Health Reform?
• Insurance reform
• Payment reform
• Incentives for new models of care
• Training funding
• Prescription drug donut hole filled in
• Long term care reform
• Other special programs and area of support
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Health Reform in California
• Health insurance exchange- CA is a leader
among states
• Medicare and MediCal reform in managed care
• Accountable Care Organizations being formed
• Patient Centered Medical Home designations
• Community Clinic and Safety Net providers
have new opportunities as well as threats
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Drivers that affect the quantity & quality of
California’s health care workforce
• Demographic shifts
– Aging, growing population
– Increasingly diverse, ESL population
• Growth in health information technology (EHR)
• New models of care
• Patient Protection and Affordable Care Act
– 3-4 million newly insured in California
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California’s Licensed and Registered
Health Care Workforce—February 2011
Other
27,740
Nursing
386,041
Total = 840,900
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Source: California DCA Professional License Masterfile
Can the current health care workforce meet
the changes in demand?
• Maldistribution is the biggest challenge
• Lack of cultural / linguistic concordance may
limit access
• Incomplete or insufficient data limits workforce
planning
• Primary care is likely to be the most impacted
by the increase in demand
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Examples of Workforce Supply and
Distribution
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Distribution of Primary Care Physicians
and Physician Assistants
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Distribution of Dentists and
Dental Assistants
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Recommendations from
Key Informants
• Improve telehealth and HIT capacity to
implement meaningful use
• Targeted workforce development
– Develop multidisciplinary teams
– NP and PA training for primary care
– Support innovations in community colleges (increase
success, focus on underrepresented groups)
• Promote regional and statewide coordination
• Strengthen the safety net providers
• Enhance diversity
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Recommendations from
Key Informants
Redesign practice models
and financing
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Solutions: Improving Supply, Distribution,
and Workforce Practice Models
• Increase training & residency opportunities in
under-served areas
• Expand loan repayment programs for
practicing in underserved areas
• Enhance telehealth
• Expand legal scope of practice for NPs & PAs
• Improve workforce data collection
• Strengthen the capacity of safety net providers
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Do we educate enough providers to
meet the state’s growing needs?
Probably not from overall perspective
• Some programs oversubscribed
• Maldistribution of training programs
• Lack of clinical training resources
• Lack of faculty in some programs
• Lack of communication between demand and
supply chains
• Cost and state budget constraints
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Solutions: Improving the Education Pipeline
• Encourage practice in primary care
• Refocus some resources on
NP & PA training
• Enhance successful retention and completion
in community college health careers programs
• Creative paths to clinical training, internships,
nursing residency
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Expansion of nursing programs has increased
the supply of nurses
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California’s Health Care Workforce:
Moving Forward
Challenge
• Growing pressure on safety net providers
• Geographic maldistribution of workforce
• Diversity challenges
Promise
• Continued job growth despite the recession
• New finance and delivery models may decrease
costs --improve access and quality of care
• HIT and telehealth to facilitate new models of care
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Recommendations from
Key Informants
Redesign practice models
and financing
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Innovations in Care Delivery Models:
Implications for Workforce Training and
Development
Case Studies of Enhanced Roles for
Medical Assistants
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Study Team
Catherine Dower, JD
Associate Director, Research
UCSF Center for the Health
Professions
[email protected]
Lisel Blash, MS, MPA
Senior Research Analyst
UCSF Center for the Health
Professions
[email protected]
Susan Chapman, PhD, RN
Associate Professor
UCSF School of Nursing
Dept of Social & Behavioral Sciences
Director, Masters Program in
Health Policy Nursing
Research Faculty,
Center for the Health Professions
[email protected]
Edward O’Neil, MPA, PhD, FAAN
Director
UCSF Center for the Health
Professions
Professor
UCSF Departments of
Family and Community Medicine,
Preventive and Restorative Dental
Sciences and Social and Behavioral
Sciences (School of Nursing)
http://www.futurehealth.ucsf.edu
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Innovative Workforce Models in Health Care
Study -- Hitachi Pioneer Employers Initiative
Inclusion Criteria
• Expanding the role of Medical Assistants
(MAs) in innovative model resulting in:
– Improved working conditions for MAs
– Improved clinical functions for the organization
– Documented evidence of successful outcomes for
patients, MAs, or the organization
•
14 case studies completed
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Who are Medical Assistants?
• The largest category of employees in outpatient primary
care (500,000 in the U.S.)
• One of the fastest growing occupations in the U.S.
• 89% female; diverse in race/ethnicity
– Being bilingual is often a job requirement
• Trained on the job or short-term training
– 3 to 10 month programs up to 2 year degree
• Little regulation of practice
• Primarily a delegation model
• Professional certification available, usually not required by
employers
• Wages: U.S. $28,300 median annual ($13.60/hr)
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Organization Type
• FQHC (4): High Plains Community Health Center; DFD
Russell Medical Centers, Cabin Creek Health System,
Family Health Center of Worcester, Inc.
• Academic Health System (3): UC Davis Family Practice
Center, University of Utah Community Clinics,
Northwestern Memorial Physicians Group
• Integrated Health System (not academic) (5): Kaiser
Baldwin Park (HMO), PeaceHealth Medical Group,
SouthCentral Foundation, Franklin Square Hospital
Center, The Special Care Center (Atlanticare)
• Stand-Alone Multi-Specialty Care Clinic (1): Union Health
Center
• Multi-Specialty Medical Group, no hospital: (1) WellMed
Medical Group
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Why Sites Innovate MA Roles
1.
2.
3.
4.
Personnel and staffing challenges
Patient needs and concerns
Electronic health records
Health care reform
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Why Sites Innovate MA Roles
1. Personnel and staffing
• Difficulty recruiting MDs and RNs
• Providers and RNs too expensive
• Providers & RNS overloaded
• Low productivity
• Retention & satisfaction concerns
(“burnout”)
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Why Sites Innovate MA Roles
2. Patient needs and concerns
– Medication safety issues
– Low patient satisfaction
– Increase in chronic disease
– Language / cultural barriers
– Appointment wait time / Access
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Why Sites Innovate MA Roles
3. Electronic Health Records Implementation
– Requires new skills and constant upkeep
– Facilitates delegation
– Facilitates documentation and QI
4. Health Care Reform (and reform)
– Team-based care requires all staff to “work at
the top of their license”
– PCMH transformation
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Traditional Medical Assistant Role
– Reception / answer telephone
– Schedule appointments
– Maintain files / charts
– Room patients / prepare for
exam
– Take vital signs / patient history
– Perform venipuncture and
immunizations
– Inventory / restock supplies
– May translate for medical
interviews
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Examples of New Roles for MAs
• Enhanced clinical roles
– Dual-role Interpreter
– Panel Coordinator / Manager
– Health Coach / Health Educator
– Home Visits / Risk Assessment
– Patient Navigator / Referral Coordinator
– Immunization Specialist / Vaccine Coordinator
• Enhanced administrative / supervisory roles
– Lead MA / Team Leader
– MA Supervisor
– Floor Coordinator
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Why Sites Innovate MA Roles
• Difficulty in recruiting MDs and RNs
• Providers and RNs too expensive / too busy
– Productivity and cost concerns
– Retention and satisfaction concerns
• MA turnover / satisfaction
• Patient needs / concerns
– Medication safety issues
– Patient satisfaction problems
MAs are a
flexible &
expandable
pool of
workers—
cross-trained
in clinical
AND clerical
skills
– Increase in chronic disease
• EHR makes redesign and delegation possible
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Two Examples
1. MA-team model
2. Ambulatory Intensive Caring Unit (A-ICU)
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Rural FQHC
High Plains Community Health Center
• 60 staff & providers:
– 7 providers MDs/NPs/
PAs
– 21 MAs
– 4 health coaches
– Dental & mental health
services
– Onsite pharmacy
• Level 3 PCMH
• Lamar, Colorado
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High Plains Community Health Center
Why Innovate?
• Flagging productivity
• Financial difficulties
• Long patient wait times
• Staff dissatisfaction / infighting
• Difficulty in recruiting & affording RN staff
• Difficulty in recruiting & retaining providers
• EHR & telemedicine implementation
• Distance from urban centers & training programs
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High Plains Community Health Center
New Model — MA-team model
• Increase MA/Provider ratio to 3:1
• Rotate MAs through front & back office duties
– Eliminate filing clerk, reception, RN positions
• Don’t move the patient; move the care
• Walkie-talkies; telemedicine facility, wireless
tablets; EHR
• Grow-your-own: onsite/online training &
certification for LLRT, Pharm Tech, CCMA
• Grant funding covers training & some positions
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High Plains Community Health Center
Why it works
• Consistent leadership over time
• Streamlined decision-making to a small group
• Provider buy-in: encourage involvement in MA
training agenda
• EHR facilitates “fine-tuning” of the model
• High MA/provider ratio increases productivity
• Cross training allows coverage during absences
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High Plains Community Health Center
Outcomes
• New positions: Health Coach,
CHW, Supervisor, Pharm Tech, LLRT
– Health Coaches earn approximately
42% more than MAs
• Wait time reduced for patients
• Provider productivity increased
- 2000 to 2003
– Pt visits 1.82/hr to 2.7/hr due to visit redesign
• Costs savings
– Up to $67K per team per year
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Urban Primary and Multi-Specialty Care Center
UNITE Health Center
New York City, NY
• 140 staff & providers,
including:
– 15 bilingual primary care
providers
– 38 part-time specialists
– 17 bilingual patient care
assistants (MAs)
– 6 health coaches (MAs)
• Level 3 PCMH
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UNITE Health Center
Facilitators to Change
• Rising costs due to increase in chronic care
• Long patient wait times
• New leadership
• Workflow redesign
• EHR implementation
• Move from fee-for-service to PMPM capitation
• Changing patient mix
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UNITE Health Center
Model—Ambulatory Intensive Caring Unit (AICU)
• Train MAs as health coaches
• Customize EHR templates to allow delegation
• Teams: 3 providers, 3 MAs, 2 MA/health
coaches, 1 greeter, 1 patient support services
person
• Provider time reserved for patients’ clinical
needs
• Patient self-management
• Morning huddles
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UNITE Health Center
How they initiated change
• Redesign including MA health coach training
• In-house curriculum (grant-funded)
– 1) didactic instruction
– 2) written competency exam for each module
– 3) clinical shadowing and supervised reinforcement
• Trainers: Senior RN administrator and dietician
• Time commitment: 2-hours onsite every week
for 9 months
• MAs who pass all modules eligible for promotion
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UNITE Health Center
Why it works
• Enhance provider buy-in by including them in
competency evaluation
• Start with a pilot
• Provide dedicated meeting and training time
– Extensive MA training required
– Training more cost effective for large clinics
• Careful MA selection during recruitment (externs)
• PMPM capitation through Union health & welfare
funds
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UNITE Health Center
Outcomes
• New positions: Health Coaches, Floor Coordinators
– 12-27% pay boost for promoted MAs
• Reduced wait and visit time
– From 2 hours to 48 min
• Improved chronic disease outcomes
– Pts with 3 markers (A1c, B/P, & cholesterol controlled)
 from 13% to 36%
• Reduced costs
– Union patients at UHC cost 17% less PMPM compared
to union patients in other care
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Career Development Insights
• More emphasis on role than career
development
• Generally increases in role and
responsibility came with modest
salary increases
• All organizations provided some
support for career movement
– The career ladder is not easy
– MAs may have debt from MA school of
$15-20,000
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Major Findings
Practice models and roles are shifting
Job and career opportunities expanding
Restructuring reimbursement makes it possible
MAs become team members
– Accountability and responsibility for patients
• Increased recognition of frontline workers
• Models, templates, training materials are
replicable
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MA Perspectives
• “Now I feel more a part of the team. I feel like I give 110%.
I feel much more important.”
• “Before this I was too scared to speak to a doctor. This
empowered me to speak up, because you have to.”
• “Communication has improved; we say my patients, not
just ‘the doctor’s patients.”
• “It’s not just my job, but everybody’s job. It is much better
patient care. You don’t just say, “There you go,” and let
the patient leave. You do follow-up, you check on how
they are doing …”
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Major Challenges
• Change management
• Making the business case
• Establishing evaluation metrics
• Identifying training time and curriculum
• Working with HR and or Unions to change job
descriptions and reimbursement
• Financing
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Focus on Financing
• Capitation for case management
• HMO structure
• Medicare Advantage Plans
• Pilot and demonstration project funding
• Ability to bill for some services under hospital
• HRSA grants to cover chronic care and other
initiatives
• Other grant funding
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There are also cost savings…
• Increased productivity per provider
• More efficient use of staffing
• Training improves coding and billing
• Increases MA retention – lowers recruitment
costs
• Decreases hospitalization, ER use
• Decreases risk (e.g. medication safety)
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Next Steps in Health Reform and
Workforce Planning
• Better data- OSHPD, other sources
• Facilitate replication of successful pilots
• Implement new financing models
• Address scope of practice issues
• Analysis of outcome
– Triple aim: better care, improve health, reduced
cost
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QUESTIONS
Contact: Susan Chapman
[email protected]
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