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Innovative Workforce Models- Projects and Research from the Center for Health Professions

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.

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Innovative Workforce Models- Projects and Research from the Center for Health Professions

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  1. 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

  2. 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

  3. 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

  4. Health Reform: Can you explain it?How will it work? http://healthreform.kff.org/the-animation.aspx UCSF-CHP

  5. Now we know that the ACA is here to stay?

  6. 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

  7. 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

  8. 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

  9. California’s Licensed and Registered Health Care Workforce—February 2011 Source: California DCA Professional License Masterfile

  10. 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

  11. Examples of Workforce Supply and Distribution

  12. Distribution of Primary Care Physicians and Physician Assistants

  13. Distribution of Dentists and Dental Assistants

  14. 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

  15. Recommendations from Key Informants Redesign practice models and financing

  16. 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

  17. Do we educate enough providers to meet the state’s growing needs? Probably not from overall perspective • Some programs oversubscribed • Maldistributionof 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

  18. 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

  19. Expansion of nursing programs has increased the supply of nurses

  20. 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 telehealthto facilitate new models of care

  21. Recommendations from Key Informants Redesign practice models and financing

  22. Innovations in Care Delivery Models: Implications for Workforce Training and DevelopmentCase Studies of Enhanced Roles for Medical Assistants

  23. Catherine Dower, JD Associate Director, Research UCSF Center for the Health Professions cdower@thecenter.ucsf.edu Susan Chapman, PhD, RN Associate Professor UCSF School of NursingDept of Social & Behavioral Sciences Director, Masters Program in Health Policy Nursing Research Faculty, Center for the Health Professions schapman@thecenter.ucsf.edu Lisel Blash, MS, MPA Senior Research Analyst UCSF Center for the Health Professions lblash@thecenter.ucsf.edu 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) Study Team http://www.futurehealth.ucsf.edu

  24. 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

  25. 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)

  26. 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

  27. Why Sites Innovate MA Roles • Personnel and staffing challenges • Patient needs and concerns • Electronic health records • Health care reform

  28. 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”)

  29. 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 34

  30. 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

  31. 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

  32. 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 38

  33. 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 • Increase in chronic disease • EHR makes redesign and delegation possible MAs are a flexible & expandable pool of workers—cross-trained in clinical AND clerical skills

  34. Two Examples MA-team model Ambulatory Intensive Caring Unit (A-ICU)

  35. Rural FQHCHigh 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. Urban Primary and Multi-Specialty Care CenterUNITE 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

  41. 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

  42. UNITE Health Center Model—Ambulatory Intensive Caring Unit (A-ICU) • 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

  43. 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

  44. 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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