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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

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
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

overview of today s talk
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
health reform can you explain it how will it work
Health Reform: Can you explain it?How will it work?


what is health reform
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

health reform in california
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


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
california s licensed and registered health care workforce february 2011
California’s Licensed and Registered Health Care Workforce—February 2011

Source: California DCA Professional License Masterfile

can the current health care workforce meet the changes in demand
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
recommendations from key informants
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
recommendations from key informants1
Recommendations from Key Informants

Redesign practice models

and financing

solutions improving supply distribution and workforce practice models
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
do we educate enough providers to meet the state s growing needs
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
solutions improving the education pipeline
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
california s health care workforce moving forward
California’s Health Care Workforce: Moving Forward


  • Growing pressure on safety net providers
  • Geographic maldistribution of workforce
  • Diversity challenges


  • 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
recommendations from key informants2
Recommendations from Key Informants

Redesign practice models

and financing


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

study team
Catherine Dower, JD

Associate Director, Research

UCSF Center for the Health Professions

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

Lisel Blash, MS, MPA

Senior Research Analyst

UCSF Center for the Health Professions

Edward O’Neil,MPA, PhD, FAAN


UCSF Center for the Health Professions


UCSF Departments of Family and Community Medicine, Preventive and Restorative Dental Sciences and Social and Behavioral Sciences (School of Nursing)

Study Team

innovative workforce models in health care
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
who are medical assistants
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)
organization type
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
why sites innovate ma roles
Why Sites Innovate MA Roles
  • Personnel and staffing challenges
  • Patient needs and concerns
  • Electronic health records
  • Health care reform
why sites innovate ma roles1
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”)
why sites innovate ma roles2
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


why sites innovate ma roles3
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
traditional medical assistant role
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
examples of new roles for mas
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


why sites innovate ma roles4
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

two examples
Two Examples

MA-team model

Ambulatory Intensive Caring Unit (A-ICU)

rural fqhc high plains community health center
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
high plains community health center
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
high plains community health center1
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
high plains community health center2
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
high plains community health center3
High Plains Community Health Center


  • 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
urban primary and multi specialty care center unite health center
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
unite health center
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
unite health center1
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
unite health center2
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
unite health center3
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
unite health center4
UNITE Health Center


  • 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
career development insights
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
major findings
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
ma perspectives
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 …”

major challenges
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


focus on financing
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
there are also cost savings
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)
next steps in health reform and workforce planning
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

Contact: Susan Chapman