The Nursing Workforce: Navigang through Transformave ... · Workforce already employed in the...
Transcript of The Nursing Workforce: Navigang through Transformave ... · Workforce already employed in the...
TheNursingWorkforce:Naviga4ngthroughTransforma4ve
HealthSystemChangeErinFraher,PhDMPP
ProgramonHealthWorkforceResearch&PolicyCecilG.ShepsCenterforHealthServicesResearch,UNC-CH
CenterforInterdisciplinaryHealthWorkforceStudiesWebinar
January20,2016
ThisworkisfundedbygrantsfromtheRobertWoodJohnsonFoundaHonandHRSA
Presenta4onOverview
• Anursingshortage?Isthattherightques>on?• Thecontext:newcaredeliveryandpaymentmodels
• Oldschoolversusnewschoolapproachestoworkforceplanning
• Howdowegettherefromhere?
• Q&A
Areweaskingtherightques4ons?
• The“shortagenarra>ve”—agrowing,agingpopula>onwithincreasedchronicdiseaseandexpandedhealthinsurancecoveragewilldemandmorecarethancanbeprovidedbynursingworkforce
• Na>onalnursingmodelsmixed:somesuggestoverallsupplywilloutpacedemand,othersfindthatdemandwillexceedsupply
• Isthereanursingshortage?That’sadifferentwebinar!• Focusingonwhetherwehaveanursingshortagedistractsusfrom
amoreimportantques>on:
Willwehavetherightmixofnursesintherightloca4ons,special4esandprac4ceseOngswiththeskillsandcompetenciesneededtomeetthedemandsofatransformedhealthcaresystem?
Let1,000flowersbloom:ongoingexperimentsinhealthsystemtransforma4on
• Growingnumberofpa>entcenteredmedicalhomes,accountablecareorganiza>onsandaccountablehealthcommuni>es
• CMSac>velyfundingdemonstra>onprojects
• SecretaryBurwellrecentlyannounced50%ofMedicarepayments>edtovalueby2018
Newmodelsofcare:keycharacteris4cs
• Goal:providepa>entswithmorecomprehensive,accessible,coordinatedandhighqualitycareatlowercosts
• Emphasisonprimary,preven>veand“upstream”socialdeterminantsofhealth
• Careisintegratedbetween:– medicalsub-special>es,homehealthagenciesandnursinghomes– healthcaresystemandcommunity-basedsocialservices
• EHRsusedtomonitorpa>entandpopula>onhealth—increaseduseofdataforrisk-stra>fica>onandhotspoang
• Interven>onsfocusedatbothpa>ent-andpopula>on-level• Paymentbasedonvalue,notvolume
Thereisintensefocusonpaymentandcaredeliverymodels,lessfocuson
workforcechangesneededtostaffnewmodels• Weconductedliteraturesynthesison
workforceimplica>onsofnewmodelsofcare
• FundedthroughHRSACoopera>veAgreementU81HP26495-01-00:HealthWorkforceResearchCenters
• Collaborators:RachelMachta,BS,PhDstudentatUNC-CHandJacquelineHalladay,MDMPH,AssociateProfessorintheDepartmentofFamilyMedicineatUNC-CH
• Ourfindingssuggestneedtoshihfrom“oldschool”to“newschool”workforceplanning
Reframe#1:Fromnumberstocontent
• Willwehaveenoughnurses?OldSchool
• Doesthenursingworkforcehavetheskillsandcompetenciesneededtofunc>oninnewmodelsofcare?
NewSchool
Howdonursesfitinnewmodelsofcare?
• PCMHsandACOsemphasizecarecoordina>on,popula>onhealthmanagement,pa>enteduca>on,healthcoaching,dataanaly>cs,pa>entengagement,qualityimprovementetc.
• Earlyevalua>onssuggestnewmodelsofcarenotshowingexpectedoutcomes
• Couldbebecause:1.educa>onsystemnotadequatelypreparinggraduatestoprac>ceinnewmodelsofcareand/or2.exis>ngworkforcenotretooledwithnewskillsandcompetencies
• Workerswiththerightskillsandtrainingareintegraltotheabilityofnewmodelsofcaretoconstraincostsandimprovecare(BodenheimerandBerry-Millel,2009)
Sources:BodenheimerT,Berry-MilleYR.Caremanagementofpa4entswithcomplexhealthcareneeds.Princeton,NJ:RobertWoodJohnsonFounda4on;2009.
Reframe#2:Fromprovidertypetoproviderrole
• Howmanyofx,y,zhealthprofessionaltypewillweneed?OldSchool
• Whatrolesareneededandhowcandifferentskillmixconfigura>onsmeetpa>ents’needsindifferentgeographiesandprac>ceseangs?
NewSchool
Manynewrolesemergingtoprovideenhancedcarefunc4ons
• Maybefilledbyexis>ngstaffornewhires
• It’scomplicated:– Someroleshavesimilarfunc>onsbutdifferent>tles– Otherroleshavedifferentfunc>onsbutsamename– Dependingonseangandpa>entpopula>on,rolesareohenfilledbydifferenttypesofproviders
• Twoofmostcommon:1. Rolesthatfocusoncoordina>ngcarewithinhealthcaresystem2. “Boundaryspanning”rolesthatcoordinatepa>entcarebetweenhealthcaresystemandcommunity-basedservices
Carecoordina4onwithinhealthcaresystemisbigandgeOngbigger
• Increasedincen>vestokeeppa>entsoutofhospital
• InJanuary2015,Medicarebeganpaying$42/monthformanagingcareforpa>entswithtwoormorechroniccondi>ons
• Nursesmostohentakingonrolesascarecoordinators,casemanagersandtransi>onspecialists
• Nursesincreasinglypartofteamwithpharmacists,socialworkers,die>ciansandothers
• Mostofwhatweseethatistermed“carecoordina>on”ishappeningwithinthehealthcaresystem
Alsogrowingquickly:boundaryspanningrolesthatreachouttopa4entincommunity
PanelManagers HealthCoaches
Assumeresponsibilityforpa>entsbetweenvisits.UseEHRsandpa>entregistriesto
iden>fyandcontactpa>entswithunmetcareneeds.Ohen
medicalassistantsbutcanbenursesorotherstaff
Improvepa>entknowledgeaboutdiseaseormedica>onandpromotehealthybehaviors.Maybemedicalassistants,nurses,
healtheducators,socialworkers,communityhealthworkers,pharmacistsorotherstaff
• Increasingnumberofstafffocusedonrolesthatshihfocusfromvisit-basedtopopula>on-basedstrategies
• Twoexamples:
Reframe#3:Fromhealthworkforceplanningtoplanningforworkforceforhealth
• HealthworkforceplanningOldSchool
• PlanningforaworkforceforhealthNewSchool
Planningtosupportaworkforceforhealth,notahealthworkforce
Increasedboundaryspanningrolesrequire:• Workforceplanningeffortsthatincludeworkerswho
typicallyprac>ceincommunityandhome-basedseangs
• Embracingroleofsocialworkers,pa>entnavigators,communityhealthworkers,homehealthworkers,communityparamedics,die>ciansandothercommunity-serviceproviders
• Weneedaworkforcefocusedonintegra>ngclinicalcarewithsocialservices
ThisistheaimofAccountableHealthCommuni4esModelannouncedbyCMS“Werecognizethatkeepingpeoplehealthyisaboutmorethanhappensinsideadoctor’soffice…wearetes>ngwhetherscreeningpa>entsforhealth-relatedsocialneedsandconnec>ngthemtolocalresourceslikehousingandtransporta>ontothedoctorwillul>matelyimprovetheirhealthandreducecoststotaxpayers…”SecretaryBurwell,hlp://www.hhs.gov/about/news/2016/01/05/first-ever-cms-innova>on-center-pilot-project-test-improving-pa>ents-health.html
AccountableHealthCommuni4esGoalsandAims
“ThefoundaHonofthemodelisuniversal,comprehensivescreeningforhealth-relatedsocial
needs—includinghousingneeds,foodinsecurity,uHlityneeds,interpersonalsafetyandtransportaHon
difficulHes—inallMedicareandMedicaidbeneficiarieswhoobtainhealthcareatparHcipaHngsites”
Alley,DE,AsomughaCN,ConwayPH,SanghaviDM.(2016).AccountableHealthCommuni>es—AssessingSocialNeedsthroughMedicareandMedicaid.NewEnglandJournalofMedicine.371;1:8-11.
Whataretheworkforceimplica4onsofthe“seamlesssocialwork”*model?
• NEJMar>cleacknowledgeschallengein“developingaworkforcetodeliverinterven>onstovulnerablepopula>ons”
• Whoistheworkforcethatwillassess,coordinateandnavigatepa>entneedsforclinicalandcommunity-basedservices?
• Onceareferralismade,istheworkforceavailabletoprovidetheservice?
• Dophysicians,socialworkers,nursesandotherhealthprofessionalshavetheskillstotakeonthese“bridgingroles”?
*New York Times, “Medicare to Test if Seamless Social Work can Improve Health”. Jan 5, 2016
Reframe#4:Fromfocusonpipelinetofocusonretoolingexis4ngworkforce
• RedesigningcurriculumfornursingstudentsinthepipelineOldSchool
• Retoolingthe2.9millionnursesalreadyemployedinUShealthcaresystemNewSchool
Workforcealreadyemployedinthesystemwillbetheonestotransformcare
• Todate,mostworkforcepolicyfocushasbeenonredesigningeduca>onalcurriculumforstudentsinthepipeline
• Butitisthe2.9millionnursesalreadyinthesystemwhowilltransformcare
• Rapidhealthsystemchangerequiresnotonlyproducing“shinynewgraduates”butalsoupgradingskillsofexis>ngworkforce
• Needtoiden>fyandcodifyemerginghealthprofessionalrolesandthenredesignpipelineandcon>nuingeduca>onprogramstotrainnursestotakeontheseroles
WorkforceisshidingfromacutetocommunityseOngs
• Changesinpaymentpolicyandhealthsystemorganiza>on:– Shihfromfee-for-servicetowardbundledcarepayments,risk-andvalue-basedmodels
– Finesthatpenalizehospitalsforreadmissions
• Willincreasinglyshihhealthcare—andthehealthcareworkforce—fromexpensiveinpa>entseangstoambulatory,communityandhome-basedseangs
• Butwegenerallyeducatenursesininpa>entseangs
• Currentworkforcenotadequatelypreparedtoworkinambulatoryseangsandpa>ents’homes
Exis4ngworkforcewillalsoneedmorecareerflexibility
• Rapidandongoinghealthsystemchangewillrequireanursingworkforcewith“careerflexibility”
• “Clinicianswantwell-definedcareerframeworksthatprovideflexibilitytochangerolesandseangs,developnewcapabili>esandaltertheirprofessionalfocusinresponsetothechanginghealthcareenvironment,theneedsofpa>entsandtheirownaspira>ons”(NHSEngland)
• Needbelerandseamlesscareerladderstoallownursestoretrainfordeploymentindifferentseangs,servicesandpa>entpopula>ons
Retooling:Howdowegettherefromhere?
It’snotjustaboutretoolingtheworkforce.Weneedtoretoolthesystemthatsupportstheworkforce:educa>on,reimbursementandregula>onneedstobemoreresponsivetochangesinfront-linehealthcaredelivery
WeneedtobeYerconnecteduca4ontoprac4ce
“RevoluHonarychangesinthenatureandformofhealthcaredeliveryarereverberaHngbackwardinto…
educaHonasleadersofthenewpracHceorganizaHonsdemandthattheeducaHonalmissionberesponsivetotheirneedsforpracHHonerswhocanworkwithteamsinmoreflexibleand
changingorganizaHons…”
• Buteduca>onsystemislaggingbecauseitremainslargelyinsulatedfromcaredeliveryreform
• Needcloserlinkagesbetweenhealthcaredeliveryandeduca>onsystems—fouryear,twoyearandcon>nuingeduca>on
Source:RickeYsT,FraherE.Reconfiguringhealthworkforcepolicysothateduca4on,training,andactualdeliveryofcarearecloselyconnected.HealthAff(Millwood).2013Nov;32(11):1874-80.
Oneduca4onside:redesigncurriculumtopreparenursingworkforcefornewroles
• Needtoredesigneduca>onsystemsonursescanflexiblygainnewskillsandcompetencies
• Trainingmustbeconvenient–>ming,loca>on,andfinancialincen>vesmustbetakenintoconsidera>on
• Needtopreparefacultytoteachnewrolesandfunc>ons
• Clinicalrota>onsneedtoinclude“purposefulexposure”tohigh-performingteams
Source:Laddenetal.TheEmergingPrimaryCareWorkforce.PreliminaryObserva4onsfromthePrimaryCareTeam:LearningfromEffec4veAmbulatoryPrac4cesProject”.AcademicMedicine;1013,88(12):1830-1835.
Onprac4ceside:redesignhumanresourceinfrastructuretosupportnewroles
• Needtominimizeroleconfusionbyclearlydefiningandtrainingfornewfunc>ons
• Jobdescrip>onshavetoberewrilenorcreated
• Workflowshavetoberedesigned
• Lackofstandardizedtrainingandfundstosupporttrainingisbigobstacle
• Exis>ngstaffwon’tdelegateorsharerolesifdon’ttrustotherstaffmembersarecompetent
• Timespenttrainingisnotspentonbillableservices
Regulatorysystemneedstoberestructured
“TheworkforceinnovaHonsneededtoimplementACAprogramsrequireanadaptableregulatorysystemcapableofevolvingwiththehealthcareenvironment.ThehealthprofessionregulaHonsysteminplacetoday
doesnothavetheflexibilitytosupportchange.”
Tocreateamoredynamicregulatorysystem,weneed:• todevelopevidencetosupportregulatorychanges,especiallyfornewroles• belerevalua>onofpilotworkforceinterven>onstounderstandifinterven>onsimprovehealth,lowercostsandenhancesa>sfac>on• toestablishana>onalclearinghousetoprovideup-to-dateandreliableinforma>onaboutscopeofprac>cechangesinotherstates
Source:DowerC,MooreJ,LangelierM.Itis4metorestructurehealthprofessionsscope-of-prac4ceregula4onstoremovebarrierstocare.HealthAff(Millwood).2013Nov;32(11)
Whoisgoingtopayforallthisretoolingweneedtodo?
• Adequateandsustainablepaymentmodelstoretoolandredeploytheworkforcearelacking
• Manyworkforceinnova>onsaresupportedbyone->mefunds.Ifpaymentmodelsdon’tchangerapidlyenough,willtheseinterven>onsbesustainable?
• 1,000flowersarebloomingbutareadequatedollarsavailabletoconductresearchandevalua>onsnecessarytodevelopevidencebaseneededtosupportworkforceredesign?
Addi4onalResources
Seeourpaper,“BuildingaValue-BasedWorkforce,”onourwebsite
FundedbyHRSAthroughtheCarolinaHealthWorkforceResearchCenter
hlp://www.shepscenter.unc.edu/programs-projects/workforce/projects/carolina-health-workforce-research-center/
AndourRWJ-fundedbrief:NursinginaTransformedHealthCareSystem:NewRoles,NewRules
Cita>on:FraherE,SpetzJ,NaylorM.NursinginaTransformedHealthCareSystem:NewRoles,NewRules.LDI/INQRIResearchBrief.June2015.hlp://ldi.upenn.edu/uploads/media_items/inqri-ldi-brief-nursing.original.pdf.
“Whatwillittaketoop1mizecontribu1onsofnurses?• Redesignthenursingcurriculumtoeducatenurseswithnewcompetencies;• RetrainexisHngnurseswithnewskillsandknowledge;• RevamplicensingexaminaHonandrequirementstoreflectthenewcurriculum;and• Restructurethestateregulatorysystemtoallowflexibledeploymentofthenurseworkforce.”
hlp://ldi.upenn.edu/uploads/media_items/inqri-ldi-brief-nursing.original.pdf-QuotedfromJanetWeiner,MPH.PennLDIVoicesBlog.“Re:Nurses”.
June25,2015.hbp://ldi.upenn.edu/voices/2015/06/25/re-nurses
Contactinfo
ErinFraher,PhD
Director
ProgramonHealthWorkforcePolicyandResearch
919-966-5012
hlp://www.healthworkforce.unc.edu