The Impact of Workforce Shortages on Cost, Quality and Access: How Should We Respond Edward Salsberg Executive Director Center for Health Workforce Studies School of Public Health, University at Albany State Long Term Care Programs: Balancing Cost, Quality and Access Indianapolis, Indiana May 7, 2002 Salsberg1

2 The Center for Health Workforce Studies School of Public Health, University at Albany, SUNY Dedicated to studying the supply, demand, use and education of the health workforce Committed to collecting and analyzing data to understand workforce dynamics and trends Goal to inform public policies, the health and education sectors and the public One of five regional centers with a cooperative agreement with HRSA/Bureau of Health Professions

3 Salsberg Overview of Presentation A. Crisis as opportunity B. Overview of the health workforce C. The long term care paraprofessional workforce D. Approaches to responding to health workforce shortages

4 Salsberg Crisis as Opportunity: The Crisis Serious shortages threatening ability to deliver services The squeeze-few new dollars and the high cost of more workers Concerns with medical errors and quality Worker and management dissatisfaction Buried in paperwork and regulation Racial and ethnic imbalances Decreased interest in health careers

5 Salsberg Where are the Shortages? Direct care workers, including home health aides and nursing home aides Registered nurses Radiologic technicians Pharmacists Lab/medical technologists Dentists Information system specialists Medical coders

6 Salsberg The Health Workforce: A Basic Premise A health care system is only as good as its workforce The workforce directly impacts on quality, cost and access System wide high turnover, difficulty recruiting and worker dissatisfaction are signs of a systemic problem

7 Salsberg Factors Contributing to Health Workforce Shortages Short term factors Competition for workers and full economy Educational system response lags Demand rising Long Term Demographic factors The aging of America: increase in demand for health services The aging of America: decrease supply of workers Changing racial/ethnic mix Career choices for women

8 Salsberg Factors Contributing to Health Workforce Shortages, continued Workplace factors Physically and emotionally demanding work Non-competitive wages and benefits Job design and working conditions Paperwork and lack of information systems Poorly trained managers

ShortagesQuality of Care Job Design- Working Conditions Poorly Trained Managers Worker Dissatisfaction/ Turnover Lack of Information Systems/ Paperwork Lack of Diversity Limited Investment in Training/ Education Lags in Education Rising Demand Aging Competition Wages & Benefits Demographics Factors Impacting on Shortages Factors Impacting on Shortages and Quality Salsberg

The Health Care Workforce

11 Salsberg More Than 1 in 10 Americans Works in Health Care or is a Health Professional Health Professionals Other Workers Total Health service setting8,642,7494,098,33112,741,080 Other work settings2,167,418126,649,685128,817,103 Total10,810,167130,748,016141,558,183 Health professionals working in health service settings8,642,7496.1% Health professionals working in other settings2,167,4181.5% Other workers in health service settings4,098,4982.9% US health workforce 14,908, % US civilian labor force 141,558, % 4.1 million other workers 8.6 million health professionals 2.2 million health professionals Health professions & Occupations Health service settings Bureau of Labor Statistics, 2001 Figures shown are the average of 12 months’ data (October 2000 – September 2001)

12 Salsberg Demographics of the Health Workforce: Gender

13 Salsberg Demographics of the Health Workforce: Age

14 Salsberg Demographics of the Health Workforce: Race/ethnicity

15 Salsberg Growth Between 1990 and 2000 and Projected Growth 2000 – 2010 Health Care Occupation and Non-Health Care Employments

16 Salsberg Health Care Occupations Forecast to Grow the Most from 2000 to 2010 Source: Bureau of Labor Statistics: Occupational Employment Projections to 2010 Page 1 of 2 Monthly Labor Review, Nov 2001

17 Salsberg Long Term Care Paraprofessionals

18 Salsberg Nurse Aides and Personal Care Workers comprise 38% of the Nursing Home Employees Nursing & Personal Care Facility Employment by Occupation, US, 1998 Source: Bureau of Labor Statistics.

19 Salsberg Home Health Aides and Personal Care Workers comprise Half of All Home Care Workers and RNs are Nearly 20% Home Health Care Services Employment by Occupation, US, 1998 Source: Bureau of Labor Statistics.

20 Salsberg Demographics of the Long Term Care Paraprofessional Workforce: Age Source: Current Population Survey 1997 – 1999

21 Salsberg Demographics of the Long Term Care Paraprofessional Workforce: Education Source: Current Population Survey 1997 – 1999

22 Salsberg Demographics of the Long Term Care Paraprofessional Workforce: Race Source: Current Population Survey 1997 – 1999

23 Salsberg A Conceptual Framework for State Responses to Workforce Shortages 1. Expand pipeline: education and training strategies (supply Side) 2. Improve retention: job related strategies (supply side) 3. Reduce numbers needed: improve productivity/reduce paperwork (demand side) 4. Other strategies

24 Salsberg 1.A Expanding the Pipeline: Educational Strategies  Scholarships and loan repayment  Grants for faculty, expansion or start up  High school health careers awareness  Marketing health careers/public service announcements  Capitation funding and/or mandates for educational programs  Support for efforts to increase minority recruitment and retention  Support for education demonstrations and development, i.e. distance learning, computer assisted learning

25 Salsberg 1.B Expanding the Pipeline: Other Strategies  Studies and reports  Increased reimbursement/higher wages  State funding for training initiatives  TANF  Medicaid  State dollars  Building Career Ladders  Nurse Aide to LPN  LPN to RN

26 Salsberg 2. Improving Retention and Job Related Strategies  Best practices conferences on job design and retention  Reimbursement support for higher wages  Fund demonstrations to improve working conditions and redesign jobs  Reimbursement and grants to encourage improved benefits for workers, i.e. health insurance, portable benefits within industry

27 Salsberg 2. Improving Retention and Job Related Strategies (cont’d)  Encourage and support management and supervisor training  Support technology that supports workers  Support for career ladders  Prohibit mandatory overtime ????  Mandate minimum staffing ratios ????

28 Salsberg 3. Modify Demand and Improve Productivity  Dissemination of information/best practices conferences on efficient and productive care  Regulatory changes on scope of practice and use of workers  Modify health facility requirements  Explore ways to reduce paperwork  Demonstrations and evaluation on job redesign  Aggressively promote technology to support efficiency and effectiveness  Collect and analyze data on staffing and productivity

29 Salsberg 4. Other Responses to Shortages  Task forces, commissions, and committees  Support for family/informal care givers  Better data collection and needs assessments  Support for or opposition to increased immigration

30 Salsberg The AHA Health Workforce Commission In Our Hands: How Hospital Leaders Can Build a Thriving Workforce

31 Salsberg “In Our Hands- How Hospital Leaders Can Build a Thriving Workforce” 5 Sets of Recommendations:  Foster meaningful work  Improve the workplace partnership  Broaden the base  Collaborate with others  Build societal support

32 Salsberg Ten Recommendations for States to Address Workforce Shortages and Improve Quality 1.Assure competitive wages and benefits 2.Invest in worker education and training 3.Use Medicaid reimbursement to support workforce development 4.Support demonstrations and evaluations related to both job design and education and training strategies 5.Support health and education sector partnerships

33 Salsberg Ten Recommendations to Address Workforce Shortages and Improve Quality, continued 6.Support career ladders 7.Support efforts to increase diversity of the workforce 8.Support efforts to improve management and supervisory skills 9.Support for family care-givers 10.Support technologies that assist workers

34 Salsberg Crisis as Opportunity: The Opportunity An adequate supply of health workers Increased worker satisfaction Better quality of care A more effective delivery system More cost effective care Information systems that work A more culturally diverse workforce