1. Enumerating the Public Health (PH) Workforce
Brian King
Program Director
Health Professions Resource Center
Center for Health Statistics
Texas Department of State Health Services
AUSTIN
CONTACT:
Center for Health Statistics

2. U.S. Shortages Affect State Shortages
“Almost 20 percent of Americans, 56 million people, have inadequate or no access to primary care physicians because of a shortage of providers, according to a report issued in March 2007 by the National Association of Community Health Centers and the American Academy of Family Physicians. Florida, Texas, and California are the hardest hit, the data show.”*
90%
70%
54%
Slide adapted presentation by Center for Health Workforce Studies, School of PH, Univ. of Albany, SUNY, “State Responses to Health Worker Shortages, 2002 Survey of States” published 11/ 2002.
*MANAGED CARE June 2007,
Modified by: Health Professions Resource Center, Center for Health Statistics, October 2008;
Center for Health Statistics

3. Some Geographic Locations have Greater Healthcare Needs than other Locations
Demographics
Texas
Border Counties
Rural Counties
Poverty Rate
16.2%
27.6%
17.0%
Population 65 and over
9.9%
9.7%
16.1%
The 32 Border counties have lower supply ratios than the State as a whole, and the 28 rural border counties have much lower ratios. The Border has a significantly higher percentage of Hispanics than the rest of the state, and also has a higher percentage of Hispanic physicians. But, the representation of Hispanics in the physician workforce still falls short of that in the general population. The poverty rate is higher in the Border areas, which can increase the need for physicians. The rural border counties also have a higher percentage of seniors in the population than the state as a whole, which is another high-need indicator. The physicians are slightly older in the rural border counties, which can mean that a higher proportion may be retiring soon than in the rest of the state, which also increases the need for increased supply in the border areas.
Of Texas’ 254 counties:
177 are Rural (defined by US Office of Management and Budget)
32 are Border (counties within 100 kilometers of US/Mexico border)
Poverty data from 2004 Census Bureau poverty estimates, Population data from the Texas State Data Center (2008)
Prepared by: Health Professions Resource Center, December 2008
Center for Health Statistics
Prepared By: Health Professions Resource Center, Center for Health Statistics, Texas Department of State Health Services, May 28, 2008

4. Ratio of Providers per 100,000 Population - 2008
Geographic Location
Ratio of Providers per 100,000 Population
Occupation
TEXAS
Urban
Rural
Border
Non-Border
Non-
Primary Care Physicians
68.4
52.8
72.7
35.4
55.0
Physician Assistants
17.3
13.5
18.5
16.0
12.8
Dentists
37.2
16.5
41.8
11.9
25.3
Dental Hygienists
38.8
18.4
42.9
8.8
30.3
Registered Nurses
671.3
483.1
730.9
230.6
470.1
Licensed Vocational Nurses
277.5
202.9
257.2
298.8
473.9
Pharmacists
77.0
42.7
84.9
31.5
56.4
Psychologists
25.9
8.7
6.2
11.7
Social Workers
67.1
45.0
73.4
20.4
46.9
Lowest ratios are in blue.
The supply ratios for almost every profession are lower in Rural areas than in Urban areas.
The supply ratios for every profession are even lower in Border areas.
The only exception is the greater supply of LVNs in Rural Areas than in Urban areas.
Prepared by: Texas Health Professions Resource Center, Center for Health Statistics; Licensing Board Data, December 2008
Center for Health Statistics

5. What Percentage of the Overall Health
Workforce is Employed in Public Health?
In 2002, public health workers were an estimated 5% of the Texas health workforce
Reference: 1. “The Texas Public Health Workforce, Texas Health Workforce Planning Partnership, Texas Health Care Policy Council, June 20, 2006, Virginia C. Kennedy, Ph.D., Director, Texas Public Health Training Center. Modified by: Health Professions Resource Center, Center for Health Statistics, October 2008.
Center for Health Statistics

6. Why do We Need More PH Workers?
Workforce Populations are Aging:
Over 65 to increase from 10% to 16% (2000 and 2040)
Labor Pool is Shrinking:
110,000 U.S. PH workers (23%) eligible to retire during next 4 years
Under 21 - decrease from 28% to 21% between 2000 and 2040
– Lost 50,000 PH workers in U.S.
U.S. Schools of PH must triple number of graduates by 2020 to replenish the workforce
Supply of Health Workers is chronically short in some settings and professions
High turnover rates for many professions
Chronic mal-distribution of health workers in rural and border areas
Minorities are disproportionately represented in the workforce
Technological innovations are increasing demand
The more we can do in the public health setting the more work we have to do.  For example, if the lab has a new test for a recently discovered virus, it will require more time to do viral studies on a patient because you may have to screen for the new virus in addition to the others.
Look at the demand for MRIs and CAT scans.  When we didn’t have those instruments we couldn’t do those tests!  Since we have these instruments we have to have a room in the hospital for them, technicians trained to do the tests, etc.
If the state requires all septic tank owners to add an additional but smaller clarification tank to the larger septic tank system, because it processes sewage more effectively, it may require more sanitarians to do the inspections.
Technological innovations may also require the addition of more regulations and the PH departments may have to add more staff in order to regulate.
If a PH clinic adds dental implants to its list of services, it may require them to hire a dental specialist to do the work.
Reference: 1. “The Texas Public Health Workforce, Texas Health Workforce Planning Partnership, Texas Health Care Policy Council, June 20, 2006, Virginia C. Kennedy, Ph.D., Director, Texas Public Health Training Center Center for Health Workforce Studies, Public Health Workforce Panel Meeting, July 16, Report presented to Capitol Hill in February 2008 by the Association of Schools of Public Health. Modified by: Health Professions Resource Center, Center for Health Statistics, October 2008.
Center for Health Statistics

7. Why are there Problems with Recruiting and Retaining PH Workers?
PH workers are often underpaid
Few career ladders for entry-level PH workers
Lack of standardized PH training for some PH professions
Competition with non-PH facilities for workers highly trained in analytical and epidemiological skills
The largest single group of PH professionals, nurses, tend to be women with families, therefore geographic mobility is often an issue.
* Reference: 1. “The Texas Public Health Workforce, Texas Health Workforce Planning Partnership, Texas Health Care Policy Council, June 20, 2006, Virginia C. Kennedy, Ph.D., Director, Texas Public Health Training Center Center for Health Workforce Studies, Public Health Workforce Panel Meeting, July 16, 2001.
Center for Health Statistics

8. Why is it so Difficult to Count the PH Workforce?
Many are unlicensed non-government generalists who can have more than one job/role
Roles/responsibilities for PH and non-PH workers may overlap
Lack of uniform job titles/roles among state PH workers limits use of data for national comparisons
Why is it so Difficult to Study and Count the PH Workforce?
Not easily defined – The PH workforce is comprised of both government and non-government workers. This causes difficulties in defining and collecting workforce data. Thus, some studies focus only on government agencies and government-mandated PH activities.
Uniform data hard to collect – Lines of responsibility do not always exist according to the type of facility at which the ph services are being given or the type of health professional delivering the services. Most PH workers function as generalists and may assume different roles in their jobs. PH job surveys allow one choice of a job so the survey results many inaccurately depict shortages.
Not Generally licensed – Excepted for titles protected by law, such as registered nurses. Data for those professions are obtainable from the licensing boards.
Overlapping roles among public agencies, hospitals and others. Federal, state, and local agencies may overlap in their roles and responsibilities creating data that is difficult to aggregate and study.
Shared between different levels of government. A clear distinction may not exist between the PH roles and responsibilities of different levels of government and may duplicate workload and FTEs.
State-by-State variations. Each state may vary on how it carries out its PH functions and the types of workers employed. This creates problems when gathering national level data.
Differences between rural and urban locations. Rural areas usually have limited PH activities, lower skilled and paid workers, less infrastructure for carrying out PH activities.
“Public Health Workforce Study, Bureau of Health Professions, HRSA, January Study accessed on 12/28/06 at Prepared by: Texas Department of State Health Services, Center for Health Statistics, Health Professions Resource Center, February 2009.
Center for Health Statistics

9. Recent Efforts at DSHS to Count PH Workers and Assess Vacancy Rates
Surveyed Local Health Departments that contract with DSHS to provide Public Health Services (Participating)
Surveyed Local Health Departments that do not contract with DSHS to provide Public Health Services (Non-Participating)
Collected information on the Public Health Workforce employees at the Health and Human Services Enterprise Agencies
Next Steps
Possibly survey Federally Qualified Health Centers/Community Health Centers
Determine and survey other entities that provide Public Health
Center for Health Statistics

10. Survey 1: Local Health Departments - That Contract with DSHS to provide Public Health Services (Participating)
Online survey conducted between Nov. 28, 2007 and Jan. 18, 2008
63 Local Health Departments (LHDs)
29% in Rural Counties (18)
8% in Border Counties (5)
100% response rate
Collected supply and vacancy information for 39 PH professions
Prepared by: Texas Health Professions Resource Center, Center for Health Statistics, January 2008
Center for Health Statistics

11. Survey 2: Local Health Departments - That DO NOT Contract with DSHS to provide Public Health Services (Non-Participating)
Online survey conducted between Jun. 15, 2008 and Aug. 6, 2008
79 Local Health Departments on DSHS list
37 not truly Local Health Departments (permitting offices, etc)
9 facilities that did not consider themselves to be public health but employed a total of 12 Sanitarians and 5 Animal Control Officers
Final report focused on remaining 33 Local Health Departments
12.1% in Rural Counties (4); 6.1% in Border Counties (2)
95% response rate
Collected supply and vacancy information for 39 PH professions
Prepared by: Texas Health Professions Resource Center, Center for Health Statistics, November 2008
Center for Health Statistics

12. Survey 3: Texas Health and Human Services Enterprise
Department of State Health Services
Department of Aging and Disability Services
Texas Health and Human Services Commission
Department of Family and Protective Services
Department of Aging and Rehabilitative Services
Information gathered from HHS Human Resources
September 2008
Collected supply and vacancy information for PH professions
Center for Health Statistics

13. Survey 1: Participating LHDs
Currently Staffed FTEs*
Vacant FTEs**
VACANCY RATE
2,514
166
6.2%
4.1% in
Rural Counties
3.6% in
13.7% in
Border Counties
11.4% in
Additional FTEs Desired by Participating LHDs
413
FTE = Full Time Equivalency (1 FTE=40 hrs/wk, 0.5 FTE= 20 hrs/wk)
* 2,419 full-time positions and 181 part-time positions
** 182 vacant positions (full-time and part-time)
Center for Health Statistics

14. Survey 2: Non-Participating LHDs
Currently Staffed FTEs*
Vacant FTEs**
VACANCY RATE
273 13
4.5%
4.9% in
Rural Counties
0% in
10.5% in
Border Counties
6.2%
Additional FTEs Desired by Non-Participating LHDs 36
* 258 full-time positions and 30 part-time positions
** 13 vacant positions (full-time and part-time)
Center for Health Statistics

15. Survey 3: Texas Health and Human Services Enterprise
Currently Staffed FTEs*
Vacant FTEs**
VACANCY RATE
7,991
1,504
15.8%
30.3% in Rural Counties
25.3% in
Rural Counties
7.5% in Border Counties
7.0% in
Border Counties
6.2%
Percentage of Currently Staffed FTEs by Agency:
73.7% at Department of State Health Services
23.2% at Department of Aging and Disability Services
2.9% at Health and Human Services Commission
0.1% at Department of Family and Protective Services
0.05% at Department of Aging and Rehabilitative Services
* 7,880 full-time positions and 222 part-time positions
** 1,466 full-time vacant positions and 76 part-time positions
Center for Health Statistics

16. With the most Currently Staffed FTEs
The top 5 Professions:
With the most Currently Staffed FTEs
Order
Participating LHDs
Non-Participating LHDs
HHS Enterprise 1
Environmental Health Workers/Engineers/
Sanitarians (345)
Animal Control Officers (97.5)
Mental Health Workers (3,326.5) 2
Licensed Vocational Nurses (315)
Environmental Health Workers/Engineers/Sanitarians (97)
Registered Nurses (1,570) 3
Registered Nurses,
non-APN (305)
Local Health
Authorities (16.5)
Licensed Vocational
Nurses (1,078) 4
Animal Care and Control Officers (249)
Public Health
Technicians (15.5)
Public Health Technicians (532) 5
APN (184)
Tie: RNs/APN, RNs/Non-APN,
Mental Health Workers (7 each)
Registered Therapists and Assistants* (214)
Mental Health Workers includes Psychiatrists, Social Workers, Psychologists, Psychological Associates, Psychological Assistants, Psychiatric Nursing Assistants, and Psychiatric Nursing Aides
*Not included in surveys of LHDs
Center for Health Statistics

17. With the highest number of Vacancies (FTEs)
The top 5 Professions:
With the highest number of Vacancies (FTEs)
Order
Participating LHDs
Non-Participating LHDs
HHS Enterprise 1
Registered Nurses, non-APN (35)
Environmental Health Workers/Engineers/Sanitarians (6)
Registered Nurses (606.5) 2
Nutritionists (28)
Local Health
Authorities (2)
Mental Health Workers (366.5) 3
Licensed Vocational Nurses (24)
Physicians (2)
Public Health
Technicians (165) 4
Environmental Health Workers/Engineers (11)
Licensed Vocational Nurses (133.5) 5
Registered Nurses, APN (11)
Registered Therapists and Assistants (60.5)
Tie:
Local Health Authorities (2)
Physicians (2)
Tie:
Physician Assistants (1)
Public Health Technicians (1)
Animal Control Officers (1)
Tie:
Environmental Health
Workers/Engineers/
Sanitarians (11)
Registered Nurses,
APN (11)
Center for Health Statistics

18. The LHDs would like to hire more of if budgets allowed
The top 5 Professions:
The LHDs would like to hire more of if budgets allowed
Order
Participating LHDs
Non-Participating LHDs 1
Animal Care and Control Officers (46)
Environmental Health Workers/Engineers/Sanitarians (11) 2
Environmental Health Workers/Engineers/Sanitarians (41)
Animal Care and Control Officers (9) 3
Registered Nurses,
non-APN (34) 4
Licensed Vocational
Nurses (30) 5
Promotor(as)/Community
Health Workers (27)
Tie:
Public Health Technicians (3)
Physicians (3)
This question was not asked of the HHS Enterprise agencies.
Center for Health Statistics

19. Ten Essential Public Health Functions
Participating (P)
Non-Participating (NP)
1) Monitor health status to identify community health problems - (P) 85.7% (NP) 30.3%
2) Diagnose and investigate health problems and health hazards in the community - (P) 92.1% (NP) 45.5%
3) Inform, educate, and empower people about health issues - (P) 96.8% (NP) 69.7%
4) Mobilize community partnerships to identify and solve health problems - (P) 87.3% (NP) 27.3%
5) Develop policies and plans that support individual and community health efforts - (P) 85.7% (NP) 39.4%
6) Enforce laws and regulations that protect health and ensure safety - (P) 88.9% (NP) 100.0%
7) Link people to needed personal health services and assure the provision of health care when otherwise unavailable - (P) 90.5% (NP) 27.3%
8) Assure a competent public health and personal health care workforce - (P) 85.7% (NP) 15.2%
9) Evaluate effectiveness, accessibility, and quality of personal and
population-based services - (P) 73.0% (NP) 18.2%
10) Research for new insights and innovative solutions to health problems - (P) 50.8% (NP) 15.2%
Only 30 of the 63 Participating LHDs performed all 10 Functions
Center for Health Statistics

20. Comparison of Participating and Non-Participating Local Health Departments
Non-Participating LHDs were more focused on Code Enforcement rather than Direct Patient Care.
Center for Health Statistics

21. Summary of all surveys Center for Health Statistics
10,777.5 Currently Staffed FTEs
1,683 Vacancies – 13.5% Vacancy Rate
Largest Professions:
Nursing – 4,844.0
Registered Nurses – 2,096.0
Licensed Vocational Nurses – 1,399.5
Mental Health Workers – 3,408.0
Psychiatric Nursing Aides, Psychiatric Nursing Assistants – 2,775.0
Social Workers, licensed and unlicensed
Psychological Associates – 186.0
Psychiatrists – 120.0
Psychologists – 59.5
Psychological Assistants – 10.0
Other – 3.0
Other Professions
Environmental Health Workers/Engineers/Sanitarians – 650.5
Public Health Technicians – 602.5
Nutritionists and Dietitians – 300.5
Physicians (not including Psychiatrists) – 170.5
Dentists – 42.0
Center for Health Statistics

22. Enumerating the Public Health (PH) Workforce
Brian King
Program Director
Health Professions Resource Center
Center for Health Statistics
Texas Department of State Health Services
AUSTIN
CONTACT:
Center for Health Statistics