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 2

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 3

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5. Health Reform: Can you explain it? How will it work? UCSF-CHP 5 http://healthreform.kff.org/the-animation.aspx 9/12

6. Now we know that the ACA is here to stay? 6

7. 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

8. 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

9. 9 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 Drivers that affect the quantity & quality of California’s health care workforce

10. 10 California’s Licensed and Registered Health Care Workforce—February 2011 Source: California DCA Professional License Masterfile

11. 11 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

12. Examples of Workforce Supply and Distribution 12

13. 13 Distribution of Primary Care Physicians and Physician Assistants

14. 14 Distribution of Dentists and Dental Assistants

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19. 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 19

20. Recommendations from Key Informants Redesign practice models and financing 20

21. 21 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

22. 22 Do we educate enough providers to meet the state’s growing needs? Probably not from overall perspective Some programs oversubscribed Maldistribution of 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

23. 23 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

24. 24 Expansion of nursing programs has increased the supply of nurses

25. 25 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 telehealth to facilitate new models of care

26. Recommendations from Key Informants Redesign practice models and financing 26

27. Innovations in Care Delivery Models: Implications for Workforce Training and Development Case Studies of Enhanced Roles for Medical Assistants 27

28. 28 Study Team 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 Nursing Dept 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) http://www.futurehealth.ucsf.edu

29. 29 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

30. 30 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)

31. 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 31

32. 32 Why Sites Innovate MA Roles 1.Personnel and staffing challenges 2.Patient needs and concerns 3.Electronic health records 4.Health care reform

33. 33 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”)

34. 34 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

35. 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 35

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37. 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 37

38. 38 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

39. 39 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

40. Two Examples 1.MA-team model 2.Ambulatory Intensive Caring Unit (A-ICU) 40

41. 41 Rural FQHC High 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

42. 42 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

43. 43 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

44. 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 44

45. 45 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

46. 46 Urban Primary and Multi-Specialty Care Center UNITE 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

47. 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 47

48. 48 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

49. 49 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

50. 50 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

51. 51 UNITE Health Center Outcomes 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

52. 52 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

53. 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 53

54. 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 …” 54

55. 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 Financing 55

56. 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 56

57. 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) 57

58. 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 58

59. 59 QUESTIONS Contact: Susan Chapman susan.chapman@ucsf.edu