Health Care Workforce Shortages

Implications for Public Health

Rediscovering the Roots of Public Health

November 4, 2001

Beth MertzProject Director

Center for the Health Professions

Our mission is to assist health care professionals, health professions schools, care delivery organizations and public policy makers respond to the challenges of educating and managing a health care workforce capable of improving the health and well being of people and their communities.

Health Workforce Centers

Californiahttp://futurehealth.ucsf.edu/cchws.html

New Yorkhttp://chws.albany.edu/chws.html

Washingtonhttp://www.fammed.washington.edu/chws/index.html

Illinoishttp://www.uic.edu/sph/ichws/

Funded by the National Center for Health Workforce Information and Analysis, Bureau of the Health Professions, HRSA

Outline

• General Trends impacting the Health Care Workforce

• The Public Health Workforce– National Data

– State Studies

• Profession Specific Examples

• Pew Recommendations

• Future Directions

Present Outlook

• General workforce issues affecting all sectors of the economy– Aging workforce– Technical skill gap– Diversity disparity– Displacement of traditional pathways of

employment– Values of next generation– Inadequate education/work integration

Three key trends•Changing Demographics•Technological Innovation•Change to market driven health system

Winds that are blowing...

• A national crisis is looming for health workforce but it has as much to do with lack of innovation, as it does with shortages of workers

The workforce is changing… Are you ready for the next

generation?• Age: Great depression/WWII era workers,

Baby Boomers, and Generation X all see the world from a different vantage point

• Race: Moving from a majority culture (1995), to diversity (2005), to multicultural (2025)

• Gender: Dramatic expansion of career opportunities for women over past 30 years, not restricted to nursing and teaching

Technology Driven Changes

Biomedical• US Investment in basic

and applied biomedical sciences leads the world

• The next generation of technology promises to reduce cost, move care to ambulatory settings, and improve outcomes 30

40

50

60

1985 1990 1999

Percentage of Total Health R&D

Gov't Private

Technology Driven Changes

• Health care is a knowledge based service enterprise

• Consumers are increasingly technology savvy

• Technological changes in health care are likely to increase the demand for skilled labor

Information

Market PressuresHow to balance

the tradition of individualism with

the needs of:Population healthSystem outcomesBroader social needsBalance of equity and

choice

Changes needed: Public understanding

and expectation Legal framework Financing system Provider expectations Funded and deployed

public system

Workforce implications

• Workforce expenditures represent the major costs to systems

• Increasing pressure to reduce/streamline personnel costs

• Competence of providers, whether technical, cultural, clinical, is key to system success

• Mal-distribution of services• Forecasting future needs is difficult but

necessary, for the pipeline is long

General state of workforce shortages across health

professions• Medicine:

• Nursing:

• Dentistry:

• Allied Health:

Public Health??

Public Health Workforce Data• US employment census information

• Local / State Surveys or Reporting• National Association of City and County

Health Organizations (NACCHO)• US Office of Personnel Management• Equal Opportunity Employment

Commission (EEO-4)• Professional Associations

•Information from:• BHPr (2001) “The Public Health Workforce: Enumeration 2000” HRSA.•Turnock and Hutchison (2000) “The Local Public Health Workforce” Illinois Center for Health Workforce Studies. •Mertz and Finocchio (1999) “A Snapshot of California’s Local Public Health Department” California Center for Health Workforce Studies.

The Public Health Workforce: Enumeration

2000Practicalities*• Range of workers?

• Level of specificity?

• Data source?

• Time period?

Data Issues*• Quality and

specificity

• Classification schemes

• Counting

• Unclassified Workers

*BHPr (2001) “The Public Health Workforce: Enumeration 2000” HRSA.

Findings• Physicians are small part of PH

workforce• Epidemiologists are less than

1% of workforce• PHNs are largest professional

group• Have most accurate numbers

on lab professionals and nutritionists

• Professional and leadership of PH is influenced by the number and quality of technical and administrative support

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Oregon PH Workforce Data

• Only data reported were from EEO-4 Categorization

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Rural Public Health Workforce

Western States Study• Rural PH has higher

per capita spending, but relies mostly on PHNs

• Similar per capita supply of PH workers

• Low turnover, but difficult to fill vacant positions

• Recruitment of Professional staff with previous experience or format training is a challenge

• Varying amount of support staff

• Nursing core of staff, more diversity in urban regions

*Data from two reports done by WWAMI Center for Health Workforce StudiesAnd a third from the Illinois Center for Health Workforce Studies

Urban and Rural Composition of the PH

WorkforceUrban

2915

38

18

ManagementNursesNonClinicalOther Clinical

Rural

17 18

64

1

*Data from two reports done by WWAMI Center for Health Workforce StudiesAnd a third from the Illinois Center for Health Workforce Studies

Illinois and California

• Low Ratio• Unevenly distributed• Diverse

*Data from reports done by the Illinois Center for Health Workforce Studies and And the California Center for Health Workforce Studies

• Large urban / rural differences

• Little data• Hospitals

Augmenting a limited PH workforce

Lessons from recent studies show:– Collaborations with local hospitals and other services to

ensure population coverage are successful– Volunteers play a key role in provision of PH– Leadership in creating and maintaining partnerships is

key– Focus on strengths as a way to build relationships and

attract new talent– Composition of staff and aspects of organizational

structure may be more important influences on core functions than pure quantity of workers

War for Talent

• Comprehensive issue in health care• Demand for specialized, skilled workers coupled

with push for cost reduction• Health care consumers growing while providers

are shrinking

Public Health Nursing: Staff

• Average age is greater than that of RNs >45• Most had worked >16 yrs and most with the same

employer• 48% very satisfied• Work 37 hrs/week on average• 45% worked in MCAH with primarily female

clients, 40% of clients don’t speak English• Interventions focused at family level (case mgmt)

and community. Felt more prepared for family level work than community or system level work

Public Health Nursing: Managers

• 50% supervise general PHN programs, only 32% on MCH (compared to majority of staff PHNs)

• 50% had been in position from 1-5 years

• 75% satisfied with their position

• 75% indicated funding for services had not kept pace with inflation

• 65% indicated wages had not kept pace with inflation

Forecasting PHN needsIncrease No Change Decrease

Change in Positions in past 5 years

40% 30% 30%

Change in proportion of PHNs to other providers

25% 25% 40%

Change predicted proportion of PHNs in future

20% 25% 25%

Mental Health Workforce

• Includes advanced practice nurses, psychiatric technicians, social workers, licensed counselors, psychologists and psychiatrists

• Currently little to no workforce data on non-physician practitioners in this field

• Licensing and certification requirements vary per state & numerous states do not offer reciprocity to non-physicians

Mental Health Workforce• A growing need for these providers because

of changing laws concerning substance abuse and the treatment of non-institutionalized, child & adolescent, long-term care, and elderly users of services

• Currently little to no emphasis on geriatric training for mental health providers although there is a critical need for this

• Insurance limitations & legislative mandates put a heavy burden on the public sector to provide mental health services

Dental Public Health

• There significant shortage of oral health services, particularly in rural communities

• Dental public health measures are essential if we are to stop the epidemic of oral diseases in children currently manifesting

• The primary care system is not prepared to deal with oral health issues

• There are more barriers to obtaining dental care and fewer people have dental insurance than medical care or insurance

Oral Health Workforce Shortages

Two Strategies

1) Increase the number of dentists and allied dental professionals who will serve underserved populations

2) Redefine the oral health care workforce and expand roles of all practitioners as appropriate

Redefining the Oral Health Care Workforce• Interdisciplinary models for

care delivery exist• Expand roles of non-oral health professionals to assist

in prevention, referrals and oral health education• Easiest to reach underserved populations in existing

settings (primary care clinics, WIC offices, schools)• Many barriers as professional boundaries and

traditional modes of practice are change averse

Diversifying:Shifting your Perspective

• Update your concept on future pools of workers, i.e., for nurses, pool may include allied health workers as well as young people

• Research on values and goals of new workers to understand how to recruit them into health careers

• Educators and employers work together to design work and learning environments that integrate these findings

Diversity Strategies Strategy DefinitionMentoring Explicit mentoring programs pairing

students with either professionals, faculty or more advanced students for social support, academic and career guidance

Financial Support Scholarships, loans, or loan repayment

Academic Support Academic enrichment, tutorials or admissions preparations

Psychosocial Support Counseling, motivational programs or peer groups to assist students in social adjustment

Professional Opportunities

Internships, apprenticeships, information dissemination to expose students to health careers

Workplace and Professions Changes

• Replicate the best of innovative approaches which have demonstrated success

• Mentoring, volunteering

• Develop career pathways across professions

• Focus on early and sustained education in health careers, flexible pathways

• Facilitate life-long learning

Strategic Recommendations

• Change professional training to meet the demands of the new health care system

• Ensure that the health profession workforce reflects the diversity of the nation’s population

• Require interdisciplinary competence in all health professionals

• Continue to move education into ambulatory practice

• Encourage public service of all health professional students and graduates

Pew Health Professions Commission “Recreating Health Professions PracticeFor a New Century: Fourth Report of the Pew Health Professions Commission “

Recommendations for Public Health

• Each state should undertake a broad assessment of its public health workforce in order to facilitate workforce planning and training

• Public health schools and departments should develop certification and continuing education programs to help providers upgrade and maintain their competence

Pew Health Professions Commission “Recreating Health Professions PracticeFor a New Century: Fourth Report of the Pew Health Professions Commission “

Recommendations for Public Health• Public health curricula and training in both schools and

individual programs should expose students to, and prepare them for, the multiple sectors in which public health services are delivered

• Public health departments, schools and professions should urge other professions and organizations in assessing and promoting the public’s health.

• Public health schools, program and departments should focus some of their resources on training lay health workers and community residents to understand the mission of public health and equip them the basic competence to accomplish this mission

Pew Health Professions Commission “Recreating Health Professions PracticeFor a New Century: Fourth Report of the Pew Health Professions Commission “

Scramble

Start Over

Reinvent

Improve

Low

High

Short Long

Continuum of Responses

Time

Com

ple

xity

Future Directions• Scramble

– Buy more workers, threaten action, study the issue, 4 color brochures and ads, sign-on bonuses, debate the problem

• Improve existing processes to fit today’s challenges– Adjust education, improve management, engage

workers in problem solving, collaborate, fund tuition scholarships, distance learning, mentor programs

Future Directions• Reinvent the fundamental properties of work,

education, and professional organization– Experiment with new models, diversify, lower the wall

between education and work/practice, integrate

• Start Over– Community integration, collaborative partnerships, new

care delivery models based on patient needs and wants, new professional and practice models, cultural competency, technology adoption

• ACT!

Useful Responses

• Move this issue to the strategic level

• Assume partnerships will be necessary

• Look for balance of short and long-term goals

• Look for creative options

• Create sustainable workplace

Parting Shots

• Most change is PSYCHOLOGICAL • Partnerships are ABSOLUTELY necessary• Important that we NOT enfranchise the status quo

“The doctors of the future will give no medicine, rather they will interest their patients in care of the human frame, in diet, and in the cause and prevention of disease”--Albert Einstein

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