Building the Health Workforce as We Transform

the Delivery System

Mary D. Naylor, PhD, RN

Marian S. Ware Professor in Gerontology

University of Pennsylvania School of Nursing

The Commonwealth Fund-Nuffield Trust 15th International Meeting

on the Quality and Efficiency of Health Care

July 17, 2015

Initial Reflections

• The “high need, high cost” (HNHC) population is comprised of many subgroups with diverse trajectories but share in common the need for upfront investment and longitudinal follow-up.

• Health system transformation “is best conceptualized…as a process that involves concurrent redesign of the service and workers’ roles.” (Bohmer & Imison, Health Affairs, 2013, p. 2028)

A Population Health Framework to Guide

Workforce Transformation for HNHC Patients

Upstream: Community-Based Care

Community-based high need, high cost patients and

family caregivers

Risk Stratification

Implementation of care plan collaboratively developed by patients/caregivers, primary

care clinicians/teams

Follow-Up Based on Risk

Engaged patients/ caregivers, improved symptom/function,

prevention of hospitalizations/ED

visits/timely access to palliative care

Screening Monitoring

Downstream: Acute/Post-Acute/Follow-Up

Level 1 illness (primary care)

Level 2 illness (palliative care)

Level 3 life (hospice)

Population of Acutely Ill

HNHC Patients

Hospital Phase

Post Acute/ Rehab Phase

Long-Term Follow-up

Palliative Care

Transitional Care

Patients’/caregivers’ goals met;

improved symptoms +function; reduced

hospitalizations+ED visits; death with dignity

Common foci of international workforce transformation for this patient population:

Enhanced Competencies

Patient/ caregiver engagement;

shared decision making;

partnership

Managing complexity using holistic approach;

emphasis on palliative care

Population health (risk stratification;

evidence-based decision making; team-based, care management that

optimizes technology)

Performance (measurement,

processes); stewardship;

focus on longer term value

Increased Use of Teams

Integrating clinical, public health and social service staff

Adding new team members (e.g., community health workers)

Using telehealth to improve communication and collaboration

Focusing on both clinical and non-clinical staff

Training to strengthen “team work”

“Upskilling” current staff (e.g., palliative care)

A Few Examples

“Care Team Integration of the Home Based

Workforce”: CMS funded California initiative

designed to: 1) promote core competencies of

6000 personal health care aides supporting

Medicare and Medicaid beneficiaries with

disabilities, and 2) integrate aides within care

team.

European HANDOVER Project: Among outcomes of a multi-nation program to improve transitions at the primary care-inpatient interface has been a “toolbox” designed by patients and healthcare professionals that can then be adapted by local educators and clinicians to “upskill” current workforce.

What do available innovations suggest about members of our

future workforce and their roles?

• Major emphasis on self-management

Patients

• Substantial increase in expectations

• Largely “invisible workforce” Family

caregivers/ direct care workers

• Major shift in responsibilities re: primary care, care transitions or “handovers”, and population health management, including coordination of teams managing HNHC patients

Nurses

Examples of role transformation related to current health system redesign

Examples of role transformation related to current health system redesign

• Increasingly, consult with other clinicians/teams or directly provide medication management services

Pharmacists

• Diverse training, roles; have capacity to extend contributions of health professionals for most vulnerable HNHC patients

• Questions remain about optimal conditions for effectiveness

Community health workers

• Increasingly, recognized as core team members because of their role in linking HNHC patients with essential services such as meals and transportation

Staff in community-

based organizations

Challenges with Current Responses

• Rapid proliferation of new roles may increase fragmentation and decrease productivity; value proposition needs to be examined.

• Limited change in overall health care practices has occurred, despite substantial advances in specific team members’ contributions.

• In U.S., numerous health care workforce innovations have not been linked to broader systems to assure optimal distribution and use of team members.

• Emphasis on “team-based care” has not been accompanied by a playbook (focus of new U.S. Center) or policies that foster and sustain teams of different backgrounds and professional pedigrees and center on the needs of HNHC patients.

A few “fast track” workforce development opportunities targeting HCHN patients?

• Encourage current workforce’s use of well-designed resources to advance population health competencies

• Convene international workforce leaders to: develop repository of HNHC patient centered, effective and efficient interprofessional or team-based workforce planning; and, promote rapid scaling of high-value workforce innovations

• Advance regulatory changes that enable all team members to function at top of their educational preparation and licenses

Sample Resources

• U.S. Department of Health and Human Services

Education and Training Resources on Multiple Chronic Conditions (MCC), http://www.hhs.gov/ash/initiatives/mcc/education-and-

training/index.html

Centers for Disease Control and Prevention, http://www.cdc.gov/chronicdisease/index.htm

• National Center for Interprofessional Practice and Education (University of Minnesota) https://nexusipe.org/about

• Institute for Patient- and Family-Centered Care, link to the Picker

Institute archive, http://www.ipfcc.org/tools/picker-institute.html

• ICARE4EU, Innovating care for people with MCCs in Europe, http://www.icare4eu.org/index.php

Direction of

Future Policies

Promote close alignment between health system and workforce redesign

Assure adequate skill mix and supply within and across all settings

that care for HNHC patients

Emphasize continuity of care across multiple team members and

settings Foster restructuring of roles and relationships among members of the care team focused on

patient outcomes

Prioritize the role of HNHC patients and

their family caregivers