Encountering obstacles but seeking creative solutions, stakeholders across the healthcare industry strive to enhance the ability of workforces to provide value-based care.
Ted Wymyslo, MD, has a tough task. As chief medical officer of the Ohio Association of Community Health Centers, his central role is to enhance the workforce at the state’s 49 federally qualified health centers and to expand use of the patient-centered medical home (PCMH) model of care.
“What’s my biggest challenge? It’s finding primary care providers,” Wymyslo says. “It’s the weak link in this whole chain. All these great ideas, new care models, and payment reforms don’t turn into anything if primary care workforce needs aren’t met. And providers are much more effective if they’re practicing comprehensive primary care.”
Indeed, as the healthcare industry continues to shift from volume to value, the workforce has to evolve as well, particularly with cost and care quality in mind. New models of care and payment, a focus on population health management, a growing emphasis on behavioral health, and an aging, more diverse population are changing workforce requirements, necessitating the development or repositioning of traditional roles in primary care.
In addition to the challenge of providing appropriate education and training for healthcare professionals, healthcare organizations also face issues with clinician shortages (see the exhibit below) and funding that may hamper their ability to optimize their workforce. Organizations can use various strategies to prepare their workforce for value, but stakeholders say long-term solutions involve improving collaboration across the spectrum of health care, including among providers, health plans, state and federal agencies, and educators.
Projected Physician Shortage Through 2025
Connecting the Workforce
The drive to lower costs while providing better care and meeting the needs of a diverse group of patients has required a reengineering of care. Value-based care models such as the PCMH are designed to provide seamless care via teams of providers who coordinate care along the continuum.
Processes and tasks that once were the domain of physicians only or were not part of primary care at all are being delegated to physician assistants and nurse practitioners, along with case managers, clinical care managers, and relatively new roles such as patient navigators, health coaches, and community health workers.
Physician assistants and nurse practitioners. These roles have become more prevalent as providers seek ways to enhance the quality of care and patient satisfaction in addition to making care more cost-effective According to the Bureau of Labor Statistics (BLS), nurse practitioners (grouped with nurse anesthetists and certified nurse midwives) and physician assistants are among the fastest-growing occupations nationwide, with expected growth between 2014 and 2024 of 35 percent and 30 percent, respectively. a
Patient navigators. This role has become more prominent at both primary care and specialty practices as a resource for patients winding their way through an often complex and confusing healthcare system.
“The most important characteristic of a patient navigator is the ability to effectively serve as a broker between the patient and the system,” says Mandi Pratt-Chapman, MA, associate center director of the GW Cancer Center, part of the GW School of Medicine and Health Sciences at The George Washington University in Washington, D.C. “Your ideal navigator would be someone who understands the culture of many of their patients, what their lives are like, and also understands the needs of the healthcare team.”
Although registered nurses fill many patient navigator roles, non-licensed staff are becoming a more significant part of the care team, especially for logistical coordination, patient advocacy, and support. At the GW Cancer Center, patient navigators help identify insurance plans and co-pay assistance for eligible patients, arrange transportation to appointments, obtain missing information on referrals so patients are not turned away, and smooth the authorization process for patients to receive necessary treatments.
Other patient-support roles. These roles include health educators, who teach and promote community wellness; and community health workers, who work on health issues with specific populations or communities. According to BLS, the number of health educators and community health workers is expected to grow by 15,600, or about 13 percent, from 2014 to 2024. b
“The other important roles for non-licensed team members would be parent advocates and peer advocates,” says Jean Carlevale, RN, a healthcare consultant with Commonwealth Medicine, the public service consulting and operations division of UMass Medical School, Shrewsbury, Mass. “There’s an incredible value to be gained by adding peer support for individuals and families coping with severe and persistent mental illness to the primary care team. To have with you a peer or a parent advocate who’s been through it, there’s a tremendous amount of evidence that the outcomes are better and your experience of care is better.”
Telehealth. Skill in virtual care is also becoming more important as telehealth gains momentum in the drive to enhance the value of care.
“We believe a significant portion of our workforce must be retrained to do virtual care,” says Randy Moore, MD, MBA, president of Mercy Virtual, the telehealth organization of Chesterfield, Mo.-based Mercy. Moore predicts that in five years, about 30 to 50 percent of primary care encounters at large organizations such as Mercy will be virtual-based.
About 500 FTEs at Mercy Virtual—ranging from physicians, nurse practitioners, registered nurses, and patient navigators to those in nonclinical roles—work primarily in virtual care. The telehealth employee learns how to effectively integrate data and analytics supplied by technology that monitors patients, how to work collaboratively with a team member who is in a separate location—and even how to be effective on camera, the communication vehicle used for patient encounters and clinical collaborations.
Even clinicians in Mercy’s intensive care unit (ICU) rotate through virtual care as part of their training. “During their training rotations within the tele-ICU unit, they progressively learn how virtual care complements care at the bedside,” Moore says. “And when they’re at the bedside, they’re also interacting with the virtual care team.”
Mercy has added virtual care to bedside-nursing roles. Onboarding an ICU nurse in virtual care, for example, requires about two months of training. This concurrent experience enables nurses to determine which functions are best performed at the bedside and which are best done virtually, Moore says.
Standing in the Way
Incorporating these new and reengineered roles into the healthcare workforce can be challenging given issues such as training requirements, clinician shortages, and funding deficiencies.
If value-based care demands coordinated, team-based care, but physicians, care managers, and social workers are schooled only in the fee-for-service (FFS) model, then value cannot be achieved. Those skills are often lacking in clinical education.
Carlevale says medical, social work, and nursing schools, along with other clinical institutions that provide education for healthcare professionals, have not embraced interdisciplinary training despite evidence that team-based education is critical for enhanced care. “Our learning institutions aren’t producing clinicians at every level who actually are trained in a team-based model,” she says.
As an example, Carlevale says, nurses are generally trained in a specialty such as psychiatry or geriatrics. “But these newer models are demanding that you understand chronic diseases and the patient’s needs as they move through the continuum of care,” she says.
That may leave the education of care coordinators to the provider organizations. “Health systems have taken on a commitment to the education of providers, including nurses—specifically targeting the skills that are needed to work in this new kind of environment, where performance is linked to a series of patient-related quality metrics and ultimately to payment,” says Bobbie Berkowitz, PhD, RN, NEA-BC, FAAN, dean of Columbia University School of Nursing, New York City.
Perhaps the issue felt most acutely across healthcare organizations is how to fund these new roles and approaches. Breaking down the silos of FFS care to deliver care across a continuum may improve quality, but it also leaves a funding gap. Many of the new roles have no billing codes associated with them and are not reimbursed.
“I don’t advocate for billing piecemeal for those services,” Pratt-Chapman says. “I don’t think going back to a fee-for-service model where volume is rewarded is the way to go. But I do think we need to pay attention to research results showing the impact of patient navigation, the impact of patient-centered care. It does save money and improve the quality of care. Creating adequate bundled payments or global payment structures that compensate providers for the real costs of patient navigation and care coordination is what we need to ensure sustainable infrastructure for value-based care.”
Thinking Outside the Box
Staffing, training, and funding may present considerable obstacles to securing a value-ready workforce, but healthcare organizations are pursuing various strategies for surmounting those obstacles.
A telehealth workforce may solve some of the clinician shortage issues. Mercy Virtual employs “electronic” sitters who monitor patients across multiple locations. One trained technician can monitor four to 10 patients virtually as opposed to a single patient at the bedside, Moore says.
“We believe as the market goes toward value that our ability to really drive significant increase in efficiencies and effectiveness is going to go up significantly, as is the impact of each team, which may significantly mitigate what people see as the looming shortages in different areas,” he says.
The use of advanced practice registered nurses such as nurse practitioners can help relieve the shortage of primary care physicians, Berkowitz says. Utilizing nurse practitioners to the full scope of their license can improve patient outcomes and optimize the healthcare workforce, she says, but the state-by-state approach to regulating scope-of-practice remains a challenge.
Pratt-Chapman says using non-licensed healthcare workers also can help clinicians work at the top of their license and produce more cost-efficient care. She references a study recently published online in JAMA Oncology showing that nonclinical navigators used by the University of Alabama Health System’s Cancer Community Network for geriatric patients saved the system about $780 per patient per quarter, for an estimated $19 million in annual savings. c “At GW Cancer Center,” Pratt-Chapman says, “our patient navigators often identify insurance products that patients do not know they are eligible for, reducing uncompensated care for the cancer center and putting treatment within the reach of patients.”
Ensuring that patient navigators are trained to effectively serve as brokers between patients and the healthcare system has been a top priority for Pratt-Chapman. “These allied health professions, these support roles, are critical to help make physicians and nursing roles more efficient, but they need training. For patient navigators, we developed free competency-based training that anyone with Internet access can complete to ensure their foundational knowledge as a patient navigator,” she says.
Collaboration is Key
Addressing the root of the problem, however, most likely requires innovative collaboration among providers, health plans, academic institutions, and state and federal agencies.
On the health plan side, Humana provides physician practices with support in areas such as care coordination, value-based capabilities, wellness, care delivery, and behavioral health, says Mike Funk, vice president for thought leadership in the Provider Development Center of Excellence at Humana.
“We have been focused on a number of initiatives to assist physicians and their office staff in meeting the demands of today’s workplace,” Funk says. “While it may still appear very disconnected, there is a tremendous amount of work taking place to develop a more connected, seamless, efficient, and effective healthcare system that simplifies and integrates healthcare delivery.”
For example, Humana reimburses telehealth services under certain plans in some rural areas and some areas that are experiencing clinician shortages.
Carlevale strongly advocates incorporating interdisciplinary team-care training at medical schools and in other clinical educational and training programs. She also supports the idea of establishing a consortium integrating multiple stakeholders to address the need for value-based training and the funding of such training and roles in the clinical setting.
“I would really encourage everyone to think outside the box,” Carlevale says.
Wymyslo used a $2.68 million state subsidy to fund training for medical and other clinical students who work at Ohio community health centers that are also qualified PCMHs. In the first year of the subsidized program, 900 students were trained at 35 health centers, Wymyslo says.
“Students are getting the chance to see comprehensive team care provided to patients that considers their biological, psychological, and social needs,” says Wymyslo, a former director of the Ohio Department of Health and a practicing physician who ran a family practice residency program for about 20 years. Medical students in the training program work not only with physicians but also with advanced practice nurses, dentists, social workers, and even front- and back-office staff to attain a holistic understanding of the clinical and operational aspects of a practice, he says.
Wymyslo says the next step is for graduate medical school education to incorporate comprehensive primary care training.
Berkowitz says graduate-level nursing education, the focus of nursing education programs at Columbia, often encompasses such training. The school of nursing has recently developed a tailored master’s program for its partners at NewYork-Presbyterian. The program is designed specifically to focus on evidence-based nursing practice and on preparation for care coordination, team-based care, and care transitions.
“Those partnerships are really ideal because we can work together to make sure we’re creating clinicians who are relevant to current practice,” she says. “It’s a challenge, of course, but I think it’s a new direction that is essential.”
Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill.
Interviewed for this article:
Bobbie Berkowitz, PhD, RN, NEW-BC, FAAN, dean and professor, Columbia University School of Nursing and Sr. Vice President of the Columbia University Medical Center, Columbia University, New York City; Jean Carlevale, RN, program support, Commonwealth Medicine, UMass (University of Massachusetts) Medical School, Shrewsbury, Mass.; Mike Funk, vice president, Thought Leadership, Provider Development Center of Excellence, Humana, Louisville, Ky.; Randy Moore, MD, MBA, president, Mercy Virtual, Chesterfield, Mo.; Mandi Pratt-Chapman, MA, associate center director, Patient-Centered Initiatives & Health Equity, GW Cancer Center, GW School of Medical and Health Science, The George Washington University, Washington, D.C.; Ted Wymyslo, CMO, Ohio Association of Community Health Centers, Columbus, Ohio.
a.“Fastest Growing Occupations,” Occupational Outlook Handbook, 2016-17 Edition, Bureau of Labor Statistics, U.S. Department of Labor, Dec. 17, 2015.
b. “Health Educators and Community Health Workers,” Occupational Outlook Handbook, 2016-17 Edition, Bureau of Labor Statistics, U.S. Department of Labor, Dec. 17, 2015.
c. Rocque, G.B., Pisu, M., Jackson, B.E., et al., “Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer,” JAMA Oncology, Jan. 26, 2017.