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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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4

Workforce Needs to Support Community Living

The health care workforce is a critical component of the supports needed to enable people with disabilities and older adults to maximize their independence and live in the community. However, the required ingredients for this much-needed workforce go beyond making sure there are enough providers; having providers with the right knowledge base is also key. The four speakers in the workshop’s second panel explored how to support and enhance this workforce through changing the workforce culture to support an aging America, enhancing training and job satisfaction for the direct-care workforce, and identifying research gaps and needs and emerging workforce trends in the post-Patient Protection and Affordable Care Act (ACA) era.

PROGRESS IN CHANGING WORKFORCE CULTURE IN AN AGING AMERICA

Anne Montgomery
Senior Analyst, Altarum Institute

Although discussions about delivery system reform often focus on financing, said Anne Montgomery of the Altarum Institute, improving the geriatric competence of the nation’s health care workforce will be a big contributor in determining the on-the-ground success of the delivery of both health care and long-term services and supports (LTSS) to the millions of Americans who will require a mix of both. She added

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

that although she would be speaking specifically about older adults, the nation also needs to establish disability-informed competencies in the workforce.

Compared to other countries with comparable economies and demographics, the United States spends, as a percentage of its gross domestic product, substantially more on health care and substantially less on social services, Montgomery said (see Figure 4-1). Although the total amount spent on health care and social services is not that different from the total in some other countries, the distribution of expenditures between these two sectors is very different. Given the rapidly aging society in the United States, Montgomery suggested that the United States might be over-invested in acute health care services and under-invested in social supports and services. This underinvestment, she added, is mirrored in the workforce dedicated to older adults. For example, the number of prac-

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FIGURE 4-1 Health and social expenditures as a percentage of gross domestic product in 2009, by country.
NOTE: GDP = gross domestic product.
SOURCES: Montgomery presentation, 2015. Adapted from The American Health Care Paradox: Why Spending More Is Getting Us Less by Elizabeth H. Bradley and Lauren A. Taylor, copyright © 2013. Reprinted by permission of PublicAffairs, a member of The Perseus Books Group.
Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

ticing geriatricians in the United States, which is already low, is projected to decline, not grow, even though the number of older adults is rising. A related trend holds true for the broader licensed health care workforce, of which only a small fraction of professionals have training in geriatrics. Without further action, Montgomery said, a gap may develop between the supply of direct-care workers and the demand for those workers to deliver home- and community-based services (HCBS).

Montgomery noted that with the population of adults over age 65 increasing as a proportion of the U.S. population, most health care providers will be delivering some services to older adults in the future. Furthermore, women will account for approximately 55 percent of the population of adults over age 65 in 2030 and approximately 62 percent of those over age 85 in 2050. Because women live longer, they will have higher rates of disability over time and a greater need for LTSS. Over the same time period, service delivery will be channeled increasingly into bundled, capitated, shared-savings, pay-for-success, and other types of financial models with more accountability built into them. All of this means that the workforce will have to become more efficient. Montgomery suggested that on-the-job training in the form of continuing education, in-service training, online webinars with interactive presentations, train-the-trainer courses, and other types of creative learning modalities will play an important role in increasing the number of specialists with geriatric training.

While acknowledging it will not be easy to build bridges between the very different health care and social services sectors, Montgomery said she believes that the workforce is in a position to accomplish this. In fact initiatives are already under way to do this. The Administration for Community Living’s Business Acumen Learning Collaborative that Kathy Greenlee described is one such initiative, and Montgomery discussed two other successful efforts: the Personal and Home Care Aide State Training (PHCAST) Program1 and the Geriatric Workforce Enhancement Program (GWEP),2 both of which are administered by the Health Resources and Services Administration (HRSA).

PHCAST

PHCAST, Montgomery said, is a six-state demonstration focused on establishing a series of evidence-based training standards and curricula for personal and home care aides, for whom there are no national stan-

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1 For more information, see http://bhpr.hrsa.gov/nursing/grants/phcast.html (accessed January 29, 2016).

2 For more information, see http://bhpr.hrsa.gov/grants/geriatricsalliedhealth/gwep.html (accessed January 29, 2016).

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

dards. This program was created based on recommendations in the Institute of Medicine (IOM) report, Retooling for an Aging America: Building the Health Care Workforce (IOM, 2008)¸ and it was included as a provision in the ACA. PHCAST has specific goals, including a set of required core competencies for personal and home care aides (see Box 4-1). California, Iowa, Maine, Massachusetts, Michigan, and North Carolina were awarded PHCAST grants which also included funds for evaluations. The evaluations analyze the curricula developed by these six states, along with the curricula’s effects on job satisfaction, mastery of job skills, and beneficiary and family caregiver satisfaction. Montgomery suggested that the results of this demonstration could at some point serve as the basis for national standards or guidelines.

The PHCAST demonstrations have already made progress. Montgomery said that California’s training curriculum leads to certification for personal care aides. The curriculum includes 25 modules, 7 of

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

which address consumer direction, with classes conducted at community colleges and one long-term care workforce institute, and many of the graduates go on to work at California Medicaid’s In-Home Services and Supports program, which provides a certain number of hours of in-home personal care and household help for beneficiaries. Maine has developed curricula and a credentialing system that enables direct-care workers to become personal-support specialists, direct-support professionals, or mental health rehabilitation technicians. Michigan adopted the Paraprofessional Healthcare Institute’s (PHI’s) Personal Care Services curriculum3 and additional trainings in dementia, home skills, and the prevention of adult abuse and neglect. In North Carolina, training is integrated into both high school and community colleges and targets both unemployed and new workers. North Carolina has developed basic, intermediate, and advanced training levels, with advanced training divided into home care, geriatric care, and medication aide specialties.

In summarizing these preliminary results from PHCAST, Montgomery said that a big benefit of PHCAST is that it shows how career ladders can be built into the direct-care workforce by providing core and advanced trainings and opportunities to specialize. It is a key investment in building skills and LTSS, which is fundamental to the success of the evolving care system. Care workers, she added, will need to be positioned to undertake more complex and sophisticated tasks as the population of older adults rises. This will be particularly important, she said, as the trend of shifting long-term care from more costly institutional care to HCBS continues (Eiken et al., 2014).

GWEP

Montgomery characterized the GWEP program as a bold initiative to integrate geriatrics and primary care and connect geriatric education centers and community-based organizations that go into the homes of older adults. The four focus areas of this program are

  1. Transforming clinical training environments into integrated geriatrics and primary care delivery systems to ensure that trainees are well prepared to practice in and lead these systems.
  2. Developing providers who can assess and address the needs of older adults and their families and caregivers at the individual, community, and population levels.

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3 For more information, see http://phinational.org/workforce/resources/phi-curricula/personal-care-services-curriculum (accessed January 29, 2016).

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×
  1. Creating and delivering community-based programs that will provide patients, families, and caregivers with the necessary knowledge and skills to improve health outcomes and the quality of care for older adults.
  2. Providing education on Alzheimer’s disease and related dementias to families, caregivers, direct-care workers, and health professions students, faculty, and providers.

GWEP, Montgomery explained, rewrites many existing Title VII and Title VIII programs that fall under the Public Health Service Act, and it provides $35 million over 3 years to dozens of organizations, including nursing schools and a certified nurse aide training and certification program. A key aspect of GWEP is that grant recipients must partner with at least one primary care program and at least one community-based organization that serves the local needs of older adults, their families, and their caregivers. Grantees can also include behavioral and mental health practices as partners. Rush University’s GWEP, for example, is collaborating with dozens of organizations across Illinois. New York University’s GWEP is going to use community-based organizations to hire a health care volunteer core to go into homes and coach individuals about health conditions such as uncontrolled diabetes.

Montgomery said that HRSA staff members hope that much of the work in GWEP will move existing curricula into operational protocols that can be tested and evaluated for whether and how geriatric training can be shown to improve primary care practices for older adults. The questions that HRSA hopes GWEP will answer include

  • Once trained, do primary care practices refer their older patients more to community resources or to a geriatrician?
  • Do primary care practices know when their patients should have home visiting, and do they refer someone who is struggling at home with an uncontrolled condition such as diabetes to a community health worker who can provide ongoing assistance?
  • Is the care plan useful?
  • If a GWEP practice is located within a larger health system, is there evidence that the training can produce more effective care, reduce costs, or lower hospital utilization?

Progress in Enhancing the Geriatric Care Workforce

In her final comments, Montgomery returned to the recommendations for enhancing geriatric competence that were outlined in the IOM report Retooling for an Aging America (see Box 4-2) to discuss the progress that has

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

been made in enhancing the workforce. For the first recommendation—that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes—there are a few modest reforms included in the ACA regarding general medical education that allows hospitals to train residents in long-term care settings, nursing homes, assisted-living facilities, residences, and other places. Montgomery said she believes that this will be tremendously important for the aging society and suggested tracking whether this education is happening. She also recommended requiring it as part of legislation on general medical education accountability. With regard to the second recommendation on licensure and certification, she said that there is still a long way to go. PHCAST, Montgomery said, is helping the nation move in the direction of building a more robust and better-trained workforce, the subject of the report’s third recommendation, but there is still room for improvement in other aspects of the direct-care workforce. For example, the training standards for certified nursing assistants (CNAs) and home health aides have not been rewritten, as the report recommended. With regard to the fourth

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

recommendation concerning training family caregivers, Montgomery said that this area is getting attention, including bipartisan interest in Congress. She noted that there is a congressional caucus reviewing family caregiver policy and considering the creation of a requirement that the U.S. Department of Health and Human Services examine its programs to determine where family caregivers could be helped.

As far as addressing the report’s recommendations on redesigning models of care, Montgomery suggested building on successful programs such as the Program of All-Inclusive Care for the Elderly, Home Based Primary Care at the U.S. Department of Veterans Affairs,4 and Independence at Home5 so that they can be scaled up to address the coming wave of older Americans. “I think we have a responsibility to taxpayers and to individuals who are older adults to do that,” she said.

ENHANCING AND SUPPORTING THE DIRECT-CARE WORKFORCE

Jodi M. Sturgeon
President, Paraprofessional Healthcare Institute

The core focus of PHI’s quality care and quality jobs mission is the direct-care workforce—personal care aides, home health aides, and CNAs—and the critical role they play in supporting community living, said Jodi Sturgeon of PHI. The approximately 4.3 million direct-care workers employed in 2015, which made up 27 percent of the entire U.S. health care workforce, provided 80 percent of the paid care and support services delivered in the community, Sturgeon said. It is estimated that by 2022, the direct-care workforce will comprise some 5 million people, more than the number of teachers in kindergarten through grade 12, fast food workers, registered nurses, police officers, or firefighters, Sturgeon said.

At the same time that growth is needed in the direct-care workforce, Sturgeon said, the number of women ages 25 to 54 years old entering this profession is shrinking, even though this age demographic of women is the traditional source of direct-care workers. Between 2012 and 2022, only 227,000 women in this age group are projected to enter the direct-care workforce, which is a fraction of the approximately 1.3 million new workers that will be needed in that same decade to meet the needs of the growing population of older Americans, Sturgeon said. “If you add to that demographic the successful minimum wage efforts that are going on

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4 For more information, see http://www.va.gov/geriatrics/guide/longtermcare/home_based_primary_care.asp (accessed January 29, 2016).

5 For more information, see http://www.iahnow.com (accessed January 29, 2016).

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

in this country and the decreasing numbers in unemployment, the ability to attract workers into this workforce becomes even more difficult,” Sturgeon said.

PHI has described the direct-care workforce as being a low-investment, high-turnover model characterized by poverty-level wages; part-time and inconsistent hours; few benefits, including a lack of health insurance; inadequate training and supervision; and limited opportunities for advancement. Direct-care workers, Sturgeon said, are treated as an expense item rather than as an investment, and a turnover of 40 to 60 percent is considered a cost of doing business. So while there is little the health care enterprise can do to control the demographics that affect the supply of direct-care workers and the demand for services, it can control the quality of the job. “From my perspective, we must make direct-care jobs more attractive in order to fill the need over the next 10 years,” Sturgeon said.

PHI, she explained, conducts advocacy and policy-based research, but it also has a practice-based approach. PHI’s affiliation with Cooperative Home Care Associates (CHCA),6 a direct-care worker-owned cooperative in Bronx, New York, has demonstrated that improved working conditions, training, and coaching-focused supervision reduce employee turnover, improve patient outcomes, and reduce overall costs. PHI and CHCA have developed and implemented training programs that Sturgeon characterized as being more rigorous than the federal standard and customized for the adult learner. The curriculum is skills-based rather than didactic, and it emphasizes skills demonstration. The training and employment programs also include workforce supports in areas such as financial literacy and communication skills. The training program, which has a waiting list, in conjunction with the workforce supports, have cut the employee turnover rate to 20 percent—a rate that is much lower than the industry’s average of 40 to 60 percent—and increased both worker and client satisfaction. PHI also collaborates with Independence Care System (ICS),7 which is a Medicaid-managed long-term care program focused on client-centered care coordination with a strong emphasis on valuing the direct-care worker in that care coordination.

In addition to working on the core job of the direct-care worker, PHI has developed what Sturgeon called “advanced role” jobs that support home health aides and test technology to improve communication and reduce client hospital and emergency department visits. Aides holding one of these types of advanced roles are embedded within interdisciplinary care teams and their inclusion in these teams has increased ICS client

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6 For more information, see http://www.chcany.org (accessed January 29, 2016).

7 For more information, see http://www.icsny.org (accessed January 29, 2016).

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

satisfaction and shortened the time needed to get appropriate interventions to ICS clients. With funding from New York City’s Balancing Incentive Program, PHI has created another advanced role focused on care transitions. These advanced aides support home health aides who have an identified subset of ICS clients who are at risk for hospital readmission or have an extensive history of emergency department visits. Sturgeon added that PHI is using technology primarily as a tool to improve communication between the clients and the aides and not as a means of connecting people in their homes to clinicians.

As a final comment, Sturgeon said that there are many individual models, such as those developed at PHI, that are demonstrating success. PHI believes that part of its mission is to take what it has learned and bring those lessons to other providers across the country. The question, she said, is how to take these successes and deploy them in a targeted yet collective way to have a positive impact on the LTSS delivery system.

RESEARCH GAPS AND NEEDS

Susan Chapman
Professor, University of California, San Francisco

The mission of the University of California, San Francisco’s (UCSF’s) Health Workforce Research Center on Long-Term Care, said Susan Chapman of UCSF, is to determine whether the long-term care workforce is prepared to meet the growing needs of the U.S. population. Though this might seem to be a yes-or-no question, she and her colleagues are answering it in a more complex way. The center conducts policy-oriented research to collect, analyze, and report data on issues surrounding the long-term care workforce and its impact on high-quality, efficient, long-term care across the nation and within the individual states. Each of the center’s projects is conducted within a 1-year time frame so that the results can be provided to policy makers quickly. In addition, the center operates from the premise that long-term care cuts across age and demographic groups, so its research is not limited to an aging population, nor is it limited to studying any one health care profession. A project looking at the national landscape of personal-aide training standards, conducted in collaboration with PHI, found wide variation in minimum training requirements across states and between programs within states (Marquand and Chapman, 2014b). This project identified seven states that were leaders in both the consistency and the rigor of training requirements (Marquand and Chapman, 2014a). Another project studying trends in long-term care service use and workforce demands found that overall demand does not change substantially, regardless of how care settings

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

change (Spetz et al., 2015). A third project found that licensed practical nurses are moving out of hospitals and into long-term care and, in particular, into home health care.

Despite all of the research into the health workforce, many gaps in understanding remain. A lack of good information on the size and distribution of the workforce is one challenge, Chapman said. The lack is due in part to the mix of job categories in national datasets and to employment settings that are not always specific. Data from the private home health care agencies and individual markets are not available. As a result, there is no good way of identifying the geographic or economic areas of need.

A second research gap is in the area of training and certification requirements. Among the questions in need of answers are

  • What standards and competencies should be adopted for the training and certification of personal care aides?
  • What training should be required for licensed professionals caring for older adults or individuals with a disability, given that training is known to be weak in these areas?
  • What incentives are effective in training health workforce specialists in aging and disability?

All of these questions about setting standards for training and certification leave open the question of who should play a role in setting the standards. Possibilities include state and federal governments, health plans, and communities. What is known is that standards and requirements vary widely, and Chapman noted that one of the goals of California’s PHCAST demonstration, in which she was involved as a project evaluator, was to explore what a national standard might be and how it could be set. She said that there are national standards for home health aides and CNAs, but she added that research is needed to understand how to link these different standards. Chapman said she is involved in another project studying what managed health care plans should be expected to provide in terms of care management, case management, training, and the minimum expertise needed for care management.

A “big picture question” that needs answering, Chapman said, is what effect workforce training has on outcomes. Some research has focused on worker and consumer satisfaction, employee turnover rates, and health status improvements. Current research is attempting to link training to the Triple Aim outcomes of better care, better health, and reduced cost. However, Chapman said, it is unclear what level of evidence is needed to truly demonstrate such linkages.

Another research need is to understand how to make long-term care a better job and to reduce the high turnover rates in the long-term

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

care workforce. One study from the center found that exit rates exceed entrance rates by 5 to 10 percent across settings (Frogner and Spetz, 2015). The high rate of turnover prompts the questions of whether and how turnover affects the quality and consistency of care. Research into how to assess and address the needs of family and informal caregivers is also needed because caregivers often need care themselves. Potential solutions could include providing respite or training for these caregivers. However, gaps in understanding remain. It is unclear if training should be the same standardized training that home health care professionals receive or if there should be specific training related to the care needs of the recipient.

Related to what Sturgeon had noted earlier, Chapman said that there is a need to develop approaches to make long-term care work sustainable and to provide opportunities for those who enter the field looking to build a career. Chronic issues for personal care aides are low wages, part-time hours, and the need to rely on public assistance. Injury rates are high in the long-term care workforce, and research is needed to understand why. Perhaps, for example, it is a result of inadequate training.

In conclusion, Chapman raised the question of whether this field needs more research or more policy action. The challenge, she said, is to distinguish between those issues that need further research and evidence for action and those issues for which the research base is sufficient and thus ready for decision making and policy action.

DRIVERS OF WORKFORCE CHANGE IN THE HEALTH CARE SYSTEM

Patricia Pittman
Associate Professor, The George Washington University

In the panel’s final presentation, Patricia Pittman of The George Washington University focused on the major drivers of systems transformation and the impacts they might have on the workforce. She noted she was drawing information specifically from two studies—one funded by HRSA that looked at how large health systems are changing the way they do workforce development and planning, and the other funded by the Office of Minority Health looking specifically at community health workers.

Drivers of Health Care Workforce Change

From the perspective of large health systems, there emerged four major drivers of health care workforce change, Pittman said. The first was the growth of a culture of convenience, that is, a culture of people wanting

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

care wherever and whenever they want it. With the advent of health care exchanges, health care systems are shifting a lot of negotiation for benefits from large employers to individuals. This is leading health systems to be more aware than they were in the past of individuals’ demands of how and when they want to receive care, she explained. As a result, there is a fair amount of scrambling to figure out what that means and how to reorganize the workforce to be responsive to that demand, Pittman said.

Market consolidation is another driver of change that is happening nationwide, with stand-alone hospitals disappearing and health care systems merging with one another. In addition, policies are driving the formation of provider networks such as accountable care organizations. Medicaid waivers in some states are also driving the creation of provider networks. Taken together, market consolidation and network formation have important implications for the workforce, particularly in terms of downsizing and moving workers to new settings. In the same vein, affordability is also a major driver, which itself has been driven by the health exchanges.

The fourth driver is that the risk in payment models is being shifted to providers, with the goal of keeping patients healthy and in their homes and thus away from high-cost doctors and hospitals. Previously, the goal of health systems had been to drive people to doctors and hospitals. This shift has triggered a major change in thinking about the workforce because the objectives have changed completely. This has led to a great deal of data analysis on patient risk stratification and workforce models, Pittman said. The new paradigm associated with shifting risk is leading to the development of complex population management models focused on transitions, particularly in the post-acute setting of long-term and home-based care. Care coordination is moving away from registered nurse-based telephonic care to a model that may rely on home visits, often conducted by nurse practitioners (who can prescribe medications) in coordination with community health workers. In the new world of shared risk there is also a major push to integrate behavioral health into long-term and community-based care and for the health care system to take on more responsibility for addressing the social determinants of health.

The Blurring of Workforce Boundaries

Pittman said she has noticed a blurring of workforce boundaries, resulting both from the growth of provider networks and from health plans hiring health workers who function in parallel to the provider workforce. The increasing number of partnerships with community-based organizations is another factor blurring workforce boundaries, Pittman said, noting that at least one large health system in New York is training

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

community health workers who work for community-based organizations because the health system is now financially at risk for the quality of care these community-based organizations provide. Other factors that blur the lines of who is in which workforce are health systems’ efforts to invest in internal workforce wellness as part of population health and their efforts to invest in health workforce pipelines to bring in new workers, even when those workers may or may not end up in that particular health system’s workforce.

All of these blurred boundaries may have implications for how the health care workforce is planned for and developed, Pittman said. The movement to team-based care, for example, places an emphasis on having workers practice at the top of their license and education, shifting care from physicians to advanced practice clinicians and from registered nurses to unlicensed assistive personnel. There are many challenges involved in this shift in terms of professional resistance, not to mention the dearth of evidence as to whether these models are actually the most efficient models. This is a place where more research is needed, Pittman said.

Moving staff from the hospital to the ambulatory care setting is another huge workforce issue. Pittman said there is resistance from nurses who are not pleased about being sent into ambulatory settings, which tend not to be unionized and where pay tends to be lower. The adoption of health information and the use of data for decision making has workforce implications, too, in that it is driving demands for new skills and for health care workers to adopt new roles. In particular, older licensed personnel may have trouble adapting to a new technology-driven world in which health information technology is used to make decisions. In addition, health systems are having to make large investments in technology and employee training.

Community Health Workers

Another way in which the movement of health care beyond the walls of the clinic affects the workforce is through increasing the emphasis on care coordination and outreach to the sickest patients. As a result, the demand for community health workers is rising, raising questions about what the right level of education, training, and certification should be for community health workers. There are also the questions of how to integrate behavioral health into care coordination and how to meet the growing demand for workers with behavioral health training, as well as how to address the social determinants of health and the competencies and payment models needed to affect those determinants.

Pittman noted that as health care systems have been hiring more community health workers, they have been searching for information to deter-

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

mine the right competencies for these new employees. An HRSA-funded study conducted by her center compared the list of core competencies for community health workers that different states have put forth to develop their own certifications. The competencies are pretty well developed for a stand-alone community-based organization employee. What seems to be missing from those competencies, Pittman said, is the set of skills that community health workers need when they are going to be integrated into a health system. The challenge, Pittman said, is how these people are going to interact with the health system without “essentially losing what is their ‘magic ingredient,’ their own identity, because we know health systems tend to mold people to their liking.” Community health workers should be incorporated in a way that allows them to continue to do what they are very good at doing, she said.

Not only are providers increasing the number of community health workers they are hiring, so too are health plans, which are using them in a “seek and find” function, particularly in the Medicaid sector, Pittman said. The Medicaid waiver that states can have that allows them to use and license assistive personnel for preventive services will likely be a driver of this increased use of community health workers, though few states have begun making use of that provision. Pittman said there is an expectation and a hope that Medicaid plans will be able to bill for the services that community health workers provide or have them covered under the Medical Loss Ratio regulations.

Pittman said there is enormous diversity in terms of how health systems and health plans are using community health workers. Some, for example, are focused on individuals and families, while others are working to produce change at the level of the community. In some cases, community health workers are doing clinical work as unlicensed assistive personnel. The challenge, she said, is to use community health workers in the roles that make good use of their unique skills and not to have them become unlicensed assistive personnel much like the other types of entry-level jobs already in the health care system. Thus, Pittman said, there is a need to have a clear community health worker identity in terms of what the modes of impact are that are unique to community health workers.

Community health workers in this new world of being integrated into health systems need to be able to articulate and defend their unique contributions regarding outreach, trust, social determinants, and empowerment. They also need to be able to speak the provider’s language and meet the provider’s standards, such as for confidentiality of health data and entering adequate notes in the electronic health record; to combine empathy for the provider with advocacy for the patient, which requires high-level negotiating, diplomacy, and conflict resolution skills; and to possess leadership skills in the community and in the system as a rep-

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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resentative of the community. What all of this means, Pittman said, is that health systems cannot bring community health workers into their organizations and expect them to do the work they have been doing for decades; a support structure will be required. This could be in the form of a community health worker as a supervisor or a supervisor sensitized to the very specific and unique work of community health workers and the tendency of health delivery organizations to shape things around the needs of the health system.

Community health workers are just one example of a growing occupation within the system that is going to be important for long-term care, Pittman said. Going forward, the health care enterprise is going to need new models with which to evaluate the workforce. Pittman and her colleagues have developed a conceptual model that stratifies patients based on risk and then looks at who will provide services to that population, what they need to do in which setting, and the desired outcomes for that risk-stratified population. She explained that risk stratification is the key to an apples-to-apples comparison of workforce models and noted that the model for the patient population of top hospital users, for example, is much different from the model for the young and healthy. She concluded her remarks by saying that the field should think about a program of research that can keep track of what is changing with regard to workforce needs and what leaders are trying in terms of developing new workforce models.

DISCUSSION

An open discussion followed the panel’s presentations. Workshop participants were able to ask questions of and offer comments to the speakers. This section summarizes the discussion.

Terry Fulmer of The John A. Hartford Foundation asked the panelists to comment on the opportunities to bring together the vectors of self-care, self-management, and advanced technologies to improve care and patient-centeredness while also making better use of home health attendants and community workers. She noted, for example, that if she were a patient, her granddaughter could give her the medications she needs, but a home health attendant could not. Montgomery said that there is training for medication aides in the PHCAST demonstration in at least one state. If it can be shown to be effective and safe with good outcomes, Montgomery said, there is no reason not to do it, but more research is needed, and that research needs to be conducted not only in academic settings, but also in actual health care delivery system models. Chapman agreed and added that there have been demonstration projects showing that training medication aides does work, and the state of New York is working to

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

get approval for the use of medication aides. Chapman also said that, in addition to research, advocacy is needed to help states include this type of delivery in their scope of practice regulations. Sturgeon said that this is an opportunity for a collaboration with the nursing community to address the concerns of registered nurses about expanding the scope of practice for direct-care workers, to which Chapman replied that scope-of-practice and regulatory issues are ultimately turf and political battles.

Amy York of the Eldercare Workforce Alliance asked the panelists for their ideas on how to provide incentives for people to go into geriatrics at all levels of care. Montgomery responded that this is an important question given that the geriatric specialization approach has not worked, in large part because there is not a good educational pipeline. She said that this problem has to be fixed at the practice level by insisting that standards and measures concerning geriatric competence be updated. Hospitals should be required to train all residents in long-term care settings and to demonstrate that all residents are as competent at taking care of a 90-year-old as they are with younger adults and children. The strategy to address the shortage of health care workers with geriatric training needs to be broad, Montgomery said, and it could include financial incentives and licensure requirements. Chapman agreed that the strategy has to be broad and include the entire health care workforce. She noted that geriatric training is missing from most curricula, even those of nursing schools. Pittman said that holding health professional schools responsible to some extent for the careers that their graduates pursue might be possible, although waiting until graduate medical education or loan repayment may be too late to get people to pursue training in geriatrics.

FACILITATED TABLE DISCUSSIONS

Three questions were posed to the workshop participants for short facilitated table discussions (answers not limited to what was covered in panel presentations):

  • What are the two or three biggest policy barriers for the workforce supporting community living?
  • What should be the top three research and policy priorities to enhance and support the workforce?
  • What best practices have been identified?

The reports from the table discussions were delivered by the following individuals, listed alphabetically: Gretchen Alkema, The SCAN Foundation; Margaret Campbell, National Institute on Disability, Independent Living, and Rehabilitation Research; Jessica Nagro, Eldercare

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×

Workforce Alliance; Rasheda Parks, National Institute on Aging; Julianna Rava, National Institutes of Health Office of Autism Research; Lori Simon-Rusinowitz, University of Maryland School of Public Health; and JoHannah Torkelson, President’s Council on Fitness, Sports and Nutrition.

Policy Barriers

The facilitated table discussions produced the following list of policy barriers for the workforce supporting community living, as noted by the table rapporteurs.

Training and Scope of Practice
  • A lack of skills and tasks that cross workforce domains (Alkema)
  • A lack of national standards in training, certification, service delivery models, or scope of practice, all of which leads to regional variation in service delivery (Alkema, Campbell, Nagro, Parks, Rava, Simon-Rusinowitz)
  • A lack of cohesive geriatric, disability, and multiple disability training programs for the direct-care and medical professional workforce (Nagro, Parks)
  • A lack of a requirement that any health professional take geriatric or disability training (Nagro)
  • Scope-of-practice policies that restrict some care providers from helping patients manage their medications (Torkelson)
  • A lack of training on person-centeredness, including cultural sensitivity, across the entire spectrum of health care occupations (Simon-Rusinowitz)
Financing
  • A lack of payment models for various workforce classifications and for bundled service agreements that focus on services rather than workforce designation and fee codes (Alkema)
  • A lack of government funding for programs such as the ACL Business Acumen Learning Collaborative initiative (Campbell)
  • Large disparities in pay between medical workers and community health workers, reflecting an imbalance in both societal and national priorities and funding that emphasizes medical services over social services (Campbell)
Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×
Workforce
  • Labor policy concerns with regard to employee versus independent contractor status and worker misclassification (Nagro)
  • Insufficient incentives or continuing education opportunities to make direct care a more worthwhile career (Parks, Rava, Torkelson)
  • Difficulty implementing policies at the state and federal level that would beneficially affect the workforce (Parks)

Research and Policy Priorities

The facilitated table discussions produced the following list of research and policy priorities to enhance and support the workforce, as noted by the table rapporteurs.

Areas for Additional Research
  • Study how value-based systems use direct-care and rehabilitation workers as part of larger care teams in order to understand the impacts on quality and cost of using a range of workers (Alkema)
  • Determine the optimal workforce roles and responsibilities, as opposed to job classification, needed to support independent living (Alkema)
  • Invest in the development and validation of standardized sets of robust and reliable competency measures and test them within service delivery models to evaluate their effect on clinical, financial, and person-reported quality-of-life outcomes (Campbell, Parks)
  • Study what long-term care and home- and community-based workers want from their jobs and use that information to determine what combination of training, career ladders, incentives, and engagement strategies are needed to recruit and retain more workers, particularly those with geriatric training, to meet the future demand (Campbell, Nagro, Rava, Torkelson)
  • Collect more data on who receives what types of training, what training means to those being trained and to those receiving care, and whether the public understands the different levels of training that various workers receive (Nagro)
  • Study different training models to determine which are most effective in developing workers who can play key roles in delivering appropriate, high-quality, patient-centered care (Nagro)
Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×
  • Develop a better understanding of who is providing geriatric care and to what extent they are providing it (Rava)
  • Determine the impact of workforce training on health outcomes and disseminate that information to the public in order to build support for training programs (Parks, Rava)
  • Determine the impact of new labor laws on the desirability of direct-care jobs (Rava)
  • Determine if there is an intersection between health and education policy, not only within caregiving and medical care but also across sectors (Torkelson)
  • Establish models for evaluating the workforces at the community level (Parks)
  • Evaluate state versus national approaches to increase the direct-care workforce (Parks)
  • Conduct research on integrating licensed and unlicensed health care support providers (Simon-Rusinowitz)
Policy Priorities
  • Develop policies, such as tax incentives, to support family and private caregivers (Parks)
  • Develop a long-term care profession shortage area designation building off HRSA’s existing health care shortage designations (Simon-Rusinowitz)
  • Align reimbursement with best practices and effectiveness (Nagro)

Best Practices

The facilitated table discussions produced the following list of best practices, as noted by the table rapporteurs.

Possible Approaches
  • Supporting family caregivers and ensure maximum community integration using methods such as those that have been developed by the children-with-special-needs community (Alkema)
  • Engaging community health workers who in turn can advocate for and empower individuals, such as programs like Promotores de Salud (Alkema)
  • Focusing on training direct-care workers and family caregivers, which the Center for Medicare & Medicaid Innovation is study-
Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
×
  • ing through demonstration projects in California and Washington (Nagro)

  • The Green House Project8 and hospice care models for team care (Nagro)
  • Building tools to help with decision making, for which the National Resource Center for Supported Decision-Making is funding grants (Nagro)
  • Developing and maintaining state registries of direct-care worker agencies (Rava)
  • Enabling collaborations between primary care and community-based organizations (Rava)

In addition to reporting the best practices suggested by people at the various tables, several of the rapporteurs also noted comments that had been made during the discussions at their tables. Montgomery said that the discussion at her table included a suggestion that more effort is needed to move best practices into mainstream operational protocols across the spectrum of public programs, including Medicaid and Medicare, so that they can be more fully evaluated and refined. The goal, she explained, would be to create an ongoing continuous improvement cycle. Alkema reported that the participants at her table discussed that the lack of payment models is particularly apparent for rehabilitation services. She said that the dialogue at her table also touched on the point that some speech therapists are not paid under a particular Medicare fee-for-service code, but occupational therapists are, even though there may be skills that each profession could bring to a particular situation. Nagro reported that the discussion at her table raised the point that clarifying the definitions of terms such as “direct-care workforce” would be helpful for policy makers. Simon-Rusinowitz suggested that it would be valuable to look for best practices identified by other health care occupations and determine if they can be adapted to the LTSS sector.

___________________

8 For more information, see http://www.thegreenhouseproject.org (accessed January 29, 2016).

Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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Suggested Citation:"4 Workforce Needs to Support Community Living." National Academies of Sciences, Engineering, and Medicine. 2016. Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/21893.
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 Policy and Research Needs to Maximize Independence and Support Community Living: Workshop Summary
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Living independently and participating in one’s community are priorities for many people. In many regions across the United States, there are programs that support and enable people with disabilities and older adults to live where they choose and with whom they choose and to participate fully in their communities. Tremendous progress has been made. However, in many cases, the programs themselves – and access to them – vary not only between states but also within states. Many programs are small, and even when they prove to be successful they are still not scaled up to meet the needs of the many people who would benefit from them. The challenges can include insufficient workforce, insufficient funding, and lack of evidence demonstrating effectiveness or value.

To get a better understanding of the policies needed to maximize independence and support community living and of the research needed to support implementation of those policies, the National Academies of Sciences, Engineering, and Medicine convened a public workshop in October 2015. Participants explored policies in place that promote independence and community living for older adults and people with physical disabilities, and identified policies and gaps in policies that can be barriers to independence and the research needed to support changing those policies. This report summarizes the presentations and discussions from the workshop.

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