Healthcare Quality Summit: Building the Health Care Workforce of the Future (Part 2 of 2)

Uploaded by USGOVHHS on 08.10.2010

bjbjLULU Complicated chronic illnesses that we have specialists taking care of, probably
even more of them today are spending their time on primary care. And so the combination
of specialists and nurse practitioners in PA, which is part of Buz s point, is really
a solution that could be highly effective as a health care home, even though as specialty
oriented, but we re not sort of thinking there because we have a lot of blinders on with
regard to all the innovations have to be in the so-called primary care specialties. Dr.
Marcia Brand: Thank you. I want to be mindful of our time and make sure we have an opportunity
for questions, and so I think five of my six panelists are currently academics or have
been and are very comfortable in front of a group, providing information. We need to
move just a little bit quicker, so I want to try to get to a few more questions that
we are hopeful to discuss today. Dr. Villarruel, one of the things we ve talked about is the
need for more providers and certainly increasing the diversity of the health care workforce
is the right thing to do, and something that we will need to do to have an adequate number
of providers, so what do you think the strategies are by population or by target group or by
profession that we might need to engage in? Dr. Antonia Villarruel: I think this topic
is pretty frustrating because I think it s one that there s the most agreement in across
professions, across populations that we need to increase diversity, but it s the one that
we have absolutely failed miserably. If you take a look across professions, you ll see
that we ve not made appreciable gains in increasing the representation of minorities in any particular
area. Part of the reason for that is in light of the programs that we have funded for that,
if not, again, don t good outcomes or they re not measured or we have processed outcomes
that are measured. And, again, that s for a lot of HRSA-related programs. I think across
the government, we don t have a good diversity strategy or hallmarks or, again, strategies
for which it happened, not only within HRSA, but across the federal government, with GME,
with the Department of Defense, and also with VA. We do know that there are, again, from
the anecdotal evidence, that there are some things that we are doing well. Certainly we
are getting minority individuals interested in health professions, so getting people to
apply has been good, but the issue is from places, admission all the way through graduation.
So we really need strategies on that particular area. One of the things that falls back on
the previous question is that one of the challenges in increasing diversity is that much of the
funding for diversity, like many health professions, is [unintelligible]. So you have parallel
programs in Title 7, in Title 8, primarily all health professions, when, again, they
could be maximized to increase, because a lot of the issues that minorities face in
schools are similar across. So some strategies, some anecdotal and anything what we know is
promising are, first of all, financial support for students, and I think anything that can
decrease the debt burden for minority students is important, so once on the loans and more
on the repayment plans, just the fact [unintelligible] repayment plan, such as the National Health
Service Corps, I think, are good strategies to be able to do that. I think we have to
be very clear about creating a pipeline for health professions education, and, again,
with multiple entry and also exit points. I support Linda s [unintelligible], for example,
that we should have BSN prepared nurses, but we need to able to figure out how to move
them through a pipeline quicker since baccalaureate education is not accessible to many of our
minority places. And then finally I think we need to have some institutional supports.
Those, I think, are tried and true recipes [spelled phonetically], but, again, I m pretty
comprehensive in terms of mentoring leadership development and against port to deal [spelled
phonetically] with some of the other social issues that are there. Dr. Marcia Brand: Doug
and Jack, are there others comments that you would like to add at this time? Jack Rowe:
I would support the view that teams don t all have to have to have the same numbers
and the same physicians. It s not like they re basketball teams; it has to be five on
every team, and it has to be centers and forwards. And so we should think flexibly. I don t think
they need to always be led by physicians by any means. I think that it s very much dependent
on patient population and the setting in which the care is being delivered, and I m not sure
there s anything new about it. I mean, I was -- I trained as a nephrologist at the Massachusetts
General Hospital. I was a member of the transplant team. Unthinkable that you d have one person
taking care of a transplant patient, no immunologist, kidney doctor, surgeon, so on and so on, social
worker, et cetera, nurse et cetera. So -- but I certainly agree that teams can be more
efficient and more effective and do a better job, but they only do it if they work together
rather than a situation where you re laying one discipline and activity on top of the
other. So it s got to be integrated teams rather than just groups of people. Dr. Marcia
Brand: Doug, are there any issues we should ve brought up and haven t stressed yet? Doug
Cropper: m going to go back to a comment that Buz made earlier, that we need to both work
on systems and supply. I ll give you a perspective on that. The comment was made earlier that
25 percent of all health care in the United States is delivered in a rural area, and like
I mentioned earlier, I oversee three different critical access hospitals. And the number
one challenge for a critical access hospital is specialty care and getting access to specialists,
not that there aren t specialists, even in our market, to deliver that care, but they
have no interest in going there. And why don t they have an interest in going there? Well,
because the markets -- the delivery system is so fragmented right now that our specialists,
for instance, are consolidated because of payer negotiations -- lead to one large group
of cardiologists, one large of oncologists, and one large group of orthopedists. And they
re busy enough, and because they re oriented towards their interest, they re not looking
at the population perspective or the broad systems perspective. And the answer is to
work on both supply and systems, just what Buz said. Because if you look at truly the
adoption of the accountable [spelled phonetically] care organization philosophy or will address
the redesign of care delivery and also the redesign of the payment mechanism and bring
people together and orient them towards caring for a population you address this already.
Because then what happens is I can say to the specialists, Well, we need you to work
in multiple different locations, and this is not necessarily going to hurt your income.
In fact, we can help your income because we ll get into shared savings model to care for
prime populations where we re spending maybe twice as much money as we need to. So you
only find the answer to all these issues as you address the whole system. You can t just
address a part of it. It s a huge issue. That s why if you really want to make a difference
in workforce, you have to go back to what we talked about earlier today and address
it from an accountable care organization standpoint and redesign the system and redesign the payment
model and address the supply and the other issues we re talking about. Dr. Marcia Brand:
Okay, thank you. Well, as you can see we have extraordinary group of folks with [unintelligible].
We have a little bit more time for questions, and so if you could stand, identify yourself
and your affiliation. [unintelligible] And I think they are trying to record everything,
so -- Maureen Kathlan [spelled phonetically]: Thank you so much. I really appreciate the
discussion today. I m Maureen Kathlan. I m from the American College of [unintelligible].
I just want to echo -- I really appreciate Dr. Cooper s comments, and that a lot of work
has been done by the advance practice nursing organizations of identifying barriers to practitioners
functioning up -- being able to practice up the full extent of their scope of practice.
So I think we ve talked a lot of it in a really good way about supply today, but it isn t
just supply. It s looking at on the federal and state level, what are those barriers to
practice that we need to bring down in order to let those practitioners provide the care
that s needed. So it isn t just a supply problem, and these issues have been identified, and
myself and other advanced practice nursing colleagues would be happy to provide that
information to policy makers to start working on those issues. Thank you. Dr. Marcia Brand:
Response? Dr. Antonia Villarruel: I think that s a fabulous point. That was really my
third point that I was trying to make in my introduction, but we still have, as you well
know, vestiges of defacto practice acts embedded in Medicare and Medicaid, and they should
all go. There s no reason for the federal government to be involved in the specification
of anything that has to do with the role of health providers, because that s a role that
belongs at the states. An example would be the supervision requirements for nursing anesthetists,
which now CMS is allowing governors to opt out of, and 17 states have opted out of them.
So if you wanted to cite one thing that should be like immediately eliminated is any payment
provision in Medicare and Medicaid that has anything to do with who can do what. There
s really no reason for it at all. We go through many others, but -- that would be a really
simple thing that the federal government can change right now. Dr. Marcia Brand: Thank
you. Next question. Male Speaker: Hi, good evening. My name is Byron [spelled phonetically].
I m with the National Medical Association, and there are multiple questions in my head,
but I m just going to ask one just because of time because people are standing behind
me. But I m very fascinated by this discussion about system change, and one thing that continues
to be a source of interest to me is that we have this echo chamber in health care where
we have these health care meetings and everybody in the room is in health care. So we don t
get enough input from people in other disciplines who are also consumers of the care, and as
you mention it -- both of you mentioned this, if we don t deal with systems problems, we
re not going to solve some of these problems. So my question is: how do we, for example
dealing with pipeline problem, work with education as a discipline to solve this problem, because
some of these byproduct problems cannot be solved at med school; we have to go all the
way back to high school and middle school, getting people -- kids interested in science,
and get people to graduate high school in some of these minority communities where we
re going to need minority occupants to get interested in the health professions. Where
are we building these exchanges? Where are building these alliances? Where are we building
this overlap, these interdisciplinary models where we can get everybody involved, and so
it won t be a massive societal problem? Male Speaker: Well, you know, it s interesting
that this is a federally sponsored conference, but right now the road is the NIH. The National
Cancer Institute undertook this -- I lost track of time -- probably in the 70s, let
s say, 1970s. The long-term goal of having the cancer center, which is an interdisciplinary
system of care, within the reach of 90 percent of the population, easy reach, and I believe
that s been achieved. So, yes, I think -- I would look to the cancer model as a model
of systems of care. So now we re talking about systems that relate to disease and [unintelligible]
relate to the turf and the state prerogatives and so forth. But it s that kind of -- and
even with that, we have lots of very [unintelligible] oncology practices, much like primary care
practices that persist. But I think the systems approach, there are models, and in my experience,
that probably is the best. Dr. Marie Bernard: As an NIHer [spelled phonetically] -- [laughter]
-- [unintelligible], and would say, yes, there s been quite a bit of outreach from
NIH at the elementary, middle school, high school level and on, and very active programs
to bring people onto campus to learn more about science and to be inspired, programs
to teach teachers, so that they can go back out to the community. We were particularly
[unintelligible] for that with the American Recovery and Reinvestment Act, an extra investment
that we can make along those lines. And thank you for the question, because it allowed me
to bring in another point that I wanted to make, that as we think about what needs to
be done to enhance the future health care workforce, we cannot forget that there need
to be people who are the experts who are generating more knowledge, because we do not know everything.
We do know that there are a number of models of care out there that aren t well disseminated,
and we need to get those disseminated and implemented, but there are still gaps with
regards to care as well. We re discovering that needs to be done and more teaching that
needs to be done to teach the teachers to then help develop our future health care workforce.
Dr. Marcia Brand: Next question. Roland Goertz: m Roland Goertz. I m president of the American
Academy of Family Physicians. I have attended other workforce conferences, and I have to
say that one of the things that is very unfortunate about them is they all sort of degrade themselves
into members of the panels or others promoting their individual background or their individual
piece of the system, and that s happened today again. I would challenge you that if that
s all we care about, we will miss the point entirely. Because what s missing in our system,
our very expensive system, is there s not a defined way to coordinate care well. That
s what s missing it s not the pieces. We can train more nurse practitioners, more PAs,
more social workers, more primary care doctors, more [unintelligible], more geriatricians.
If we don t coordinate their care, if we don t have that care worked together and focus
on the patient, we re kidding ourselves. We re just promoting our own background. And
that s what needs to happen. My question really is related to this. As the rush to fill this
void occurs, Buz what you re talking about is the old system. That s the old model of
education. That s the old model of care delivery. I sat next to an intel person who basically
says in other countries they get the same amount of work done using modern tools and
technology with half the workforce. We haven t seen technology apply itself to process
of care in this country in any way shape or fashion to coordinate care. In some way that
has to happen. Now, in the rush of it, how are we going to maintain competency of all
of the different elements that are sitting up here to make sure that we don t harm the
public because I have a belief that policy makers believe some care is better than no
care, and I have plenty of anecdotal stories to show that that s not true. So how are we
going to maintain competency levels? I mean, I -- nurse practitioners, or PAs, or physicians
of whoever else is in the pipeline as the rush to fill this void occurs. Dr. Jack Rowe:
I think that there has been a very substantial effort to try to coordinate care, and I don
t think it s right to indicate that there hasn t, although maybe you haven t heard it
today. But I think the whole idea of the medical home is an effort to coordinate care in a
patient-centered way. And that s my understanding of the definition. I -- Roland Goertz: I can
tell you the definition because I -- we helped create it [spelled phonetically]. And that
s imitation is the purest form of flattery, but it was an attempt by primary care physicians
to fix the -- to change themselves. It -- you wouldn t hire me to change urology. You
wouldn t hire me to change nurse practitioners. You wouldn t hire me to change anyone else
up there. It was the four primary care medical physician specialties trying to change themselves.
Dr. Jack Rowe: All right, I m withdrawing that comment -- [laughter] -- let me try another
one. I may be just as wrong as this one. I think that the effort in the Affordable Care
Act to bundle payments to pay for episodes of care, the first one being after [unintelligible]
coordination of care in the first 30 days after hospitalization, pay a global payment,
that will force some interaction, coordination, is an example of an attempt to begin to coordinate
care as well. I think also the accountable care organizations, and I may have this wrong
as well, are attempting to define things in an integrated and coordinated way so that
they take responsibility for the beginning to the end of the care. I think that that
-- those changes, if they re underway, or those efforts that are underway are important,
but it doesn t mean training more expert nurses or social workers isn t important. What we
want to do is train people who have the competence to take care of the needs of the future patients
in an evolving health care system. The coordination is part of the evolution, but if the individuals
don t have the competence, then the system won t have the competence regardless of how
well it s organized and coordinated. So I think there s both those things. [low audio]
Dr. Marcia Brand: Next question. Male Speaker: The coast is clear, sir. Male Speaker: Bob
[unintelligible], American Academy of Physician Assistants, and thank you for the report of
this panel and thank you all for being here. I m going to be helping to lead a task force
in our profession to help figure out how to sort of expand our ranks a bit and to do it
competently, make sure the PAs are competently trained. And we re dealing with three main
obstacles to expansion. One is diversity of the health workforce. We have been backsliding
in our profession in terms of our racial and ethnic diversity, and we re going to be working
through that. But we ve talked a little bit about that already. The second thing is going
to be clinical training sites to have learners have a place where they can learn. And the
third point is going to be distribution of those clinicians after they come out, geographically,
and then specialties, things like that. [unintelligible] folks are just the one part and that is about
sites for people to learn. And maybe, Doug, you might have the most insight because we
re having a hard time finding training sites. I look at Philadelphia, for example. There
s four PA programs, several medical schools, several MD and nurse programs all competing
for the same really relatively rare training sites. And any insights on that would be helpful.
Doug Cropper: Well, I think that is a tremendously difficult issue. You know, the question was
asked earlier, what can we do in relationship to education, and I started out my recommendations
saying we need more partnerships. And when I lived here in the Washington, D.C. area,
we set up two partnerships with VCU, between VCU and INOVA. One was the first branch campus
medical school in Northern Virginia, and the second was a pharmacy school. And it was only
through the partnership that we were able to meet the needs of both organizations and
both [unintelligible]. Now, when I moved to Iowa, we pulled together all the nursing programs
in the area, and we said to them, What s your biggest challenge? Because we said, Our biggest
challenge is you re not producing enough supply. And they said, Well, our biggest challenge
is, you know, rotations and faculty. And we said, Well, we have to work together then.
I have no interest in getting into business of education of health care professionals
because we re not good at it. We re very good at delivery. However, we can partner with
the educational professionals to produce a better relationship that meets the needs of
both, and it s not easy, but it can be bad. When I was at INOVA we tripled with Karen
Grantner who s now the head of Magnet, we tripled the number of locations for nurses
to come in and do their trainingship in hospitals, and we did that by getting really creative
about it. Some was in the evening, some was on the weekends, and it was in all different
ways in order to do that. But the only way you can make that happen is if everybody has
skin in the game. If I sit across from somebody and I make a promise to them and they make
a promise to me that neither of us is going to break, then you can change the world. So.
Dr. Antonia Villarruel: So the issue you bring up is a real important one, and I think is
one comment across disciplines and we certainly had those issues in finding placements for
our advanced practice nurses. And again, just as we re saying there s practice issues barriers
at a state level, we ve found them within our own health systems in terms of finding
sites for nurse practitioners. What has been successful for us and then we re trying to
replicate these models again the whole notion of partnerships, but rather than, you know,
two weeks here, four weeks here, we re really looking at embedding some of our clinical
faculty in practice sites so again it s a win-win situation for both of us. And again,
the health system gives -- and again it s not just our own health system but other health
systems are anxious to partner with us as well because again it provides what they need,
continuity of care, and again development of their own staff as well as providing practice
sites for us. Dr. Marcia Brand: Thank you, [unintelligible]. Last two questions. Donna
Kollanker: My name is Donna Kollanker [spelled phonetically]. I m with the Service Employees
International Union, and we represent 1.1 million health care workers in public and
private settings, and I want to start by actually thanking Dr. Bernard for mentioning -- well,
for raising the issue that there s work, often, in a team that multiple people are doing or
can do, and we do have a lot of, you know, something we get from our members is a desire
to be able to work up to their license, which isn t always a process in the way our medical
system s structured now. And expanding on that, is there actually a way that we can
think about that for those patients who are using at-home and community-based services
who are -- long-term services, is there a way to bring those providers into the team
to perhaps provide the training that they can be a part of that primary care team and
perhaps prevent more unnecessary complications? Dr. Marie Bernard: ll begin to address that
and Jack may want to comment as well. One of the primary recommendations from the Retooling
for an Aging America IOM Report from 2008 was exactly what you re asking about, that
there be opportunities for direct care workers and others to move up the ladder, and that
we look at what various members of the team are doing, what their responsibilities are,
what sorts of things can be delegated to others if appropriately trained. That will allow
people who are direct care workers or CNAs or whatever to potentially move up the ladder.
It would allow the nurse, nurse practitioner, physician assistant, physician to delegate
some other responsibilities and it would then allow all members of the team to be more efficient
in the way that care is provided. And it truly was with the expectation that you are interacting
as a team. I think it may have been in the previous session that was here, there was
discussion about the fact that on the team sometimes it s the CNA who has the most important
information about what is going on with the patient and if you re really working as a
team you re being cognizant of that and recognizing that that CNA really has the lead of that
time. Or the nurse has the lead, or the social worker depending on the patient s needs. So,
you know, that s all in keeping with our view of what needs to be done that requires, however,
changes in regulations at the state level and at the federal level. Dr. Jack Rowe: I
would, to be very brief, Steve is going to speak next
so we re going to hear something very smart in about thirty seconds. I want to give you time, this is really important,
I mean, really important -- urn:schemas-microsoft-com:office:smarttags State urn:schemas-microsoft-com:office:smarttags
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PlaceName urn:schemas-microsoft-com:office:smarttags PlaceType urn:schemas-microsoft-com:office:smarttags
place Complicated chronic illnesses that
we have specialists taking care
of, probably even more of them today are spending their time on primary care bhurtt
bhurtt Microsoft Office Word HHSTV Complicated chronic illnesses that we have specialists
taking care of, probably even more of them today are spending their time on primary care
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