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Study: Better work force planning needed
The Association of Academic Health Centers (AAHC) says that work force planning is rapidly becoming one of the most critically important functions that states need to address.
A new AAHC report found that states lack comprehensive and coordinated long-term planning for the health work force and thus are not prepared to address an emerging national health work force crisis.
AAHC assistant vice president for policy and program Denise Holmes tells State Health Watch that by 2014, there will be a need for 6 million new health care workers, with fully half of them needed to replace workers who will be retiring. "The current shortage in nursing gets all the attention," she says, "but shortages really are across the board."
And AAHC program associate Michal Cohen Moskowitz says some states operate from crisis to crisis, without a comprehensive long-term plan. "They are very reactive," she says, "and not very coordinated."
The report notes that states leverage much influence over development and practice of the health work force through education, financing, and regulation of health professionals. Thus, it says, state action is critical not only in resolving current shortages but also in producing and sustaining a work force for the future.
The AAHC study sought to determine the outcomes of state task forces established to address work force issues, explore current state activities, and examine the extent to which states are engaged in planning for the future. Ms. Holmes and Ms. Moskowitz studied eight representative states—California, Georgia, Maryland, Massachusetts, Montana, Nebraska, New York, and Texas. They selected the states to reflect diversity in geographic distribution, population size, and urban/rural distribution.
The analysts say their research was hampered by an initial difficulty in determining which, if any, agency in each state has responsibility for the health work force and which functions are delegated to various agencies and offices. "As these states generally lack a central coordinating mechanism to monitor and plan for the health work force, state decision-making for health work force issues is often splintered between several bodies," they explain.
Of the eight study states, only in Texas has the state health department developed comprehensive coordinated mechanisms for analyzing and addressing statewide, cross-professions work force issues. Montana has recently formed a group to perform similar functions.
Vital role for colleges, universities
The report says institutions of higher education play an indispensable role in nearly all aspects of health work force development, including outreach to elementary and secondary school students, education of health professionals, and work force data analysis. Historically, it says, states have been dedicated to educating and retaining residents to work within the state after graduation. Accordingly, state higher education authorities are leading health work force projects in seven profiled states. But only in California and Georgia have higher education systems or authorities produced comprehensive analyses of the state's health work force and developed strategic plans to align health professions education with the state's work force needs.
State labor and work force offices aggregate data and perform analyses on industry trends in employment, vacancies, and wages; producing short-term and long-term labor projections; disseminating career information to job seekers; and conducting job training programs.
A consistent report from state officials was that work force initiative success depends on direct support from their governor's office, but they said that activity and involvement from that office varies and it is often difficult to determine what priority the health work force has on a governor's agenda.
"Texas Gov. Rick Perry appears to be only one of the eight whose office houses a standing council dedicated to strategic health work force planning and monitoring," the report said. "The council, whose members include representatives from state agencies as well as higher education, identified nursing education as a major work force priority, and successfully influenced inclusion of $47 million in new funding for nursing education in the governor's 2008-2009 budget."
The report said other governors have authorized and supported significant health work force-related initiatives, mostly related to nursing and allied health professions.
Funding influences work force
Most state work force action can be traced in some way to state funding and legislative decision making. Higher education institutions receive major financial support from state budgets. Also, in many states, Medicaid provides significant financial support for graduate medical education programs. Because more states successfully retain physicians who completed their graduate medical education, rather than medical school education, in the state, support for graduate medical education may be critical for filling a state's physician work force needs. States also promote health profession education through their investment in elementary and secondary education, financing of scholarships, distribution of worker training funds, and public and rural health initiatives.
The analysts said budget crises and subsequent decreases in higher education funding hurt appropriations to colleges and universities at the beginning of this century. State budgets have been showing signs of recovery and state higher education appropriations have grown at faster rates in the 2005-2006 and 2006-2007 fiscal years. But even though state funding for medical education has more than doubled since the early 1980s, state appropriations have declined proportionally as a source of allopathic medical school revenue. While in the 1980s and 1990s many states were promoting an increase in the supply of physicians, many legislatures now appear to be focused on nursing, the report said.
State attention appears to be focused on the most visible issue of public or current concern. Thus, in the eight study states, nursing receives the greatest share of state action and analysis. All eight study states have implemented initiatives to address the nursing crisis. Significant attention also has been paid to the long-term care work force.
Specific state actions on nursing have included commissioning task forces and reports, establishing state nursing work force centers as central places to gather data and make policy recommendations, enacting legislation such as mandatory overtime protection and minimum hospital staffing ratios, funding faculty loan repayment, expanding educational capacity, and developing partnerships between schools and health care providers to educate more nurses and place them in jobs.
While other health care professions tend to be addressed piecemeal, there are indications that some state are seeing the need to develop a cross-professions perspective on work force capacity, particularly as shortages in pharmacy, allied health, and veterinary medicine attract increasing media coverage. Thus, Texas and Montana now have standing bodies dedicated to studying and advising the state on its entire health work force.
The report identifies five strategies and tactics states can employ to boost the health work force:
1. Data collection and analysis. Experts have emphasized the need for current, comprehensive data about the work force to address worker shortages. States vary tremendously in their health professions information systems. Examples of centers for work force data collection and analysis include state nursing centers, centers for health work force studies, and university centers.
2. Pipeline development. Pipeline development efforts can include marketing campaigns, elementary and secondary school outreach initiatives, and scholarships for students entering high-need professions. State recruitment tactics include health career web sites, K-12 outreach programs, and scholarships.
3. Retention. Efforts to improve health worker retention are considered essential to ensure continuity of the health work force. The vast majority of state-sponsored programs geared toward improving retention dealt with nurses, with some being created for allied health. Examples included career ladders, mandatory overtime, and minimum staffing ratios.
4. Licensure and credentialing. States have enacted regulatory changes that affect the supply and practice of health professionals. They include scope of practice changes and changes in licensure requirements.
5. Educational capacity building. Health professions require years of advanced education, meaning the health work force depends on a strong educational system capable of producing a sufficient supply of future professionals. Limited educational capacity can pose a major obstacle across the health professions. Strategies to increase supply through education and training include faculty scholarships and loan repayment, increasing educational capacity, and innovation in educational delivery.
Multiple complexities to address
The analysts conclude that states are facing current or looming shortages in health care workers stemming from multiple complex factors such as the aging population, changing educational and practice environments, and a limited pipeline of people entering health professions. AAHC says that several themes have emerged in states' activities over the last five years.
First, there is a lack of comprehensive planning. The report says that calls for cohesive, thorough health work force planning are evident in task force reports across all states. But despite these calls, many states still lack long-term planning.
Second, responsibility for the health work force often is divided between several bodies within states. While growing collaboration between state agencies in addressing work force problems is a positive sign and a signal of changing practices, many gaps still remain, the report says.
Next, the absence of leadership poses a major challenge to sustained work force initiatives and planning. Most of the eight study states lack a central leading body to set the state's health work force agenda. And many state work force initiatives have faced challenges in sustaining funding and have struggled to maintain visibility and prioritization of health work force issues among governors and legislatures.
Fourth, state activities have focused heavily on immediate crises, most recently nursing. Many states also have looked at developing and investing in the long-term care work force. It appears, the analysts said, that new cross-profession approaches to the health work force are emerging, which will enable states to look beyond current crises and addressed broader emerging trends and concerns.
Fifth, communication and collaboration among state health, education, and labor agencies is essential for developing cohesive policy and programs and in preventing duplication of efforts. The analysts said that while state officials usually noted collaboration and communication with other offices, it appears that much activity is still conducted in silos.
Finally, the eight profiled states have developed similar strategies and tactics to address health work force needs, including data collection, pipeline development, retention, licensure and credentialing, and educational capacity building.