ARIZONAHEALTHWORKFORCEDEMANDINARAPIDLYCHANGINGMARKET:

PERSPECTIVESOFSTATELEADERS

June22,2016Preparedby:LiselBlashJoanneSpetz,PhDUniversityofCalifornia,SanFrancisco3333CaliforniaStreet,Suite265SanFrancisco,CA94118ThisstudyissupportedbyVitalystHealthFoundationofArizonaandtheCityofPhoenix.AnyviewspresentedinthisreportdonotnecessarilyreflecttheopinionsorpositionsofVitalystHealthFoundationortheCityofPhoenix.

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EXECUTIVESUMMARY

TheimplementationoftheAffordableCareActinArizonarapidlybroughtaboutnoticeableincreasesintheshareofArizonanswithhealthinsurance.This,inconjunctionwithcontinueddemographicchanges,hasledtogrowthinthedemandforhealthcareservices,causingpolicymakers,healthcaredeliveryorganizations,andeducatorstobeconcernedabouttheadequacyofthecurrentandfuturehealthworkforceofthestate.Avarietyofchangeshavebeenmadetohealthcaredelivery,bothattheorganizationallevelandatthestatewidepolicyleveltoaddressthesedevelopments.ThisreportpresentsfindingsfrominterviewswithhealthcareleadersacrossArizonaaboutthetrendstheyareobservingandtheirexpectationsforfuturehealthworkforceneeds.

Methods

Weconductedinterviewswith16healthcareleaderstolearntheirplansandprojectionsabouthowhealthcaredeliveryischangingandimpactingworkerneeds.

SummaryofFindings

1. TheformationofAccountableCareOrganizationsandestablishmentofvalue-basedpurchasingareacceleratinganddrivingafocusonpopulationhealth,integratinginformationsystems,andquality-basedpayments.However,mergersandshiftingcoveragealsocausedisruptionforpatientsandhealthcareworkersalike.

2. Thereisaheightenedfocusonpreventionandwellness,andonbringingcareoutofthehospitalandintocommunitysettings.Thisincludestheplacementofphysicalfacilities,suchasclinicsandstandaloneemergencycenters;thedeploymentofworkerstohomelocations,especiallyinlong-termcareandcommunityhealthoutreach;theuseoftechnologytoenhanceremotemonitoringandcommunicationacrossdistances;andgreaterpatientengagementinself-managementofchronicdiseases.

3. Anemphasisonpatient-centeredcare(“consumerism”)andpatientexperience,aswellastheneedforpatientself-management,isleadingtoincreasedeffortsatpatientengagement.Thisrequiresthathealthcareworkersimprovetheircustomerserviceandcriticalthinkingskills,aswellasculturalcompetencytraining.Patientnavigatorsandcarecoordinatorsmaybeneededinincreasingnumbers.

4. Theintegrationofbehavioralhealthandprimarycareisacceleratingbuttheinformationsystems,reimbursementmethods,andlicensingthatwouldfacilitatethischangearecurrentlyinadequate.Providersandnursesneedcross-traininginbehavioralhealthandprimarycareinordertoworkinintegratedmodels.

5. Healthinformationtechnologies,especiallyelectronichealthrecords,arecommonintheworkplace.Remotetechnologiessuchastelehealthandremotemonitoringsystemsshowgreatpotentialforexpandingaccesstocare,especiallyinruralareas,buttheyarenotyetwidespreadduetolackofreimbursement.Staff,providersandpatientsallneedfurthereducationintheuseofnewtechnologies,andincumbentstaffneedtraininginbetterdocumentationanddrawdownofdatatouseinformationsystemstotheirfullestcapacityinpopulationmanagement.

6. Newmodelsofcarearebeingpiloted,suchascommunityparamedicine,team-basedcare,primarycareandbehavioralhealthintegration.Newrolesarealsoemerging,includingthe

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increaseduseofcommunityhealthworkers,dentalhealthaidetherapists,andpotentiallyclinicalscribes.

7. Changesneedtobemadetohealthcareeducationtomeetthechangingneedsofthefield.a. Graduates,particularlyproviders,needtounderstandhealthcarereimbursement,

healthsystemorganization,populationhealth,andthebasictenetsofpatient-centeredcare.

b. Growingdependenceoninformationtechnologymayrequiremoregraduateswithskillsindataanalytics,computersystemmanagement,andsetupandmaintenanceofhardwaresystemsandsecurity.

c. Adiminishedsupplyofclinicalplacementsnecessaryforstudentandnewgraduatetraininghasinspirededucationorganizationstousetechnologytocoordinateplacementsandprovideclinicalsimulationexperiencesforarangeofprofessions.

d. Theexpandedemphasisonprimarycarehasincreaseddemandforandexpectationsofmedicalassistants,butintervieweesindicatedthatexistingprogramsformedicalassistantsdonotprovidesufficienttrainingforemploymentinnewrolesandmodelsofcare.

e. Newrolesmaynecessitatenewdegreeprograms,includingthosewithaninterprofessionalfocustomeetchangesinthefield.

8. Regulatorychangescanfacilitatebetteruseofthehealthcareworkforce.Theseinclude:a. Statewidecertificationofcommunityhealthworkersb. Credentialingofmedicalinterpretersc. Expandedscopeofpracticefordentalhygienists,nursepractitionersd. Streamlinedrulepackagesforprimarycareandbehavioralhealthtoenhance

integratione. Streamlinedlicensureprocessestodecreasecycletimeforhiringout-of-statephysiciansf. Increasingandenhancingthestateloanrepaymentprogram

Conclusions

Ashealthsystemtransformationcontinues,acombinationofregulatory,education,andtrainingchangeswillbenecessarytofacilitatenewmodelsofcareandaddresschangingdemographics.Thereareshortagesormaldistributioninsomeoccupations,particularlybehavioralhealthproviders,nurses,andsomemedicalproviders,especiallyinruralareas.Newoccupationsaredevelopingthatwillrequirenewcredentialsandtrainingprograms,whileexistingoccupationsarechangingasalliedhealthworkerstakeonincreasedresponsibilitythatwillrequiremoreadvancedtraining.Mostoccupationsnowrequireskillsincaremanagement,patientengagement,newtechnology,andteam-basedcare.Employersandeducatorswillneedtobothexpandtheireducationprogramsintheseareasandreassessthecurricularcontentoftheirprogramstoensureanadequatelysizedandskilledworkforceinthefuture.

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TABLEOFCONTENTS

EXECUTIVESUMMARY.................................................................................................................................2Methods..........................................................................................................................................2SummaryofFindings........................................................................................................................2Conclusions......................................................................................................................................3VisualSummary...............................................................................................................................4

BACKGROUND:HEALTHWORKERDEMANDINARIZONA............................................................................6

FINDINGS......................................................................................................................................................9Driversofchange.............................................................................................................................9Newmodelsofcare........................................................................................................................10Impactofchangesinthehealthcaresystemonthehealthcareworkforce....................................12Changesneededtoensureanadequatehealthcareworkforce......................................................14Interviewees’topthreepriorities...................................................................................................18

CONCLUSIONS............................................................................................................................................19

ACKNOWLEDGEMENTS..............................................................................................................................20

APPENDIX...................................................................................................................................................21

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BACKGROUND:HEALTHWORKERDEMANDINARIZONA

Arizona,alongwiththerestofthenation,experiencedadeepeconomicrecessionstartinginDecember2007andasloweconomicrecoverysincemid-2009.Whilethestate’seconomyhasbeenrecovering,therehavebeensignificantchangesinhealthcarefinancinganddelivery.ThestaterestoredandexpandedMedicaidcoverage,andtheimplementationoftheAffordableCareAct(ACA)of2010expandedprivatehealthinsuranceaccesstothousandsinthestate.TheACAcontainsprovisionsthatarespurringanincreasedemphasisontheintegrationofcare,providinghigh-valuecare,andconsideringpopulationhealthbroadly.Inaddition,Arizonafacesanagingpopulation,withincreasingratesofchronicconditionsanddisabilities.1

Thesefactorsaredrivingdemandforhealthcareworkersacrossthestate.Overthepastdecade,employmentgrewinallthehealthoccupationsinArizona,from75,490in2004to135,070in2013.2Shortagesofmanyhealthworkershavebeenreportedinrecentyears,includingforphysicians,andsurveyresearchhasrevealedthatphysiciansarethemostdifficulthealthprofessionaltorecruit,followedbynursepractitionersandphysicianassistants.3LicensednurseshortagesalsoareasignificantconcernforArizona,withprojectionsthatArizonawillneed87,200registerednurses(RNs)by2025,butsupplywillbeonly59,100RNs,producingashortfallof32percent.BureauofHealthWorkforce(BHW)alsoforecastsashortfallof9,590licensedpracticalnurses(LPNs),whichisabout50percentofanticipateddemand.4

Otherhealthcareoccupationsalsoarefacingsubstantialgrowthindemand.About47,000newjobsareexpectedinthealliedhealthprofessionsbetween2013and2020,withthegreatestgrowthprojectedforpersonalcareaides,medicalrecordsandhealthinformationtechnicians,emergencymedicaltechniciansandparamedics,medicalandhealthservicesmanagers,medicalassistants,andpharmacytechnicians.TheAffordableCareAct’sprovisionsalsoareexpectedtospurgrowthinemergingoccupations,suchasexpandedfunctiondentalassistants,communitydentalhealthcoordinators,healthandtransitioncoaches,communityhealthworkers,andintegratedcarecasemanagers.5

ThechallengeofmeetinganticipateddemandforhealthcareworkersismademorecomplexbythesignificantgeographicvariationfoundinArizona.ThestatehasoneofthelargestmetropolitanareasintheUnitedStatesandsomeofthemostruralareasinthecountry.6Thenumbersofphysicians,

1Borns,Kristin,andVanPelt,Kim.HealthWorkforce,HealthyEconomy.ArizonaHealthFuturesPolicyPrimer,December2014.2DatafromtheArizonaDepartmentofAdministration,reportedinIrvine,Jane,andWilliamG.Johnson,AlliedHealthNeedsAssessment.Phoenix,AZ:MaricopaCommunityColleges.May14,2015.3Tabor,Joe,NickJennings,LindsayKohler,BillDegnan,HowardEng,DougCampos-Outcalt,andDanDerksen.ArizonaCenterforRuralHealth2015SupplyandDemandStudyofArizonaHealthPractitionersandProfessionals.Tucson,AZ:UniversityofArizona.February2016.4BureauofHealthWorkforce,HealthResourcesandServicesAdministration,U.S.DepartmentofHealthandHumanServices.TheFutureoftheNursingWorkforce:NationalandState-LevelProjections,2012-2025.Rockville,MD:U.S.DepartmentofHealthandHumanServices.December2014.5Irvine,Jane,andWilliamG.Johnson,AlliedHealthNeedsAssessment.Phoenix,AZ:MaricopaCommunityColleges.May14,2015.6Borns,Kristin,andVanPelt,Kim.HealthWorkforce,HealthyEconomy.ArizonaHealthFuturesPolicyPrimer,December2014.

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physicianassistants,nursepractitioners,RNs,andpharmacistsper100,000populationaresubstantiallyhigherinurbansettingsofArizonathanruralsettings.7

TounderstandtheimpactofArizona’sagingpopulation,growinginsurancecoverage,andchangingdeliverysystemoncurrentandfutureneedsforhealthcareworkers,theVitalystHealthFoundationandtheCityofPhoenixcommissionedtheUniversityofCalifornia,SanFrancisco(UCSF),toconductastudyofcurrentandfuturehealthworkforceneedsinthestate.Thefirstphraseofthisstudyinvolvedsurveysofhospitals,communityhealthcenters,long-termcarefacilities,andhomehealthagenciesinArizona.Thesecondphaseofthissurvey,whichisthefocusofthisreport,involvedconductinginterviewswith16stateleadersregardingtheworkforcepressuresfacedbytheirorganization,theirperceptionsofemploymentandeducationneeds,andtheirexpectationsforthefuture.

7Tabor,Joe,NickJennings,LindsayKohler,BillDegnan,HowardEng,DougCampos-Outcalt,andDanDerksen.ArizonaCenterforRuralHealth2015SupplyandDemandStudyofArizonaHealthPractitionersandProfessionals.Tucson,AZ:UniversityofArizona.February2016.

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METHODS

ASteeringCommitteewasconvenedtoguidethisresearch.Wedevelopedalistofcategoriesofhealthcareworkforceleadersandexperts,suchasclinicleaders,healthsystemleaders,educators,andstategovernmentofficials,anddevelopedalistofpotentialintervieweeswithineachcategory.TheSteeringCommitteeandresearchteamcollaboratedtoprioritizeinvitationsanddevelopinterviewquestions.

AfterobtainingapprovalfromtheUCSFCommitteeonHumanResearch(UCSF’sInstitutionalReviewBoard),emailinvitationsweresentto20individualsbetweenMarch22andApril28,2016.Weconductedsemi-structuredinterviewswith16peopletolearntheirperceptionsofchangesinthestate’shealthcaredeliverysystem,howthesechangeswillaffectworkforceemploymentandtraining,andtheirorganization’splanstoadapttotherapidly-changingenvironment.Allinterviewswereattheexecutivelevel,werevoluntary,andfollowedtheguidelinesoutlinedbytheCommitteeonHumanResearch.

Sixoftheintervieweeswererepresentativesofstatewideassociationsrepresentingbehavioralhealth,long-termcarefacilities,hospitals,humanresourcesdirectors,NativeAmericantribes,andnurses.Interviewswereconductedwithleadersfromtwocommunityhealthcenters,twohomehealthagencies,onelong-termcarefacility,andonelargehealthcaresystem.ThreeinterviewswereconductedwithrepresentativesofArizona’shighereducationinstitutions,andoneinterviewwasconductedwitharepresentativeofstategovernment.

Interviewquestionsweresemi-structuredandfocusedonhowtheintervieweethoughtchangesinhealthcaredelivery,technology,education,skills,reimbursement,regulation,impactofnewlyinsured,andjobturnoverwouldimpactthefuturehealthcareworkforceinArizona.AppendixAliststheinterviewquestionsthatservedasaguideforeachinterview.Questionsweremodifieddependinguponexpertiseoftheinterviewee.

InterviewnoteswereanalyzedtoidentifykeythemesdescribingchangesinhealthcaredeliveryinArizona,andhowthesechangesareimpactinghealthworkforceneeds.Challengesfacedbyintervieweeswereexamined,aswererecommendedsolutions.

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FINDINGS

Driversofchange

IntervieweesidentifiedmultiplefactorsthataredrivingchangesinhealthcaredeliveryinArizona.ThereboundingeconomyandtheimplementationoftheAffordableCareAct(ACA)withtheMedicaidrestoration/expansionin2013broughtaboutadramaticincreaseininsurancecoverageandasurgeindemandforhealthcareservicesinArizona.However,thestateisfacingshortagesofmedical,dental,andmentalhealthproviders,whichhavebeenexacerbatedbycutsduringtherecessionof2007-2009,particularlyinruralareas.

ThemandatesoftheAffordableCareAct(ACA)areleadingtoanemphasisonpopulation-basedandprevention-orientedcare.Relatedchangesinreimbursementmodelsthatrewardqualityratherthanvolume-basedincentivesarepushinghealthcareorganizationstoproducemeasurablequalityimprovements—andtomakemoreeffectiveuseoftechnologytotrackandcompilethesemeasures.However,newpaymentmodelsarestillinearlystagesandnotwidespread.

Healthinformationtechnology(HIT)implementationrequirementsestablishedbytheFederalgovernment,aswellasfinancialincentivesformeaningfuluseofHIT,aredrivingthedevelopmentofnewcomputerandphonesystems,especiallyinfederally-qualifiedhealthcenters(FQHCs).Thewidespreaduseofelectronichealthrecords(EHRs)bothfacilitatesandhinderscareaccordingtointerviewees.Itcanenhancetheabilityoforganizationstotrackoutcomes,sharedata,anddelegatetasks,butitalsoconfoundsinterpersonalinteractionsbetweenpatientsandclinicians.Moreadvancedtechnologiesliketelehealthandhomemonitoringholdpromisetoimproveaccessandqualityofpatient-providerinteractions,butreimbursementandtrainingchallengeshavethusfarprecludedtheirwidespreadadoption.Whiletechnologyiscitedasapotentialfacilitatorinpatientcare,thebenefitsareyettobefullyrealizedformostorganizations.

Inaddition,theACAincludedreauthorizationofandupdatestotheIndianHealthCareImprovementAct,whichallowedIndianHealthServices(IHS)toparticipateinthehealthcarereform,helpedmodernizesystems,andledtoanincreaseinthirdpartyrevenuestoIHShospitalsandclinics.ThesefactorsareincreasingthedemandforcareservicesamongtheNativeAmericanpopulation,andprovidingmoreresourcestoIHSfacilities.

FactorsdrivingchangeatthestatelevelincludethetransferofBehavioralHealthservicesoutoftheDepartmentofHealthServicesandintotheAHCCCS(ArizonaHealthCareCostContainmentSystem),Arizona’sMedicaidmanagedcaresystem.There-institutionofKidsCare(CHIP)inArizona,whichwillstartonSeptember1,2016afterasix-yearfreeze,alsohelpedincreaseaccessto,anddemandfor,care.

Demographicfactorsarealsoplayingapartindrivingchange,includinganagingpatientpopulation,withanincreaseinchronicdiseaseandcōmorbidities,aswellasanaginghealthcareworkforce.Theneedtoaddressbehavioralhealthissuessuchassubstanceabuse,dementiaandAlzheimer’sdiseaseinconjunctionwithprimarycareisalsochanginghowcareisdeliveredandorganized.Thelargenumberofveteransinthestatehasincreasedtheneedforappropriatebehavioralhealthservices,andmaybeafactorbehindtherelativeyouthofthelong-termcarepopulation.Finally,anincreaseinthenumberof

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single,childlessadultsinthelong-termcarepopulationwillrequirechangesinworkforcecompositionandcompensationasthesectorrelieslessonadultchildrentoprovidecare.

Despitetheincreasesinhealthinsurancecoverage,ArizonahasmanyundocumentedresidentswhoarenotcoveredbytheACAorMedicaidexpansion.Inaddition,manyproviders,especiallydentalproviders,willnotacceptMedicaidbeneficiaries,providingfurtherchallengestoaccessingcare.

Newmodelsofcare

Manyhealthcareorganizations,particularlyinthePhoenixarea,areformingaccountablecareorganizations(ACOs).Banner,Dignity,andHonorHealthwerementionedasimportantplayersmakingtheshiftfromfee-for-servicereimbursementtovalue-basedreimbursement,witharelatedfocusonpopulationhealth.HospitalsystemshavepurchasedprimarycarepracticesinanefforttomeetACOrequirementsandalsoacquiredsmallerhospitals.SomeFQHCsarealsomovingtopartnerwithACOsandhospitals.Thishasoccurredatthesametimeasthebuyoutofinsurancecompaniesbyothercompanies,resultinginshiftinginsuranceforpatients.

Someorganizationsarestartingtoimplementteam-basedcareandpatient-centeredmedicalhomes.Thisrequiresthatprimarycarestaffinparticularworkininterdisciplinaryteamsoftenmadeupofphysiciansandotherproviders,includingnurses,medicalassistants,nursingassistants,behavioralhealthproviders,andothers.

Largehealthcareorganizationshaveestablishedmoreurgentcareclinicsandfree-standingemergencydepartmentsinabidtokeepindividualsoutofthehospitalemergencyrooms.Free-standingemergencyroomsareafairlynewdevelopmentandareopenaroundtheclock,althoughpatientswouldneedtobetransferredtoahospitalforsurgeryandovernightstays.

Manyhealthcareorganizationsareworkingtowardsgreaterintegrationofmentalandphysicalhealthcare.AlargeshareofFQHCshavedonesoforsometime,utilizingstafflikesocialworkerstohelpwithdepressionscreeningandaidingpatientsinself-managementofchronicconditions.ThestatehasaCDCgranttodevelopintegratedsystemsofcareanddevelopself-managementtoolsforcommunityclinics.Atthestatelevel,RegionalBehavioralHealthAuthorities(RHBAs)havebeencontractedtodevelop“healthhomes”thatintegratebehavioralandphysicalhealthforthosewithseriousmentalillnesses(SMIs).Undertheseplans,adultMedicaidbeneficiarieswithSMIscanreceivecoordinated,integratedphysicalandbehavioralhealthcareservicesunderoneplanandinoneplace.BehavioralhealthorganizationsservingthosewithSMIsaretakingonprimarycareprovisionandapplyingtobecomeFQHCs.However,licensure,Medicaidreimbursementissuesandotherdifferencesbetweentheinformationandbillingsystemsestablishedforbehavioralandphysicalhealthchallengethisintegrationatmanyorganizations,andreportedsalarydifferentialsbetweenphysicalandbehavioralhealthstaffgeneratefurthercomplications.

Oralhealthcontinuestobeanareainwhichashortageofprovidersandlackofaccesstoservicesplaguelow-incomecommunitiesandthoselivinginruralareas.Arizona’sMedicaidagency–theArizonaHealthCareCostContainmentSystem(AHCCCS)–doesnotgenerallycoverthecostofadultdentalcareexceptforpatientsoftheArizonaLongTermCareSystem(ALTCS)orincasesofemergency,although

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children’sdentalservicesarecovered.ManydentistsreportedlywillnotworkwithAHCCCSduetolowMedicaidreimbursementrates.Thishasprovokedhealthcareorganizationstolookatcross-trainingotherphysicalcareproviderstodobasicoralhealthscreenings,andtoexperimentwithalternativestaffingsuchasdentalhealthaidetherapistsonreservationsorextendedscopefordentalhygienists,aswellasteledentistrytoincreaseaccessinremoteareas.

Overall,intervieweescitedashifttowardsa“CultureofHealth”withagreaterfocusonhealththanhealthcare,andanefforttobringhealthcareservicesintothecommunityandthehome.Thistrendincludeshome-basedcareforaginginplace,agreateremphasisonself-managementforpatientswithchronicdiseases,morehealthpromotionandwellnessactivities,andanincreasedrolefortelehealthtoallowpatientstomonitorconditionsandsharehealthinformationwithcliniciansfromhome.

Theroleoftechnology

Technologyinnovationsarebeingexploredbyhealthcareorganizationsaspotentialsolutionstosomeofthechallengesassociatedwiththestate’sdistributionofhealthcareworkersandprovidershortages.Anumberofthoseintervieweddiscussedthepotentialoftelehealth,particularlyinruralareaswherepatientsmaybeisolatedandhomehealthvisitsrequirehoursofdrivingtime.Oneintervieweeobservedthatasinglenursecanmonitor40to50long-termcarepatientsusingtelehealthtechnology.However,thecostlytechnologyandlackofreimbursementarechallengestofullimplementation.Homehealthmonitoringalsoholdspromise,especiallyinruralareasandforthosewithlong-termcareneeds.Thistechnologycouldpotentiallyenhancepatientengagementinmonitoringtheirownhealthconditionsandreportingbacktoproviderswithoutleavingtheirhomes.ThechallengeisinvalidatingthehomehealthtechnologyandintegratingitwiththeEHR,aswellastrainingstaffandpatientstouseitproperly.

Oneparticularchallengetobetterleveragingtechnologyfornewmodelsofcarehastodowithsharinghealthinformationacrossphysicalandbehavioralhealthsystemsasorganizationsmovetointegratethesetwoaspectsofhealth.Tacklingfederalrequirementsaroundbillingandservicedelivery,anddevelopingandmanagingITsystemsthatcanhandlethisintegration,willrequiremoresophisticationfromstaff.

Finally,technologycanhelpimproveaccountability,particularlyforstaffthatmeetwithpatientsintheirownhomesorinthefield,byensuringthatstaffencounterswithpatientsarerecordedwiththetimeofarrival,servicesprovided,anddurationofvisit.

Ruralregions

Shortagesofhealthcareworkerswerereportedtobemorecommoninruralareas,andskilledstaffandprovidersarehardertorecruitandretainintheseareas.Recruitingphysiciansisparticularlydifficult,especiallysurgeons,andorganizationsfindthattheyalsosometimesneedtofindemploymentforspousesinordertorecruit.Loanrepaymentprogramswerecitedasonetoolforrecruitment,althoughthereisreportedlynotenoughmoneyinthestate-supportedprogram.Behavioralhealthpractitionershaverecentlybeenincludedaseligibleforloanrepaymentprogramspartiallydueshortagesoftheseprovidersinruralareas.

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Intervieweesdiscusseddeployingnewtypesofhealthcareworkerssuchascommunityhealthworkers,dentalhealthaidetherapists,mobileteams,andcommunityparamedicinetoreachthoseinremotecommunities,includingNativeAmericanreservations.Apilotcommunityparamedicineprogramhasbeguntrainingparamedicsthroughoutthestatetoprovidepreventivecareinthecommunity,especiallyforthosemostatriskofusingthe911system.AHCCCSwillbeginreimbursing“treatandrefer”activitiesinOctober2016.

Manyofthoseinterviewedindicatedthattheyactivelysupportprogramstointerestlocalhighschoolstudentsinhealthoccupations.However,somealsonotedthatitcanbedifficulttohirelocallyandmaintainprivacywhencommunitiesaretoosmalltoprovideadegreeofanonymity.Someorganizationsusecontingentlaborandtravelingnurseswhenpermanentstaffisdifficulttorecruitandretain.

Impactofchangesinthehealthcaresystemonthehealthcareworkforce

Increasesinhealthcaredemandarespurringneweffortsatrecruitmentandretention,aswellasmorecreativeusesofstaffingandtechnology.Theincreaseindemandhasrequiredthatprimarycareproviderorganizationsutilizestaffmoreefficiently.Thisincludesincreasingthenumberofnursepractitionersandphysicianassistants,andrequiringthatallstaffworkatthetopoftheireducationandscopeofpractice.Withashortageofprovidersinsomefields,andanincreasedfocusonprimarycare,manyhealthcareorganizationsarerelyingmoreonalliedhealthworkerssuchasmedicalassistants(MAs),andcommunityhealthworkers(CHWs).However,greaterrelianceonthesetypesofworkers,particularlyMAs,isnecessitatingadditionaltraininginsoftskillsandothercompetenciesthatallowthemtoworkatashighalevelaspermittedbyscopeofpracticeregulations.Greateremphasisonpopulationhealthandprimarycarehasincreasedthedemandformedicalassistants,particularlythosewithgoodpatientcommunicationskills,ashealthcareorganizationsopenmorecommunity-basedfacilities.

Growinginsurancecoverageforbehavioralhealthserviceshasledtogreaterdemandforbehavioralhealthworkers.However,manyintervieweesindicatedthatthereisashortageofbehavioralhealthproviders,particularlyinsafetynetclinicsandinruralareas.Behavioralhealthtraineeswhoareinterestedinruralpracticehavefacedchallengesduetotheneedtohaveadequatesupervisionduringtraining.RegulationsmanagedbytheBoardofBehavioralHealthExaminersweremodifiedtoallow90%ofclinicalsupervisiontobeprovidedelectronicallyviaSkypeorteleconferencesothatmarriageandfamilytherapists(MFTs)andotherproviderscanfinishtheirclinicalhoursinruralareas.

Severalintervieweesnotedthatthelabormarketfornursesiscomplicated.Manyindicatedthattherewasashortageofnurses,andexpressedconcernthat,withanaverageageof55,manyRNsmightneedtotransitionoutofacutecareandintootherrolesinhospitals,suchascarecoordination.However,duetothelackof“newgrad”trainingprogramsthatallowyoungernursestoobtainthetrainingandexperienceneededtofillacutecarepositions,hospitalsarefacingashortage.

Long-termcare(LTC)isagrowingfieldduetotheaginglocalpopulation,thelargenumberofpeoplemovingtoArizonatoretire,and“snowbirds”wholiveinthestateonlypartoftheyear.ThiscreatesaperiodicsurgeinneedforLTCworkers,whichmakesitdifficulttostaffagenciesandorganizationsthatprovidelong-termcareservices.IntervieweesreportedanongoingshortageofLPNs,thepredominant

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workerinthisfield,aswellasCertifiedNursingAssistants(CNAs).ThelackofacareerladderforentrylevelstaffsuchasCNAsmakesitdifficulttoretainanddevelopthisgroupofworkers.Intervieweesalsoreportedshortagesofoccupational,physicalandspeechtherapistsinlong-termcare.Theseshortagessometimesresultin“poaching”betweenorganizationsandinflatedsalaries.

Somelong-termcareorganizations,whichhavereliedonLPNsandCNAs,haveneededtohiremoreRNsduetorisingcomplexityofpatientconditions.However,manyRNsreportedlyhaveahardtimeadjustingtolong-termcareemploymentbecausemuchoftheworkisone-to-onewithpatientsintheirhomes.Thereisalsoagrowingneedforstafftoassistpatientswithdailyfunctionssuchasshopping,cleaning,cooking,andaccessingmedicalappointments.Oneorganizationnotedthatthesefunctionsareoftendeliveredseparately,andthattheyaremovingtowardintegratingtheseservicesintooneposition–theAttendantCareWorker—whoisoftenretirement-ageandfrequentlyafamilymember.

Theintroductionofnewtechnologyliketelehealthorremotemonitoringcouldmakehealthcareorganizationsmoreefficient,whichcanincreasethecapacitytoseepatients,butalsomightentailreductionsintheworkforce.Oneintervieweenotedthatthecurrentdemandexceedscapacity,andthusitismorelikelythattechnologywillbeusedtoincreasecapacityandaccesstocare.However,manyintervieweesindicatedthathealthcareorganizationslacktheworkforcewithspecificskillstomakefulluseofnewtechnologytools.Whilemanyofthoseinterviewedsawpositivebenefitstonewtechnology,afewintervieweesnotedthatsomenursesandprovidersareunhappywithEHRdocumentationrequirementsthatoftendistractthemfromtheirpatientfocus.Thisisparticularlytrueforolderhealthcareworkers.Clinicalscribeswerenotedasonepossiblesolutionforassistingprovidersduringpatientencounters.Severalintervieweesnotedthattechnologycouldnotreplacetheneedforface-to-faceinteractionsandcriticalthinkingskillsforthepractitionersusingthenewtechnology.

Finally,themandatethatemployerswith50ormoreemployeesprovidehealthinsurancemighthaveanadverseimpactontheworkforce.HealthcareorganizationsandagenciesmightchoosetodownsizetokeeptheirFTEsbelow50inordertoavoidtherequirement,ortheymightchoosetouseindependentcontractorstoavoidthisprovision.

Turnoverandretention

Intervieweesnotedbothburnoutandhighdemandforcertainclassesofworkersasbeingimportantfactorsinturnoverandretention.Theycitedturnoverratesfrom14to75%dependingonoccupationandhealthcaresector,withmostreportingsomewherearound25%.Whileburnouthasalwaysbeenafactorinhealthcare,theunusuallyhighdemandbroughtaboutbyArizona’sparticipationinhealthcarereformanditsMedicaidexpansionhaveincreaseddemandandwagesforcertaintypesofhealthcareworkers.Thisvariesagreatdealbyoccupation.Therecontinuestobeanursingshortage,andnursesappeartofrequentlychangejobsforhigherwagesandbetterworkingconditions,asareoccupational,physical,andspeechtherapists.Employersalsonotedthatnursesarebeing“poached”bycompetitororganizations.Someintervieweescitehighemployeeengagementasbeingkeytotheirsuccessfulretentionefforts.

Fourintervieweesinstatewideorganizationsindicatedthattherewasaproblemwithturnoverattheleadershiplevel.Asonenoted,“Theoverallchangesinhealthcareareaffectingleaders.Tryingtocome

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upwithastrategicdirectionisarealcrap-shootrightnow.”However,threeintervieweesinproviderorganizationsindicatedthatmostoftheirturnoverwasforfrontlinestaff,notleadership.

Changesneededtoensureanadequatehealthcareworkforce

ThoseinterviewedwereaskedaboutthechangestheythinkareneededtoensurethatthehealthcareworkforceofArizonacanmeetcurrentandfuturehealthcareneeds.Avarietyofrecommendationsweremaderegardingtheskillsrequiredforhealthworkersinthefuture,educationalchangesthatwouldensureadequateskillsandnumbersofworkers,andregulatorychanges.

Newskillsneededfornewandexistinghealthcareworkers

Changesinhealthcare–includingthedesiretointegratephysical,dental,andmentalhealthservices–arenecessitatingnewskillsandknowledgeamongexistingstaff.

• Trainingforbehavioralhealthandprimarycareintegration.Medicalproviderswerecitedasneedingmoreeducationinneuroscienceandneuropsychiatrytobetterunderstandpatientconditions,andmoretraininginusingCTscansandMRIstomonitorbrainconditions.

• Trainingfordentalhealthandprimarycareintegration.Medicalcliniciansmightneedsometraininginassessingthehealthofteethandgumsinordertoreferpatientsfordentalcareortoprovidesomesimplesuggestionsonoralhealthcare.

• Interprofessionaltrainingisincreasinglynecessaryforthoseworkinginteam-basedcareaspatient-centeredmedicalhomesbecamemoreprevalent.

• BasiccomputerskillsareachallengeforolderprovidersandRNs,butalsochallengingforfrontlineworkerswithlimitededucationalpreparation,includingsomementalhealthandsubstanceabusepeerproviders.Thecontinuedadvanceofelectronichealthrecordsystemsrequiresthatstaffhavegoodcomputerskillsinordertodocumentpatientvisitsforbillingandcompliancepurposes.

• Understandingfederalrequirementsforbillingandcodingisagrowingareaofconcernasnewtypesofalliedhealthstaffbecameeligibleforreimbursement.

• Dataanalytics/healthinformatics/healthinformationtechnologists.Staffwithexpertiseinsettinguphealthinformationandphonesystems,trouble-shootingproblems,andtrainingotherstafftousethemwasmentionedasanareaofneed.Inadditiontomoreoperations-focusedstaff,individualswiththeskillstoextractandanalyzedatafromthesesystemsareneededtorealizethefullpotentialofthesenewsystems.

• Translationandculturalcompetencyskills.Thepaucityofproviderswithbiculturalandbilingualskillswhocancommunicatewiththepatientpopulationwascitedasanongoingproblem—bothforthoseservingSpanish-speakingpopulationsandontriballands.Someprovidersareutilizingmedicalassistantsastranslators.However,asoneintervieweeobserved,justbecauseastaffmemberisbilingualdoesnotguaranteegoodmedicaltranslationskills.Skillsassessmentandmedicaltranslatortrainingforexistingstaffisimportantbecausemanyprimarycareorganizationscannotaffordtoemploytranslatorsinaseparaterole.

• Traininginchronicdiseasemanagement,especiallyforfrontlinecareworkerswhomayobservesymptomstheycanconveytolicensedstaff,andtrainingininsurancenavigation,werenewskillsapplicabletofrontlinestaff.

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• Softskills/communicationskills.Patientengagementskills,customerservice,andcommunicationskillsarecriticalforincumbentstaffandfornewgraduatesenteringthehealthcarefield.OneorganizationhasdevelopedtrainingmodulesforprovidersinhowtocommunicatewithMAsandpatients,andanotherforMAstocommunicatewithpatientsandproviders.However,oneintervieweeobservedanimprovementinrecentyearsduetohealthcareorganizations’emphasisonpatientsatisfactionratings.Criticalthinkingskillsalsocameupasimportantbutoftenlacking,especiallyinfrontlinestaff.

• Understandingpatient-centeredcare.Inadditiontoimprovingskillsincommunicatingwithpatients,staffandprovidersneedtounderstandwhatpatient-centeredcareisandhowitisoperationalizedtoworkinthenewmodelsofcarelikethepatient-centeredmedicalhome.Takinginputfrompatientsisdifficultforsomeproviders.

• Carecoordinationskillswerecitedasveryimportantfornewmodelsofcareaimedatkeepingpatients,especiallylongtermcarepatients,healthyintheirhomes.Carecoordinatorscanassistpatientswithaccessingnecessarycareandservicesaswellastrackingtheircareovertimetomakesurethattheircareisfollowedthroughandintegrated.

• Usingincumbenthealthworkersmoreefficiently:Existingstaff,suchasmedicalassistantsandparamedics,canbecross-trainedtoprovidemorepreventivecarewhenprovidersareinshortsupply.

Skillsgapsinnewgraduatepreparation

Newgraduatesintohealthcareoccupationssometimeslackimportantskillsandknowledgeneededbyemployerorganizations.Specificareasofeducationwererecommendedbymanyofthoseinterviewed.

• Geriatricstraining:Forthoseworkinginlong-termcare,inparticular,trainingingeriatricsisvitaltoaddressingtheneedsofthestate’slargeseniorpopulation.However,itwasnotedthatfewnewgraduatesornewemployeescomepreparedwiththisknowledge.

• Healthcarefinancingandvalue-basedpurchasing.Oneintervieweenotedthatmedicalfacultyand,consequently,medicalstudentshavelittletraininginhealthcarefinancing.Existingstaffandadministratorsneedadditionaltraininginhowtoprepareforpaymentreforms.

• Clinicalskillsformedicalassistants:Asprimarycarebecomesmoredependentontherolesofstafflikemedicalassistants,trainingprogramsneedtopreparethesestudentsforexpandedrolesandresponsibilities.However,manycomeintoemploymentlackingbasicclinicalskillsandsometimesdonothavesufficientprimaryeducationtofunctionproperly.

• ClinicalexperiencefornewRNs:NewRNgraduatesmightnotreceiveenoughclinicaltimeintheirnursingprogramstobepreparedto“hitthegroundrunning”whentheygraduate;asaresult,theyfinditdifficulttofindemployment.

• Behavioralhealthtechnicians:Manyorganizationsusebehavioralhealthtechnicians(BHTs),whoareoftenindividualswithundergraduatedegreesinpsychiatryorsocialwork,toaddresslicensedprovidershortages.However,becauseBHTsdonothaveclinicaltrainingtoworkinthefield,theyrequireagreatdealofon-the-jobtrainingandsomepurportedlyenterthefieldwithunrealisticexpectationsandsubsequentlyencounterdifficultieswiththereportingrequirements.

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Changesneededinhealthcareeducation

Healthcareeducationwillneedtochangetoaddresstheseskillsgapsandnewskillsneeds.Inaddition,thenewoccupationsandjobtitlesnecessaryforthechanginghealthcareenvironmentarestillunderdevelopment.Intervieweesmaderecommendationsregardinghoweducationneedstochange,andhaschanged,toaddresstheseneeds.Someofthoseinterviewednotedpartnershipsbetweeneducatorandemployerorganizations.

• “Growyourown”strategiesareonesolutiontoshortages,particularlyinruralareas.Employersneedtopartnerwitheducatorstohireandtrainlocalpeople.Thiswillrequireafocusonprogramsthatinterestruralhighschoolstudentsinhealthcareersintheirowncommunities.Somecommunitycollegeprogramshaveonlineandhybridhealthcareerprogramsand/orcampusesnearruralcommunities.

• RNresidencyprograms.NewgraduateprogramssponsoredbyhealthcareorganizationscanprovideclinicaltrainingthatnewRNslackandcanhelpaddressthenursingshortageinhospitals,buttheseprogramsareinshortsupply.

• Newcategoriesofhealthcareworkertraining.Educationalprogramsareworkingwithhealthcareemployerorganizationstodeveloptrainingprogramsanddegreesfornewroles.Forexample,onecommunitycollegehasdevelopedaprograminhealthcaretechnologysystems,whichfocusesonhardware,asopposedtothesoftwareandcompliancefocusofhealthinformationmanagementprograms.ArizonaStateUniversityhasdevelopedaCollegeofHealthSolutionsthattakesaninterdisciplinaryapproachtohealthcareandincludesdegreeprogramsliketheScienceofHealthCareDelivery,whichincludestopicssuchaspopulationhealth,systemsengineering,andinformationscience.

• Concurrentenrollmentprograms/collaborativeprograms.Collaborativeprogramsbetweencommunitycollegesanduniversitiesprovideoneavenueforaddressingshortages,includingtheshortageofclinicallaboratoryscientists.IntervieweesnotedthecollaborativeprogrambetweenArizonaStateUniversityandPhoenixCollegewhichallowsstudentstosimultaneouslyearnanassociateandabaccalaureatedegreethroughahybridonline/in-personprogramwhilepursuingpartoftheirclinicalhoursinastate-of-theartsimulationlab.Associate’sdegree-to-bachelor’sdegreeprogramsinnursingaregrowinginresponsetoemployerinterestinhiringbaccalaureate-educatedRNs.

• Clinicalsimulation.Thelackofclinicalplacementsavailabletohealtheducationprogramshasbeenexacerbatedbythemergersandexpansionstakingplacebetweenhealthcareorganizations,whichhaveprecludedacceptingstudentsforclinicalrotations.Oneresponseistodevelopmorerobustclinicalsimulationtrainingfacilitiesandprograms.

o Integratingclinicalplacementsystems.MaricopaCommunityCollegesandlocallargehealthcareorganizationsformedaconsortiumtomanageclinicalplacements.Theyinstitutedasetofpre-clinicalmodulesforstudentsandfacultyin45alliedhealthand8nursingprogramsintheregiontostandardizepreparationforclinicals.Theyalsoadoptedacloud-basedplatformthatallowsthemtocentralizeplacementoperationsandtrackhours,relievinghealthcareorganizationsoftheburdenofindividualtrackingandplacementoperations.

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• Programsforveterans.Arizonahasalargenumberofveterans,anddevelopingmethodsofrecruitingandtrainingveteransfornewcareerswascitedasimportantnotonlyforveterans’financialviability,buttofillshortages.

• Improvedmedicalassistanttraining.Thequalityofmedicalassistanttrainingneedstobeimprovedtoaddressemployerneeds.

• Strongerclinicaltrainingforbehavioralhealthcarestudents.Thereissomeconcernthatbehavioralhealthandsocialworkprogramsarenotadequatelypreparingstudentstoworkinpublichealth.Graduatesneedtohavestrongerclinicaltrainingandmorebackgroundintrauma-informedcareandspecializedtreatment.

• Betterpreparationinbothbehavioralandphysicalhealth.NPsneedbetterpreparationinbehavioralhealth,andpsychiatricNPsneedbettertraininginphysicalhealth,toaddresstheneedformorecross-trainedstaffintheintegrationofphysicalandbehavioralhealth.Caremanagersthatcommunicatebetweenthephysicalandbehavioralhealthsidewillbeindemand,particularlyforthosewithchronicdiseases.

• Morecommunity-basedplacements.Thereisadearthofplacestotrainhealthprofessionalsinthecommunity.InvestingintraininginfrastructurefocusedonFQHCsandotherambulatorysites,aswellasinruralhospitalsandcriticalaccesshospitals,wouldhelprecruitmenteffortsinunderservedcommunities.

Regulatorychanges

Anumberofregulatorychangescouldbemade,orhaverecentlybeenmade,thatcouldfacilitateneededchangesinthehealthcareworkforcetoaddressthechanginghealthcarelandscape.

• Behavioralanalysts.Arizonawasoneofthefirststatestolicensebehavioralanalysts.Behavioralanalystsworkwithpeoplewithdevelopmentaldisabilitiesandautism.Theircurrentlocationforlicensing(thePsychologyBoard)haslimitedtheirscopeofpracticeandsomeintervieweeswouldlikethelicensingtransferredtotheBoardofBehavioralHealthExaminerstospurachangeintheapproachtocareandbecausethismovemightmaketheirservicesreimbursable.

• Communityhealthworkers.AlthoughanumberofintervieweesnotedtheimportantroleofCHWsandTribalHealthRepresentatives,thereisnotyetanycertificationforCHWsinArizona.IfCHWswerecertified,theirworkwouldbereimbursable.

• Oralhealthcareworkers.Expandedscopefordentalhygienistswouldallowforgreateraccesstocarewherethereareshortagesofdentists.In2015,legislationwaspassedallowingfortheuseofthedentalhealthaidetherapistroleontriballands.

• Pharmacists.Scopeenhancement(advancedpracticepharmacydesignation),similartowhathasbeenestablishedinNorthCarolinaandCalifornia,wouldallowpharmaciststoworkasprovidersandprescribefamilyplanningservicesandmedicationtherapymanagement.

• Nursepractitioners.MedicaredoesnotpermitNPstoorderhomehealthservicesforpatients.WhileArizonahaslegislationtoallowNPstopracticetotheirfullscope,federallawhasnotyetcaughtup.

• Referralstohomehealth.Physiciansdonotwanttorefertohomehealthbecausetheprocessisonerous.ThisconcernsfederalregulationthatsomeArizonaintervieweesidentifiedasaproblem.

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• Integratingprimarycareandbehavioralhealth.Whiletherehasbeenalotofemphasisonprimarycareandbehavioralhealthintegration,regulationshavemaintainedtwoseparatesetsofregulationsregardinghowlicensurecanhappen.Therulepackagesneedtobestreamlinedintoonesotheprocessislessprohibitive.

• Standardizeoutcomesinpay-for-performance.Providerefficiencymightbeimprovedifinsurancecompaniescouldreduceandstandardizethenumberofpay-for-performancemetricsprovidersarerequiredtomeet.

• Increasetheadoptionofvalue-basedreimbursementstosupportnewmodelsofcare.• Integratedentalcareandexpandaccess.AHCCCSdoesnotcoverthecostofdentalcarefor

adults,withtheexceptionoflong-termcare.Thereneedstobeanincentivetointegrateoralhealthcareandprimarycarebecausedentalandphysicalhealtharecloselylinked.

• Credentialmedicalinterpreters.Culturalandlinguisticcompetencyisacriticalfactorinhelpingminoritycommunitiesseekcare.However,Arizonadoesnothaveacredentialingprocessforhealthcareinterpreters.Thismightbothimprovetranslationservicesandprovideapayincreaseforthoseprovidingthisservice.

• Expandingthestateloanrepaymentprogram.Until2015,thestateloanrepaymentprogramcoveredprimarycareandsomedentalcareproviders(primarycarephysicians,dentists,andadvancedpracticeproviderslikenursepractitioners,physicianassistants,andnursemidwives).Asof2015,itincludesmentalhealth,pharmacyandgeriatricproviders,andtheannualdollaramountforprovidershasbeenincreased.Thispoolofmoneycouldbeexpandedinthenextcompetitionviaafederalmatchifthestateorotherentitieswerewillingtocontributemore.

Interviewees’topthreepriorities

Intervieweeswereaskedtoranktheirtopthreeprioritiesforhealthworkforcedevelopment.Onethemethatcameuprepeatedly(sixmentions)wasbetteruseoftechnology,especiallybetterimplementationofelectronicmedicalrecordsandenhancedtrainingsothatstaffcouldinputanddrawfromtheserecordsmoreeffectively.

Fiveintervieweesnotedthatimprovedtrainingandeducationforincumbentstaffandnewgraduateswereoftopimportance.

Fournotedthatrecruitmentandretention,particularlyofdoctorsandnurses,wastheirtoppriority.

Fournotedthatbetterrecognition,training,andwagesfortheparaprofessionalworkforcewouldhelpimprovecareandworkforceretention.OnenotedthatcredentialingCHWswouldstandardizetrainingandimprovereimbursementforthisclassofworker.Forone,theincreaseinparaprofessionalswasmoreofaproblemthanabenefitduetothefactthatthesepositionswerenotreimbursableand/orrequiredextensivesupervisionforreimbursement—eitherwaynecessitatingmorelicensedproviderstaff.

Threeintervieweescommentedthatimprovingreimbursementandwageswouldhelpaddressissuesaroundrecruitmentandretention.

Twobelievethatthestateneedstodoabetterjobstreamlininglicensingrequirementssothatprovidersandotherclinicianscouldmoveintotheworkforcefaster.

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Otherprioritiesincludedexpandingthescopeofpracticeforadvancedpracticeregisterednurses;expandingthestate’sloanrepaymentprogramsothattheprogramcoulddrawdownmorefederalmoneyandincentivizeemploymentinshortageareas;expandingresidencyprogramsinshortageareasforthesamereason,andgenerallyaddressingrecruitmentandretentionissuesandshortages.

CONCLUSIONS

Ashealthsystemtransformationcontinues,acombinationofregulatory,education,andtrainingchangeswillbenecessarytofacilitatenewmodelsofcareandaddresschangingdemographics.Thereareshortagesormaldistributioninsomeoccupations,particularlybehavioralhealthproviders,nurses,andsomemedicalproviders,especiallyinruralareas.Newoccupationsaredevelopingthatwillrequirenewcredentialsandtrainingprograms,whileexistingoccupationsarechangingasalliedhealthworkerstakeonincreasedresponsibilitythatwillrequiremoreadvancedtraining.Mostoccupationsnowrequireskillsincaremanagement,patientengagement,newtechnology,andteam-basedcare.Employersandeducatorswillneedtobothexpandtheireducationprogramsintheseareasandreassessthecurricularcontentoftheirprogramstoensureanadequately-sizedandskilledworkforceinthefuture.

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ACKNOWLEDGEMENTS

ThecollaborationoftheAdvisoryCommitteeconvenedbyVitalystHealthFoundation,theCityofPhoenix,andtheGreaterPhoenixChamberofCommercewasimportanttothedevelopmentofthesurveyquestionnaireandconductingofthesurvey.

AdvisingCommitteeMembers:

• AudreyBohanan(AdelanteHealthCare)• JudyClinco(CatalinaInHomeServices/AZDirectCareAlliance)• EricDosch(Cigna)• RobertFranciosi(MaricopaCommunityCollegeDistrict)• DanHunting(MorrisonInstituteforPublicPolicy)• TaraMcCollum(CommunityHealthCenters)• KathleenCollinsPagels(ArizonaHealthcareAssociation)• ScottSalzetti(BannerHealth)• SteveSchroeder(MaricopaCommunityCollegeDistrict)• JudySeiler(ScottsdaleLincolnHealthNetwork)

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APPENDIX

InterviewGuide:Thesearethegeneralquestionsthatwillbeaskedofeachinterviewee.Someinterviewsmayfocusononlyasubsetofthesequestionsdependingupontheinterviewee’sexpertiseandposition.

1. Whatisyourtitleandyourrolewithinthisorganization?Howlonghaveyoubeenwiththisorganization?

2. Whatkindsofchangesinhealthcaredeliveryareyouseeingatyourworkplaceoraroundyou?a) Whatisdrivingthesechanges?(prompt:creatinganACO,lowerMedicare

reimbursements,Medicarepenaltiesforpoorquality,morecompetitioninthemarket,lowerprivateinsurancereimbursements,agingofthepopulation,changesinnetworksandaffiliations)

b) Dothesechangesincludenewmodelsofcaresuchasintegratingphysicalandmentalhealth,patient-centeredmedicalhome,retailclinics,etc.?

c) Howrapidlyarethesechangesoccurring?d) Dothinkthesechangeswillaccelerate,decelerate,orcontinueatthesamepaceoverthe

next3-5years?3. Fromwhatyouhaveseenandheard,howdoyouthinkchangesinhealthcaredeliverywill

impactthehealthcareworkforce?a) Inwhatwaysdoyourthinkthehealthcareworkforcemightneedtochange?

Prompt:Numbersofworkers,agesofworkers,typesofworkers,training,changeinwhattheydo?

4. Areyouplanningforhealthworkforcechangesinyourhealthcaresystem(educationprogramofferings)?

a) Pleasetellusaboutthosechangesinacoupleofexamples.5. Fromyourexperienceandwhatyou’veseenandheard,whatnewskillsdoyouthinkthecurrent

healthcareworkforcemightneedtocompeteinthesechangingdeliverymodels?(Preliminarywork–overallskills,softskills,interprofessionalskills)(Alsokeepcontentonclinicalorspecificskills)

a) Couldyougiveussomeexamplesofnewskillsneededandwhyyouthinkthoseskillswillbeimportant?

6. Fromwhatyou’veseenandheardaboutchangingmodelsofcare,doyouthinkchangesintheeducationofthehealthcareworkforcewillbeneeded?

a) Whatkindsofchanges?b) Couldyougiveussomeexamples?

7. Fromyourperspectivearethereregulatorychangesneededinthehealthcareworkforcesuchaschangesinscopeofpractice(thelegaldescriptionofpracticebyaprofession),Medicaidpaymentpolicies,etc.?

a) Whatkindofchangesmightbeneeded?b) Canyougiveussomeexamples?

8. Whatisyourperspectiveonhowfuturetechnologymightimpactthehealthcareworkforce?Probe:Change in composition, trainingneeded,overall numbersanddistributionacross thestate’sregions?

9. Fromyourexperience,howwellpreparedarenewgraduatesintheskillsneededinyourorganizationtocompetentlydelivercare?

a) Ifthisisaproblem,whatarethemostsignificantgapsinpreparation?(prompts:clinicalexperience,softskills?)

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Probe:Ifthisisregionalemployer,askaboutdifferencesinthesegapsacrossregionsofthestate.

b) Pleasediscussacoupleofexamples.c) Pleasediscussanymodelsyouknowthatsuccessfullyaddressthesegapsinskillsneeded

bynewgraduates.(Specifically,howwouldyousuggestthisbeaddressed?)d) Haveyouconsidereddevelopingyourowntrainingprogramorpartneringwithaprogram

thatcould?Whyorwhynot?10. Somesuggestthatturnoverishighinsomehealthcarejobs,especiallyentry-leveljobs.Whatis

yourperspectiveand/orexperienceofturnoverinhealthcarejobs?a) Whataboutturnoverofleaders?b) Howmightturnoverbeaddressed?c) Howdoyoukeepprovidersengagedandavoidburnout?d) Doyouhavearetentionplan?

11. Forruralareas:Whenyouhaveaseriousshortage,howareyouaddressingit?(prompts:travelers,loanrepayments,etc.)

a) Arethereinnovativemodelsyouareusingorconsideringtoaddressneeds?(prompts:mid-level,CHWs,etc)

12. Insummary,whatwouldbeyourtop3prioritiestoaddressinplanningforandpreparingourstate’sfuturehealthcareworkforce?

13. Isthereanythingelseyou’dliketoaddthatwehavenotasked?