# Presentation: 213563

## The Impact of Workforce Shortages on 

***Cost, Quality and Access: ***
***How Should We Respond***
**Edward Salsberg**
- Executive Director
- Center for Health Workforce Studies
- School of Public Health, University at Albany
- _[http://](http://chws.albany.edu/)__[chws](http://chws.albany.edu/)__[.](http://chws.albany.edu/)__[albany](http://chws.albany.edu/)__[.](http://chws.albany.edu/)__[edu](http://chws.albany.edu/)_
**State Long Term Care Programs: **
**Balancing Cost, Quality and Access**
- Indianapolis, Indiana
- May 7, 2002

- Salsberg

**Notes:**
The Impact of Workforce Shortages on Cost, Quality and Access: How Should We Respond, a presentation by Edward Salsberg, Executive Director of the Center for Health Workforce Studies, School of Public Health, University at Albany.  Presented at the AHRQ-NGA meeting, State Long Term Care Systems: Reducing Cost, Quality and Access, held in Indianapolis, IN May 6-8, 2002.

## The Center for Health Workforce Studies School of Public Health,University at Albany, SUNY

- Dedicated to studying the supply, demand, use and education of the health workforce
- Committed to collecting and analyzing data to understand workforce dynamics and trends
- Goal to inform public policies, the health and education sectors and the public
- One of five regional centers with a cooperative agreement with HRSA/Bureau of Health Professions

**Notes:**
The Center for Health Workforce Studies is dedicated to studying the health workforce.  This has been a neglected area of health policy over the last decade as we always assumed there would be a workforce available, as it has been up to now. 

## Overview of Presentation 

- Crisis as opportunity
- Overview of the health workforce
- The long term care paraprofessional workforce
- Approaches to responding to health workforce shortages

**Notes:**
I will discuss why I think there is a health workforce crisis as well as an opportunity, and cover who the workforce is and possible responses to shortages.  Finally, I will talk briefly about the American Hospital Association Health Workforce Commission

## Crisis as Opportunity:The Crisis

- Serious shortages threatening ability to deliver services
- The squeeze-few new dollars and the high cost of more workers
- Concerns with medical errors and quality
- Worker and management dissatisfaction
- Buried in paperwork and regulation
- Racial and ethnic imbalances
- Decreased interest in health careers

**Notes:**
Crisis as opportunity.  This crisis is not just about shortage of workers. It also  includes the financial problems of individuals and facilities. There is worker dissatisfaction, paperwork burdens or requirements, and racial and ethnic imbalances that all contribute to the drop in people entering health careers over last decade.

## Where are the Shortages?

- Direct care workers, including home health aides and nursing home aides
- Registered nurses
- Radiologic technicians
- Pharmacists
- Lab/medical technologists
- Dentists
- Information system specialists
- Medical coders

**Notes:**
Shortages of nurses is a widespread issue, but dentists, pharmacists, and dental technicians, also face shortages.

## The Health Workforce: A  Basic Premise

- A health care system is only as good as its workforce
- The workforce directly impacts on quality, cost and access
- System wide high turnover, difficulty recruiting and worker dissatisfaction are signs of a systemic problem

**Notes:**
My basic premise is that the system is only as good as its workforce. The workforce directly impacts services.  High turnover is a sign of a systemic, not short term, problem.

## Factors Contributing to Health Workforce Shortages

- Short term factors
- Competition for workers and full economy
- Educational system response lags
- Demand rising
- Long Term Demographic factors
- The aging of America:  increase in demand for health services
- The aging of America:  decrease supply of workers
- Changing racial/ethnic mix
- Career choices for women

**Notes:**
Other short term factors facing the workforce are competition for workers in a full economy, educational system lags, and nursing school enrollment issues. Also, demand is rising rapidly. Long term phenomena are the aging of America, and the impact of aging on supply as well as demand. I expect that the nursing enrollment shortages will lessen, but that is not a signal that the problem is over. This is a serious long term problem.

## Factors Contributing to Health Workforce Shortages, continued

- Workplace factors
- Physically and emotionally demanding work
- Non-competitive wages and benefits
- Job design and working conditions
- Paperwork and lack of information systems
- Poorly trained managers

**Notes:**
Workplace factors affect the shortage. The work is physically and emotionally demanding. Compensation is low compensation. Managers are poorly trained. Working conditions are poor.  These factors can be addressed in the short term, but need a long term solution.

## Factors Impacting on Shortages

**Factors Impacting on Shortages**

**Factors Impacting on Shortages and Quality**

- Salsberg

**Notes:**
There are a number of factors influencing shortage and quality of care. Shortages have an impact on quality.  Other simultaneous factors include the lack of information systems, lack of diversity and limited investment in training. 

## The Health Care Workforce

**Notes:**
The health workforce.

## More Than 1 in 10 Americans Works in Health Care or is a Health Professional

|  | Health Professionals | Other Workers | Total |
| --- | --- | --- | --- |
| Health service setting | 8,642,749 | 4,098,331 | 12,741,080 |
| Other work settings | 2,167,418 | 126,649,685 | 128,817,103 |
| Total | 10,810,167 | 130,748,016 | 141,558,183 |

| Health professionals working in health service settings | 8,642,749 | 6.1% |
| --- | --- | --- |
| Health professionals working in other settings | 2,167,418 | 1.5% |
| Other workers in health service settings | 4,098,498 | 2.9% |
| US health workforce | 14,908,498 | 10.5% |
| US civilian labor force | 141,558,183 | 100.0% |

- Bureau of Labor Statistics, 2001
- Figures shown are the average of 12 months’ data
-  (October 2000 – September 2001)

**Notes:**
There are two groups in the workforce. There are 10 million health professionals and four million other workers classified as health workers, which includes plumbers and computer people for a total of 14.9 million Americans.   Health care is big business and an important sector of the economy.

## Demographics of the Health Workforce:  Gender

**Notes:**
Some occupations are predominantly women, and women now have more career opportunities, but the health occupations face challenges attracting an adequate supply of potential workers. 

## Demographics of the Health Workforce:  Age

**Notes:**
In the past five years, the average age of nurses jumped five years.  The whole U.S. economy grew three years in this same time period as the population as a whole aged.  Occupations that are physically demanding put more strain on this workforce. 

## Demographics of the Health Workforce:  Race/ethnicity

**Notes:**
In a series of occupations that are predominantly white, we find an under-representation of minorities, Hispanic and black, in nursing.  If you have white women between 30 and 50 as your core workers, your ability to meet demand drawing from such a narrow band of the population is limited.

## Growth Between 1990 and 2000 and Projected Growth 2000 – 2010 Health Care Occupation and Non-Health Care Employments

**Notes:**
Health care occupations are growing at a faster rate compared to other occupations.  There is enormous growth in health care occupations. 

## Health Care Occupations Forecast to Grow the Most from 2000 to 2010

- Source:  Bureau of Labor Statistics: Occupational Employment Projections to 2010 Page 1 of 2 Monthly Labor Review, Nov 2001

**Notes:**
The demand for nursing and health occupations outstrips the ability to meet the need. Where will the nation find these workers as health care keeps soaking them up and continuing to expand?

## Long Term Care Paraprofessionals

**Notes:**
Who are the workers? 

## Nurse Aides and Personal Care Workers comprise 38% of the Nursing Home EmployeesNursing & Personal Care Facility Employment by Occupation, US, 1998

- Source:  Bureau of Labor Statistics.

**Notes:**
Thirty nine percent are of nursing home employers are aides. Another concern is that we see the elderly/support ratio changing – there will be fewer workers, but more persons in need over the next decades.

## Home Health Aides and Personal Care Workers comprise Half of All Home Care Workers and RNs are Nearly 20%Home Health Care Services  Employment by Occupation, US, 1998

- Source:  Bureau of Labor Statistics.

**Notes:**
Home care accounts for 50% of all workers and 19% are RNs. The vast majority are female, most are working in home care. Eighty percent work in hospitals. 

## Demographics of the Long Term Care Paraprofessional Workforce:  Age

- Source: Current Population Survey 1997 – 1999

**Notes:**
The average age of home care aides is almost 43 and they are older than aides in nursing homes and hospitals whose average age is 36-38.

## Demographics of the Long Term Care Paraprofessional Workforce:  Education

- Source: Current Population Survey 1997 – 1999

**Notes:**
Education – home health aides are drawn from a lower educational group,  highest rate group that lack a high school degree.

## Demographics of the Long Term Care Paraprofessional Workforce:  Race

- Source: Current Population Survey 1997 – 1999

**Notes:**
Aides are primarily white (70%), but 25% black.

## A Conceptual Framework for State Responses to Workforce Shortages

- 1. Expand pipeline:  education and training strategies (supply Side)
- 2. Improve retention:  job related strategies (supply side)
- 3. Reduce numbers needed:  improve productivity/reduce paperwork (demand side)
- 4. Other strategies

**Notes:**
What do workers think of their job? They see low wages, many alternatives, little recognition, and poor treatment. So why would they want to stay? What can we do? Expand the pipeline and improve retention are the primary options.

## 1.A Expanding the Pipeline:Educational Strategies 

- Scholarships and loan repayment
- Grants for faculty, expansion or start up
- High school health careers awareness
- Marketing health careers/public service announcements
- Capitation funding and/or mandates for educational programs
- Support for efforts to increase minority recruitment and retention
- Support for education demonstrations and development, i.e. distance learning, computer assisted learning

**Notes:**
Educational strategies – there may be opportunities for strategies in this area. We have seen a discussion in the industry, but some suggestions are less likely to be implemented.  Long term care is less likely to institute a career ladder.

## 1.B Expanding the Pipeline: 	Other Strategies

- Studies and reports
- Increased reimbursement/higher wages
- State funding for training initiatives
- TANF
- Medicaid
- State dollars
- Building Career Ladders
- Nurse Aide to LPN
- LPN to RN

**Notes:**
Funding initiatives have increased wages and benefits. This is important but not sufficient. People don’t become health aides because they want to make money, which does not justify non-competitive wages. Raising wages does not disappear the problem.

## 	2. Improving Retention and Job Related Strategies 

- Best practices conferences on job design and retention
- Reimbursement support for higher wages
- Fund demonstrations to improve working conditions and redesign jobs
- Reimbursement and grants to encourage improved benefits for workers, i.e. health insurance, portable benefits within industry

**Notes:**
How do we foster more efficient delivery of services? A State strategy to improve wages will improve retention. The reality is, if you don’t satisfy existing workers, you are swimming upstream just to bring new people in. We need to learn how to work with the industry to make the job more satisfying. 

## 2. Improving Retention andJob Related Strategies (cont’d)

- Encourage and support management and supervisor training
- Support technology that supports workers
- Support for career ladders
- Prohibit mandatory overtime ????
- Mandate minimum staffing ratios ????

**Notes:**
Many assume people can move up and just assume the management position, but it requires specialized skills, and we need to train the workers in these areas. We also need to improve technology. We have seen proposals to limit mandatory overtime and increase staffing levels.

## 3. Modify Demand and Improve Productivity

- Dissemination of information/best practices conferences on efficient and productive care
- Regulatory changes on scope of practice and use of workers
- Modify health facility requirements
- Explore ways to reduce paperwork
- Demonstrations and evaluation on job redesign
- Aggressively promote technology to support efficiency and effectiveness
- Collect and analyze data on staffing and productivity

**Notes:**
Look at the time spent on paperwork. An emergency room worker spends 30 minutes on paperwork for each hour of care. Nursing workers spend 3⁄4 hour to an hour, and home care workers spend an hour on paper for each hour of care. Is the documentation worth the effort if it reduces care? If the documentation is essential, how do we assist workers to complete it and provide care?

## 4. Other Responses to Shortages

- Task forces, commissions, and committees
- Support for family/informal care givers
- Better data collection and needs assessments
- Support for or opposition to increased immigration

**Notes:**
What do we do to reduce the number of workers needed? Look at paperwork and job design. Set up a commission to lay groundwork for decisions that might be difficult in an election year. But solutions involve multiple agencies, so a State level commission could be the answer in this situation.   We lack data to track workers and understand who and what they are and how bad the shortages will be.  Immigration is a possible solution to the problem.  It may be a short term solution, but over the long term, it avoids the fundamental issues of the unsatisfactory structure of the jobs.

## The AHA Health Workforce Commission

***In Our Hands: ***
***How Hospital Leaders Can Build a Thriving Workforce***

## “In Our Hands-How Hospital Leaders Can Build a Thriving Workforce”

- 5 Sets of Recommendations:
- Foster meaningful work
- Improve the workplace partnership
- Broaden the base
- Collaborate with others
- Build societal support

**Notes:**

Administrators must balance the concern for workers with concern for finances.  The report recommended partnering with the Long Term Care industry to solve problems by fostering meaningful work, making the job rewarding and valuable, listening to workers, broadening the base and bringing in new people, improving collaboration between the health and educational industries (colleges and secondary levels), and building societal support. 

## Ten Recommendations for States to Address Workforce Shortages and Improve Quality

- Assure competitive wages and benefits
- Invest in worker education and training
- Use Medicaid reimbursement to support workforce development
- Support demonstrations and evaluations related to both job design and education and training strategies
- Support health and education sector partnerships

**Notes:**
Recommendations to address competitive wages will be difficult during times of tight budgets but you don’t get quality workers without adequate  wages. How much do we value these workers?  We won’t get workers if we don’t invest in adequate training and education  - they don’t learn by osmosis on the job.  Another strategy is to use Medicaid reimbursement to reinforce workforce development. Life long learning is critical in this field, so how can Medicaid support this in tight budget times -- by demonstrations and evaluation.

## Ten Recommendations to Address Workforce Shortages and Improve Quality, continued 

- Support career ladders
- Support efforts to increase diversity of the workforce
- Support efforts to improve management and supervisory skills
- Support for family care-givers
- Support technologies that assist workers

**Notes:**
We are starting nursing home administrative training in New York. Family caregivers are also critical and need to be supported. This crisis is an opportunity to bring in people and improve the position for workers to help retain a competent and trained workforce. 

## Crisis as Opportunity:The Opportunity

- An adequate supply of health workers
- Increased worker satisfaction
- Better quality of care
- A more effective delivery system
- More cost effective care
- Information systems that work
- A more culturally diverse workforce

**Notes:**
Because they have a commitment to the people, administrators have an obligation to support this.