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Meeting the Challenges of Healthcare Reform: Preparing the Workforce for Transformational Practice Change

There has been a tremendous amount of discussion associated with workforce retraining since the passage of the Affordable Care Act (ACA). Since its inception, it has been clear that the ACA establishes a new framework for health care from nearly universal insurance coverage to the re-conceptualization of health care service delivery. This framework includes the utilization of evidence-based treatment practices and the restructuring of service delivery systems.

Changes to the provision of health care in the U.S. are tied to and depend upon a well-equipped and trained workforce. Several questions must be considered in order to understand how the workforce can be transformed in a way that will best meet the goals of the ACA. First, who comprises the health care workforce and where can they be found? Second, what do they need to know and do in the future that is different than what they have been doing in the past? Third, where and how should they be trained? Fourth and finally, how do we achieve and measure changes with practice implementation and subsequent health care outcomes to determine the effectiveness of new processes and strategies being taught?

The health care work force consists of a diverse group of professionals, para-professionals, and peer specialists including, physicians; nurses; social workers; occupational, physical and speech therapists; dentists; pharmacists; psychologists; case managers; peer advocates as well as other administrative titles that include medical records technicians and patient resource coordinators among others. Bodenheimer and Grumbach (2012) estimate that over 5 million staff comprised the healthcare workforce in 2008, not including para-professionals and peer advocates. Specifically, 642,000 were social workers, of which 43% worked directly in health care settings. Three-million Nurses overwhelmingly represent the workforce, many of whom worked in hospital-based settings. Taken together, social workers and nurses alone comprised approximately 72% of the workforce. Contrary in concept and practice to the person centered, community based, prevention oriented, collaborative care model promulgated by the ACA, many health care providers have been trained as independent practitioners in institutional settings. Therefore, inherent challenges exist with re-training a workforce to work collaboratively and within community-based contexts.

The Affordable Care Act (ACA): Setting the Transformational Agenda

The Affordable Care Act (ACA) has been characterized as a transformational shift designed to achieve its triple aim: to expand insurance coverage, reduce the cost of healthcare, and improve healthcare outcomes. The triple aim is envisioned as being accomplished through insurance market place reform resulting in considerable expansion of insurance coverage to those who are marginally insured or uninsured. This expansion is anticipated to result in insurance coverage to more than 32 million Americans from the commercial market and through the expansion of State Medicaid programs, thereby expanding the demand for health care within communities (Hofer, Abraham, & Moscovice, 2011). Reducing the cost of health care in America is easier said than done, especially when the addition of 32 million insured health care consumers is part of the goal. Presumably, many of the people being covered by Medicaid expansion will come with a history of poorly managed care and multiple comorbidities. Under these circumstances cost reduction can only be realized by improving the quality of the care provided while providing care in the most cost-efficient manner.

America currently outspends all other industrialized nations on health care, yet ranks between 17th and 37th, depending on the measure, on many clinical outcome indicators, (Berwick, Nolan, & Whittington, 2008). The ACA improves service delivery systems to ensure that the best possible care is being delivered to those people in need, in easily accessible community locations and that the delivery system has its focus on payment for valued outcomes rather than volume.

It has been said that the most important legacy of the ACA is that it legitimizes prevention as an important individual and population health activity (Koh & Sebelius, 2010). The ACA places the management of population health front and center with its emphasis on prevention, which has led to the development of wellness self-management tools for primary, secondary, and tertiary interventions (Campanelli, 2015; Anderko et al., 2012). The ACA has changed the conversation governing research on most University campuses through the implementation of the Person-Centered Outcomes Research Institute (PCORI) not only with its focus on prevention but also on the emphasis placed on person centered, clinical outcomes.

There is not a single dimension of the triple aim that will not require workforce “re-tooling” of the existing cadre of health care workers and researchers as well as refocusing the education of our aspiring professional workforce.

While various segments of the American population are impacted by the implementation of the ACA in different ways, perhaps the populations of greatest concern are those covered by health insurance provided by the federal government: Comprehensive Health Insurance Program (CHIP) for children; Medicare for older adults, especially the frail elderly, and Medicaid for the disabled and poor. CHIP, Medicare and Medicaid are the largest health insurance carriers in the country, insuring an estimated 3.6 million children, 4.6 million older adults, and 31 million poor and disabled people (Medicaid .gov. 2014). The total cost of health care in the United States is approximately $3 trillion, hovering at 18% of the gross national product. The ACA was intended to bend this proverbial and unsustainable health care “cost curve,” while also improving the health of the nation.

Given the amount of U.S. health care expenditures and the current state of quality within the health care arena, there is no more important priority than helping the workforce re-align its skills and practice behaviors to be in sync with ACA trajectories. There are many ways to provide training and many training settings that have developed in response to this need. In response to recognizing the urgent need to re-train the workforce, both federal and state initiatives are requiring that workforce re-training be written into health care requests for funding and grants that are being made available specifically targeting this purpose.

Universities are not known for flexible curriculums that rapidly respond to changing circumstances, but continuing education programs within various graduate programs do have considerably more flexibility and have the ability to bring the considerable University resources to bear on rapidly evolving training programs to meet the needs of adult learning communities. This is precisely why several major universities across the nation have developed certificate programs in integrated primary and behavioral health care within their continuing education programs. It makes perfect sense that schools of Social Work are likely places to embrace this adult education activity given the fact that social work is the second largest profession among the health care work force (Bodenheimer & Grumbach, 2012).

The University Response to Re-Training the Workforce: Credentialing and Developing the Metrics of Practice Change

 

Higher education has historically been charged with preparing the workforce for health care delivery, specifically, by providing the training needed to produce competent professionals who have the capacity to provide high quality care. However, the vast majority of graduate health professional training programs are challenged to move away from training that prepares solo practitioners toward a new focus on on collaborative interventions that involve evidence-based treatments and technological advances. In 2010, as the ACA was signed into law, the New York University Silver School of Social Work (SSSW), under the auspices of the Dean of the SSSW, and in collaboration with the Office of Global and Life Long Learning and McSilver Institute for Poverty, Policy and Research, undertook the development of an Advanced Certificate program in Integrated Primary and Behavioral Health Care. This development was facilitated by an interdisciplinary and inter-governmental steering committee whose mission was to identify and develop a curriculum for a continuing education program that would allow participants to develop the necessary skills to successfully practice within the new, evolving health care system. Initially, five learning domains were identified which included (1) The Affordable Care Act; (2) Social Determinants of Health; (3) Person-Centered Planning; (4) Promoting Systems and Organizational Accountability; and (5) Providing Leadership through Times of Change. Subsequently, a sixth module, Trauma Informed Care, was added as an option to students interested in learning about the enormous impact that trauma has on health care outcomes (Fellitti et al., 1998). In addition, a seventh module is in development focusing in on the role of prevention and wellness management within the context of case management and chronic illness. Table 1 on page 34 reflects each module and the topic areas covered within each.

During the committees work three important principals emerged that helped guide the structure of the advanced certificate. First, it was believed that this training should be based on the most current literature related to health care practices during this time of change and it was also important to make sure the training experience was standardized. Each module is a carefully designed and outlined for students with a syllabus that includes guided readings in the current literature. Students are also provided with an instructional power point presentation for each lesson and also have the opportunity of learning from guest presenters who are experts in their respective fields. Secondly, it was acknowledged that people who participate work during the day and therefore most modules are offered during the early evening hours and also utilize distance learning technology for a hybrid format. Each module is crafted to be a stand-alone experience and therefore results in a completion certificate within the respective topic area.

Finally, recognizing the need professionals have for career advancement, students who complete any five (5) modules in any sequence within any time frame are awarded an Advanced Certificate in Integrated Primary and Behavioral Healthcare signifying the extensive training that students have undertaken. Each module is recognized by the New York State Department of Education for the award of CEU credits as noted below. Table 1 below provides topic descriptions of each module.

Measuring Training Outcome

Since its inception two years ago, the Integrated Primary and Behavioral Health Care certificate program has had 122 students participate and complete one or more of the offered modules, while 55 students have since received advanced certificates having completed a total of 5 modules. Participants were from the fields of social work, law, nursing, medicine, peer advocates and para-professionals. They represented upper and mid-management as well as direct service staff.

Measuring training outcomes is always a challenging undertaking. The purpose of training is not only to communicate new knowledge but to also teach new skills that can be applied within practice settings. Measuring skill acquisition is one issue but the more important aspect of training is whether new knowledge and skills are applied in work settings.

In an attempt to measure outcomes, students were asked to develop implementation plans utilizing aspects of principles and skills contained within each respective module. These were reviewed and feedback was provided as necessary. In addition, a specialized self-report evaluation has been developed to help understand students’ motivation to change at the conclusion of each module. The data contained in table 2 and 3 below represents only a sample of the data collected and is representative of two modules. It reflects the level of engagement and enthusiasm of the group who thus far has taken the training.

Students were asked to complete an online evaluation at the commencement of each module. Some questions were answered using a Likert scale ranging from Strongly Disagree (1) to Strongly Agree (5), while other questions were open-ended in an effort to gather qualitative data about each student’s individual experience.

Table 2 below reflects data from the first year of the program and is limited to the first several modules. This data reflects the high level of student satisfaction with the training and content. Perhaps as important, Table 3 below, also from the same cohort, reflects an equally high level of desire to change practice within the workplace, however it appeared that work place support is lagging somewhat behind employee motivation toward change.

Concluding Comments

Health care transformation brought on by the ACA is complex, multi-dimensional and spans the entire health care enterprise. Delivery systems, payment methodologies, health insurance operational protocols, evidenced based treatment, wellness self-management designs and clinical research focus are all in motion. The workforce must absorb these new movements by first learning the information necessary for implementation followed by engagement in practice change.

The purpose of this brief report was to describe one approach to re-training the workforce that several major Universities are pursuing in various forms. Alternatively, there are national conferences, web-based learning opportunities, and stand-alone workshops that are all offering various renditions of training in Integrated Primary and Behavioral Health Care, all of which have a role to play in re-training the workforce. Regardless of training venue, training in this area needs to include practice exercises that will allow participants to leave with new knowledge and skills that can be reinforced back at the workplace. Those trained in Integrated Primary and Behavioral Health Care can serve as leaders within their own organizations providing practice change sustainability within this rapidly changing health care environment.

Peter C. Campanelli is a Senior Scholar, Sr. Research Scientist, and Adjunct Professor within the McSilver Institute, NYU Silver School of Social Work; Kyle O’Brien is a Ph.D. student at NYU’s Silver School of Social Work and a Research Fellow at McSilver Institute; Dottie Lebron is a research scientist and community specialist at the McSilver Institute. Joseph Cerniglia is a MSW student at the Silver School of Social Work. Questions can be directed to Peter Campanelli at pcc3@NYU.EDU.

References

Anderko, L., Roffenbender, J. S., Goetzel R. Z., Millard, F., Wildenhaus, K., DeSantis, C. & Novelli, W. (2012). Promoting Prevention through the ACA: Workplace Wellness. Centers for Disease Control & Prevention: Preventing Chronic Disease, 9.

Bodenheimer, T., & Grumbach, K. (2012). Understanding Health Policy: A Clinical Approach. New York: McGraw Hill.

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(2), 759-769.

Campanelli, P. (2015). Blending public health & prevention models. Behavioral Health News. Fall 2015, 8-33.

Fellitti, V. J., Anda, R. A., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,…Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258.

Hardcastle, L. E., Record K. L., Jacobson, P. D., & Gostin, L. O. (2011). Improving the Population’s Health: The Affordable Care Act and the Importance of Integration. Journal of Law, Medicine, & Ethics, 39(3), 317-327

Hofer, A. N., Abraham, J. M., & Moscovice, I. (2011). Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. The Milbank Quarterly, 89(1), 69–89.

Koh, H.K. and Sebelius, K.G. (2010). Promoting Prevention through the Affordable Care Act. New England Journal of Medicine, 363(14), 1296-1299.

Stoto, M. A. (2013). Population health in the Affordable Care Act era. Retrieved from Academy Health: http://www.academyhealth.org/files/AH2013pophealth.pdf

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