Building a Workforce for Health Care’s Evolving Needs Kelley Withy, MD, PhD withy@hawaii.edu Hawaii Physician Workforce 2017 • Over 9,000 licensed physicians • Current supply of physicians is 3551 for 2978 FTEs • An Increase of 49 FTEs from last year • At least 65 retirements and 136 moving out of state Statistics • Shortage of about 419 with basic calculations, but 769 when you examine island and specialty specific needs (last year numbers were 455 and 707) • We only have 120 job openings in Hawaii… www.ahec.Hawaii.edu/doctor-jobs/ • Our average age of physicians is 54.4 with over half being over 55 • Percent of docs in groups of or less fell from 54% to 52% Actual numbers until 2017 3600 Supply Demand 3400 3200 3166 3208 3249 3291 3276 3310 3358 3000 2865 2800 2760 2600 2520 2400 2200 2000 2903 2894 2802 2806 3399 2978 3440 3481 3522 3050 2900 2950 Newest Physician Shortage Numbers Island (2016 number) Oahu (339) Big Maui Island County (183) (125) Kauai (62) Statewide Shortage 381 196 53 769 Percentage 16.5% 38.7% 34% 30% 22.6% 139 Primary Care Shortage Numbers Island (2016 number) Oahu (142) Big Island (36) Maui County (34) Kauai (16) Statewide Shortage 187 46 39 10.5 282.5 Percentage 22% 25% 26% 16% 22% Hawaii Physician Ages Compared to US Average 28 27 26 28 25 22 Percent by Age Group 21 12 Hawaii US under 35 35-44 45-54 55-64 65 and over 21 28 26 27 28 25 22 12 Greatest Specialty Shortages (by percent) by Island: Oahu Big Island Infectious Disease Colorectal Surgery Pathology Infectious Disease General & Family Practice Thoracic Surgery Pulmonology Neurological Surgery General Surgery Neonatal- Perinatal Maui County Kauai Geriatrics Infectious Disease Colorectal Surgery Endocrinology Neonatal-Perinatal Critical Care Rheumatology Neonatal-Perinatal Pulmonology Nephrology What progress have we made? AHEC promise: We will help ANY student from Hawaii interested in a health career get there! • 812 students in long term mentoring pipeline http://www.ahec.hawaii.edu/phcc/ • Shadowing, mentoring, research, test prep, college and career prep • Looking for coordinator on Maui right now Increase Rural Training In order to expand class size, we have to train on neighbor islands • Recruit, support and train students from and on neighbor islands • Work with providers to increase training-bill in legislature to give tax credit for teaching • Work with communities to host students-rhondaro@Hawaii.edu • Work with companies to sponsor travel Trained to Bridge Gaps Preventative and Chronic Disease Management Related to Medication Management Medication Therapy Management – effective drug therapy in acute and chronic diseases •Patient education and health advocacy •Vaccination •Contraception Prescribing (6th State to Pass) •Naloxone and Opioid •Antibiotic Stewardship Program •Stewards for proper drug efficacy •Correct indication and selection, dose, interval, route •Adherence – compliance •Transitions of care between institutions/community and levels of care How Pharmacists Can Bridge Provider Gap Safety Costs and Drug Shortages • Drug/drug interactions • Drug/disease interactions • Side effect and adverse drug management • DSMT (group vs individual) • Pharmacy Benefit Managers • Chronic Care Management • Long term care Challenges Designated Provider Status • Federal Bill (S.109, HR 592) Pharmacy & Medically Underserved Areas Enhancement Act • -Hawai’i State 2017 Legislature deferred • HB 1406, SB 187 – Expand RPh Scope of Practice • HB 156 Relating to Reimbursements for Pharmacist codes visit revenue Ability to bill CMS/ CPT Ability to segregate RPh CB/HB billing and Capability of Electronic Medical Record Challenges Reimbursement Legal/Legislative amount for time spent vs operation expenses (lease rent, utilities, support staff) Collaborative Agreements CB/HB ability to pay RPH salary without reimbursement Expanding Scope of Practice National: Pharmacy and Medically Underserved Areas Enhancement Act Implications of S109 and HR 592 for Hawaii Sandra Leal, PharmD, MPH, FAPhA, CDE sleal@sinfoniarx.com 520-302-5325 Federal H.R 592/S 109 National: Pharmacy and Medically Underserved Areas Enhancement Act • Section 2(a) • Amends Section 1861(s)(2) of the Social Security Act by adding a new subsection “GG” to the law that would authorize Medicare Part B coverage of “pharmacist services.” • Limits these services to services: – Provided by a State licensed pharmacist, individually or on behalf of a pharmacy provider; – Defined based on what the pharmacist is legally authorized to perform in the State in which the services are performed; – That would otherwise be covered by Medicare Part B if the services were performed by a physician or incident to a physician’s service; and – Provided in a health professional shortage area, medically underserved area, or medically underserved population (each of which is defined within the Public Health Service Act) Sandra Leal, PharmD, MPH, FAPhA, CDE sleal@sinfoniarx.com 520-302-5325 Federal H.R 592/S 109 • Section 2(b) reimbursement for practitioners in underserved areas • Amends Section 1833(a)(1) of the Social Security Act by adding a new subsection “(AA)” to the law to define payment of “pharmacist services.” • Establishes reimbursement for these services as equal to 80% of the lesser of the actual charge or 85% of the physician fee schedule amount (established in law), if these services had been furnished by a physician Sandra Leal, PharmD, MPH, FAPhA, CDE sleal@sinfoniarx.com 520-302-5325 Building a Workforce for Health Care’s Evolving Needs Jean Melnikoff Vice President, Human Resources Kaiser Permanente, Hawaii 31 | Copyright © 2017 Kaiser Foundation Health Plan, Inc Hawaii faces common and unique challenges - Physician A University of Hawaii assessment found our doctor shortage is worsening The pipeline of caregivers, including doctors, nurses, therapists, and elder care specialists has not kept pace with demand Physician Shortage 381 Primary care are the largest group in short supply, followed by infectious disease and geriatric specialists 139 196 53 Our ability to educate and train the future workforce locally is too often limited in what is available We enjoy and are challenged by our geographic location 32 Oahu Maui Big Island Kauai Hawaii faces common and unique challenges – Nursing Educational Programs Offered in Hawai‘i's As of 2016, there were roughly 11,390 RNs in the state of Hawaii According to the Health Resources and Services Administration (HRSA), it is anticipated that there will be a shortage in Hawaii of 3,311 full-time RNs by 2025 There are not enough specialty RNs in Hawaii hospitals, so travelers are being utilized more heavily, and at a greater cost This shortage is due in part to the lack of locally available training These shortages are expected to continue as the nursing workforce ages and retires, and the need for nursing services increases Educational Programs Offered CU HCC HPU Kap CC Kau CC UHH UHM UHMC UOPX Non-Baccalaureate Programs Licensed Practical Nurse (LPN) X X “Ladder” Program: Licensed Practical Nurse (LPN) combined with an Associate's degree in nursing (AS) X Licensed Practical Nurse (LPN) to Associate degree (AS) X Associate's degree in nursing (AS) Associate's degree Assistant Associate's degree Technician Associate's degree Assistant Associate's degree Technology X X X X - Occupational Therapy X - Medical Laboratory X - Physical Therapist X - Radiologic X Baccalaureate Programs Bachelor of science in nursing (BS) X X X X LPN to bachelor of science in nursing (BS) X Registered Nurse (RN) to bachelor of science in nursing (BS) Accelerated RN to BS X Bachelor of Social Work (BSW) X X RN to Master of Science in Nursing (MS) X X BS to MSN Master's Entry Program in Nursing (MEPN) X X X Master of Social Work (MSW) X X X X X X X Master of Science Programs X Doctoral Programs Doctor of Nursing Practice BS to Doctor of Nursing Practice (DNP) Chaminade University; Community College; Hawai‘i Pacific University; Kapi‘olani Community College; Kaua‘i Community College; Hawai‘i 33 University of Hawai‘i at Hilo; University of Hawai‘i at Manoa; University of Hawai‘i Maui College; University of Phoenix X X BS to Doctor Philosophy in Nursing (PhD) MS to DNP MS to PhD X X X X Hawaii faces common and unique challenges – Other Job Family Behavioral Health Access to care is impacted by the lack of Psychologists (PhD), Medical Social Workers and others (LCSWs, MFTs) Allied Health Many health care professionals work at the bedside or behind the scenes providing laboratory, imaging and other critical services needed to diagnose and treat patients Due to the shortage in local pipeline program, we have partnered with educational institutions in the lower 50 states to meet the workforce need in the region Nursing Management Nursing is the largest licensed professional group and to step into leadership required new skills and competencies They are discouraged by administrative burdens, competing demands, and lack of clarity in role and responsibility 34 Ongoing study of Enterprise-wide High Reliability Operating Model (HRO) to reduce nurse management burnout and turnover Examples of Supporting Workforce Planning and Development Residency and Internships The Ben Hudnall Memorial Trust Graduate Medical Education to provide educational support, guidance and supervision of interns, residents and fellows KP Primary Care Residency program is in it’s year Front-line workforce is provided guidance for career development and resilience training to adapt to health care’s evolving needs Nurses accessed specialty training in NICU, L&D, and Emergency Career Management Program Supporting for lifelong learning with financial support through tuition reimbursement, resources and on-line tools to support growth in current or new areas Over 1,200 courses and videos support individual development Skills of the Future National and local focus on digital fluency, collaboration, process improvement to help create a change-ready, highly-skilled, flexible workforce What Can We Do to Help? As an industry we have to articulate our needs and work together to push for education that is relevant to our emerging needs • Share information broadly about workforce future shifts • Invest in relationships with education institutions and common work across our industry • Create collective solutions not just individual ones • Promote the strengths of our location and culture to attract a workforce who values our many benefits • Create an early warning system for upcoming workforce shortage 36 Recruit Students-We have 800 students in the pipeline Encourage middle school and high school STEM programs, provide mentoring, shadowing We need to increase and expand training and support them so that we can KEEP them all Professionals-Recruit enough here from elsewhere until we train Hawaii Physician Recruiters Group, spreading the word to Hawaii students and across US What else can we do? Prepare Expand training: OT, PT (UHWO? UH Hilo?), specialty Nursing, Social Work Residencies: Psychology, Nurse, Pharmacy Internships/Apprenticeships-money available from Department of Labor and Industrial Relations for training for interns, especially IT Jobs waiting upon graduation-partnership between academia and industry Preceptor Tax Credit Early Warning System in development Support Loan repayment: MD/DO, APRN, PA, Psychology, SW, MFT Local area consortia to support current and upcoming health professionals Legislation to expand scope of practice for better inter-professional healthcare for patients Student stewardship programs Welcome wagon Create integrated clinics in areas of need? Do you see yourself as part of the solution? Educational Institutions Legislators Employers Technology developers Healthcare providers and systems Patient advocates