Raising a Healthcare Workforce in NC to Care for People and Families with Serious Illness Mitchell T. Heflin, MD, MHS Duke Geriatrics April 12, 2019 Duke GWEP https://geriatrichub.nursing.duke.edu/
Overview • Needs – Who has serious illness and who cares for them? – What are the quantitative and qualitative gaps in workforce preparation? • Opportunities – New roles – Resources & funding – Current models Duke GWEP https://geriatrichub.nursing.duke.edu/
Aging Population in North Carolina Reddy S, NC State Aging Profile, December 2017. Duke GWEP https://geriatrichub.nursing.duke.edu/
Older adults in NC: Health • 81% with at least 1 chronic condition; 51% have 2 or more • 160,000 with Alzheimer’s disease • 22% report difficulty with mobility – 29% had at least one fall; 16 % with two or more • High rates of poverty, limited education, isolation • Average life expectancy at age 65 is 20 years Reddy S, NC State Aging Profile, December 2017. Duke GWEP https://geriatrichub.nursing.duke.edu/
Serious Illness in NC: Other populations • End stage renal disease • Chronic obstructive pulmonary disease • Congestive heart failure • Cancer (as a chronic disease?) • Neurologic conditions: spinal cord, brain injury, stroke, dementia • Children with medical complexity (CMC) (D. Ming, MD) – 1% of children; 33% of pediatric health spending – Technological needs and caregiver burden Duke GWEP https://geriatrichub.nursing.duke.edu/
Workforce drivers • Demand – Medically and technologically complex care – Care increasingly in ambulatory and community environments – Family caregiver needs • Supply – Newly graduated professionals unlikely to meet demands – Concentrated in large centers in more urban areas – Limited resources for retraining individuals and teams Duke GWEP https://geriatrichub.nursing.duke.edu/
NC Community Health Worker Report, May 2018. Duke GWEP https://geriatrichub.nursing.duke.edu/
https://nchealthworkforce.unc.edu/ Duke GWEP https://geriatrichub.nursing.duke.edu/
https://nchealthworkforce.unc.edu/ Duke GWEP https://geriatrichub.nursing.duke.edu/
https://nchealthworkforce.unc.edu/ Duke GWEP https://geriatrichub.nursing.duke.edu/
https://nchealthworkforce.unc.edu/ Duke GWEP https://geriatrichub.nursing.duke.edu/
Workforce Needs in NC • Increase health professions serving rural areas • Enhance/incent training in ambulatory, long term care, and community settings • Recruit and train a more diverse workforce to reflect the population served Erin Fraher, PhD, MPP. Presentation on Program on Health Workforce Research and Policy, March 2, 2018 Duke GWEP https://geriatrichub.nursing.duke.edu/
Workforce Needs in NC: Curriculum • Management of multiple chronic conditions and medications—ie medical complexity • Diagnostic and therapeutic technologies • Geriatrics and palliative care • Information access and exchange • Communication and coordination • Community engagement • Teamwork Duke GWEP https://geriatrichub.nursing.duke.edu/
Interprofessional teams • Increased competence in IP collaborative practice • Team members functioning at “top of scope of practice” – E.g. Licensing and supervision of NPs • Greater flexibility/variability of roles within and between professions • New roles requiring retraining and new credentials • Educators skilled at training in team-based care – Teaching across professions • Clinical practice sites with high functioning teams Interprofessional Education Collaborative. (2016). Washington, DC. Duke GWEP https://geriatrichub.nursing.duke.edu/
Interprofessional Education to Enhance Learner Outcomes Interdependent with Collaborative Practice to Enhance Patient Outcomes Professional Systems Educational Systems (Regulatory and Payment) (Accreditation– Institutional Structures) Teaching Interactional Institutional Organizational factors factors factors factors Health Patient Educators Educators Shared Learning Professions Governance Provider Goals Content Learner Vision & Org. Learner Outcomes Learner Leadership- Outcomes Resources Educators Educators Administrative Faculty Structuring Sense of Development Belonging Processes Clinical Care Modified from D’Amour & Oandasan, 2005, J. of Interprofessional Care Supplement 1, 8-20 Duke GWEP https://geriatrichub.nursing.duke.edu/
Changing definitions of workforce • Value-based, person-centered care • Evolving roles: – Care coordination • Navigators, care managers, case managers, transition specialists – Practice facilitators • Workflow redesign and change managers – Population-based approaches • Population health nurses – “Boundary spanning” roles • Assessing and addressing social drivers of health – Health information technologists Fraher E, Ricketts T. NCMJ, 2016. Duke GWEP https://geriatrichub.nursing.duke.edu/
Evolving role of nursing • Care management experts – Billable services through TCM and CCM • Population health specialists – Health information specialists • Health educators – Group/Centering clinics • Practice and system leaders • Barriers: Reimbursement, Licensing Fraher E, Spetz J, LDI Interdisciplinary Nursing Quality Research Initiative, 2015. Duke GWEP https://geriatrichub.nursing.duke.edu/
Expanded definitions of workforce • Advanced Direct Care Worker: (www.eldercareworkforce.org ) – Increased demand for homecare for disabled and dying – DCW as extension of care team – Enhanced training • Monitoring for and communicating changes in condition • Support adherence to medication, nutrition, activity • Disease specific: CHF, Diabetes, Dementia – Questions regarding supervision and financing EWA Issue Brief, September 2014. Duke GWEP https://geriatrichub.nursing.duke.edu/
Expanded definitions of workforce • Community Health Workers: (https://files.nc.gov/ncdhhs/DHHS-CWH- Report_Web%205-21-18.pdf) – “Boundary spanning” role with community connection – Focus on social connector function– “last 5 feet” – NC DHHS CHW Initiative final report May 2018 – Roles, curriculum, certification • Family Caregivers: (www.eldercareworkforce.org ) – Nearly 18 million in US; one third > 65 years old – 50 % employed with $250B in lost wages – Do “heroic amounts of work daily just to tread water” (D. Ming) – Need training, resources, respite and voice as team member Duke GWEP https://geriatrichub.nursing.duke.edu/
Resources/Networks • Academic health centers and Community-based training programs • Area Health Education Centers • Community Colleges • Office of Rural Health • Area Agencies on Aging • NC Medical Society • Other…. Duke GWEP https://geriatrichub.nursing.duke.edu/
Funding • Limited funding for education • Debt driven decisions • Health Resources and Services Administration (HRSA) • Insurers, ACO’s, Health systems • Medicare/Medicaid • Accountable Care Communities – http://nciom.org/task-force-on-accountable-care- communities/ • Low or no tuition/loan repayment Duke GWEP https://geriatrichub.nursing.duke.edu/
Summary • Future healthcare workforce needs to account for value-based care • Shift focus to rural areas and community-based sites • Emphasize team-based care and flexible roles • Expand direct care and community health worker programs • Include family caregivers as team members • Engage government, health systems, and insurers in training redesign and finance Duke GWEP https://geriatrichub.nursing.duke.edu/
Duke GWEP https://geriatrichub.nursing.duke.edu/
Geriatric Workforce Enhancement Programs (GWEP) Establish centers to develop a healthcare workforce that maximizes patient and family engagement and improves health outcomes for older adults by integrating geriatrics with primary care . • 44 nationwide • 3 in North Carolina—including UNC and ECU Duke GWEP https://geriatrichub.nursing.duke.edu/
Duke Geriatric Resource Team (GRT) Training Program Improved care of older adults Connections: Continuous Referrals to ICT, Improvement: community Focused projects Competencies: agencies Upfront training for frontline staff and nurses Monthly Communication: webinars, online IPCP training resources workshop Duke GWEP https://geriatrichub.nursing.duke.edu/
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