addressing staffing shortages in an era of reform

A few weeks ago, one of my colleagues handed me a list of brand-new jobs in our health system. The list included titles such as continuing care network director, advanced practice navigator, medical home quality director, post-acute advanced practitioner, outpatient coach, ACO care manager, ACO navigator, virtual care advanced practitioner, system vice president for outpatient quality, and system vice president for care management. As I glanced over the page, my friend pointed out the requirements for these roles.

"Almost all of the positions are for nurses," she said, "except for the two system vice president roles, which are for physicians."

I was not surprised. As systems develop clinically integrated networks and accountable care organizations (ACOs), opportunities for nursing professionals are expanding. Reporter Maggie Fox highlighted this point in recent comments on N BC News: "[Nurses are] being tapped to take on the lion's share of the work as millions of Americans get health insurance for the first time."a At the same time, new management positions are opening up for physicians as hospitals and health systems try to strengthen their alignment.

Both of these trends are positive. Nurses, with their broad knowledge and holistic view of patient care, are especially well-suited for new roles in the next era of health care, which will likely focus more on prevention and population health management. Similarly, having more physicians in leadership positions may help connect the clinical and the business sides of our industry. However, there is a downside: The demand for physicians and nurses to fill these new roles is exacerbating the current and impending shortages in both professions.

How the Shortages Connect

According to forecasters, the United States will face a shortage of 91,000 physicians within a decade and more than 900,000 nurses by 2030.b The shortage will be particularly acute in primary care, with the United States projected to face a shortage of 45,000 primary care physicians by 2020.c

This last statistic is especially important to those who are planning strategies for health systems in an era of reform. Accountable care and population management require a robust primary care enterprise to keep patients as healthy as possible throughout the continuum of care.

For this reason, a growing number of primary care practices are adding advanced practice nurses (APNs) and physician assistants (PAs) to their ranks. On the surface, this strategy makes sense. Working in teams, physicians and advance practitioners can provide greater access to high-quality care. The research backs this up: A review from the Robert Wood Johnson Foundation found that patients treated by APNs have health outcomes equal to those of patients treated directly by physicians/*

But dig a little deeper into the issue, and the potential downside becomes clearer. As the Council on Physician and Nurse Supply points out, "Nurses and physicians are interdependent, so shortages in one group will aggravate shortages in the other."' Utilizing APNs and PAs to extend physician practices may lead to shortages of advance practitioners in other important roles.

Combating Shortages

Health system leaders recognize that these shortages threaten the quality of care they can provide to patients. As a result, competition for talent is becoming more heated in several parts of the country. But bidding wars do little to address the shortage of physicians and nurses itself. As hospital and health system leaders, we also should work to increase the total supply of clinicians and develop new models of care that will best use our limited supply. One strategy is to create more "slots" for clinical students to pursue medicine and nursing. Another is to ramp up our efforts to inform the public about job opportunities in the healthcare sector.

But these are not short-term solutions. That is why hospitals and health systems should make it a priority to project their own workforce needs for both the near and long term. The short term can be approached with familiar tactics: analyzing current workforce numbers and skills, projecting retirements and turnover, and executing recruitment plans that assume care models will stay the same. On the other hand, workforce needs could be radically different in the next era of health care, which will likely focus less on acute care and more on the continuum of care.

Workforce Planning at CHI

CHI has embarked on a comprehensive, strategic workforce planning approach focused on identifying the roles that are essential for current and future success. Strategic workforce planning requires that system leaders have a vision of how they will deliver care in the future. Human resource leaders, finance leaders, strategy leaders, and clinical leaders should work together to project a year-by-year forecast of what the integrated delivery system may look like (including the physician enterprise, the acute care enterprise, and the post-acute enterprise). Just as a budget is based on assumptions, the vision should be based on assumptions about payment systems, actions by government and other payers, and the speed of technology innovations that may change workflows. For example, leaders might develop their vision based on the following assumptions:

* For at least eight years, both government and private insurance will continue to be significant payers in health care.

* Within five years, clinically integrated care and population health will be the predominant care model in the United States.

* Within 10 years, we will need only half the current number of hospital beds in the communities our systems serve.

* Within 10 years, new technology will decrease the level of education and licensure needed to diagnose and prescribe for many individual medical conditions.

Leaders should review this vision frequently so that they may change it as needed.

Once a system has a vision for future care delivery, it can design a plan to attract and develop the appropriate workforce, even in the face of projected personnel shortages. Clarence Hauer, vice president of human resources strategy and operations at CHI, advocates this approach: "By identifying strategic roles for the future, we can forecast and profile the available and required talent pool within and external to our organization. This drives our strategies. In other words, we need to be ready to manage the health of populations effectively by ensuring we have the right people in the right roles, doing their jobs in the right way for the next era, which may be different from today."

Leadership plays a foundational role in workforce development, which is one reason why CHI has developed a physician and nursing leadership program. The system is encouraging leadership dyads (such as the chief medical officer and chief nursing officer) to attend classes together for one year. In addition to learning about how to manage in teams, each attendee is required to complete a reallife project, including those that prepare CHI for the next era of integrated networks.

Like many systems, CHI has already moved to increase the talent pool in some strategic positions based on assumptions about the emerging models of care. These models include team-based care in outpatient areas and a newly designed nursing team model on inpatient units. Both models are designed to utilize human resources in a way that improves quality while decreasing costs.

Team-based care in outpatient settings. In this model, physicians work with advanced practitioners to deliver primary care in an outpatient setting. CHI has recently hired a national vice president for advanced practice (an advanced practice nurse) to work as a dyad leader with the vice president for clinical quality for physician services (a primary care physician). Together, they will design primary care teams for the future, which will likely include members from other professions and roles (such as pharmacists, dietitians, social workers, psychologists, healthcare coaches, and care managers) to ensure that each works at the top of his or her license. In this team-based care model, which is part of the system's preparation for population management, care managers will help triage patients so that each individual receives the appropriate level of care. Triage procedures in the office may determine whether a clinical examination could be performed by an advanced practitioner or requires a physician.

The CHI inpatient nursing model. This pilot model, which currently is being trademarked, changes team workflows with the help of technology. This new model also changes the job descriptions of nursing team members and adds new roles. Under the model, the vice president for advanced practice is responsible for working with human resources to project the number of advanced practitioners needed for the next decade in each market. The vice president for advanced practice is also responsible for working with academic institutions to design innovative programs for educating new practitioners in markets where there is the most need. As part of the model, CHI also is adding clinical nurse leaders (CNLs), who are frontline nurse leaders with master's degrees. Their role is to oversee, coordinate, and direct the care delivered by specialized team members. The team members will be either technical and procedural experts, direct care and comfort providers, or assessment and education professionals. This model differs from current models in which a single nurse must be expert in all three areas.

Many of the new roles being created at CHI require-or strongly prefer-a master's degree. That is why part of CHI's strategic planning includes consideration of possible special tuition assistance programs for strategic positions. As the number of jobs for some areas (such as inpatient unit nurse positions) decreases, this policy also is a way to retain valuable employees who want to move on to new roles.

CNLs exemplify how critical education is to the system's workforce strategy, as many of the emerging roles will require higher education. The Council on Physician and Nurse Supply points out that the emphasis on nursing education "should be at the baccalaureate level, rather than on associate programs, as few advanced practice nurse graduates move on to advanced practice or faculty levels, both of which are needed." (Advanced practitioners have a minimum of a master's degree, and an increasing number are getting doctorates.)

Leading the Way

To those of us who have chosen to lead in this era, it is clear that a strategic workforce plan is critical for successful integration in the next era. Taking steps to plan today may help us ensure the stability of tomorrow's workforce. It also helps us achieve our goal of ensuring that patients receive care from an appropriately skilled team of caregivers in the future. *

AT A GLANCE

* Health system leaders should understand that physician and nursing shortages threaten a hospital's ability to offer high-quality care.

* Integrated delivery systems should project their workforce needs for both the near term and longterm.

* Catholic Health Initiatives (CHI) is using two new models of care that deploy staff in new ways.

As hospital and health system leaders, we also should work to increase the total supply of clinicians and develop new models of care that will best use our limited supply.

a. Fox, M., "Double Whammy: Nursing Shortage Starts in the Classroom," NBC News Health, Aug. 31,2013 (www.nbcnews.com/health/double-whammy-nursing-shortage-starts-classroom-8c10990502).

b. Krupa, C., "Physician Shortage Projected to Soar to More than 91,000 in a Decade," American Medical News, Oct. 11,2010 (available at www.amednews.com/article/20101011/profession/ 310119958/6/%29); and Juraschek, S.P., Zhang, X., Ranganathan, V., et al., "United States Registered Nurse Workforce Report Card and Shortage Forecast," American Journal of Medical Quality, May-June 2012 (available at www.ajm.sagepub.com).

c. Ermack, L. "Newly Insured Ranks Could Deepen Primary Care Doctor Gap," The Holland Sentinel, Sept. 30,2013 (available at www.hollandsentinel.com).

d. "Quality of Care Provided by Advanced Practice Registered Nurses (APRNs)," Robert Wood Johnson Foundation, May 2011 (available at www.thefutureofnursing.org/resource/detail/quality-care-provided-advanced-practice-registered-nurses-aprns).

e. "Finding Solutions to the Healthcare Staffing Shortage," The Council on Physician and Nurse Supply (www.physician nursesupply.com).

Kathleen D. Sanlord, RN, DBA, MBA, MA, FACHE, is senior vice president and chief nursing officer, Catholic Health Initiatives, Denver, and a member of HFM A's Colorado Chapter ([email protected]).