Creating a Boundary-Spanning Workforce of Health

Maggie-SauerOver the past year, our newsletters have focused on the efforts of the Foundation and state and national leaders to transform health care.  Success in these efforts will, in part, be measured by the transformation of our current and future workforce.  Recently, NCFAHP hosted a national webinar with 3RNET, the National Recruitment and Retention Network discussing workforce needs in the current environment, New Models of Care and their Impact on Rural Workforce.

Dr. Erin Fraher, Ph.D*  framed the conversation with her presentation:  “The Workforce Needed to Staff Value-Based Models of Care”.  According to Dr. Fraher, new roles are emerging to provide enhanced care functions.

Dr. Fraher suggests that two of the common new roles are:

  • Roles that focus on coordinating care within a health care system
  • “Boundary spanning” roles that coordinate patient care between health care system and community-based settings

Improving patient care and population health is dependent on “boundary spanning.” It’s one thing to create a descriptive title for the process and quite another to engage the workforce in the process. Change is never easy. Yet, to Dr. Fraher’s point we need to “Plan to provide a workforce of health not a healthcare workforce.” Additionally, she makes the following points regarding boundary spanning roles.

  • Workforce planning efforts that include workers who typically practice in community and home-based settings
  • Embracing role of social workers, patient navigators, community health workers, home health workers, mental health workers, dieticians and other community-based worker
  • Integrating health workforce and public health workforce and planning

Hmmmm, this sounds vaguely familiar… Our May newsletter focused on Accountable Care Communities, which are defined as: “a collaborative, integrated, and measurable multi-institutional approach that emphasizes shared responsibility for the health of the community, including health promotion and disease prevention, access to quality services and healthcare delivery.  The ultimate goal of the ACC is a healthier community.”  (Healthier by Design: Creating Accountable Care Communities)

At the Foundation, we are impatiently awaiting the release of the Accountable Care Community model by the CMS Innovation Center.  Fingers crossed, it will provide the opportunity for uniquely partnering these “boundary spanners” together with a payment model to support the work.

Again, in a previous newsletter, Dr. Jerome Grossman and Dr. Jason Hwang’s “The Innovator’s Prescription: A Disruptive Solution for Healthcare” presents a compelling argument regarding the common sense of a “boundary spanning” workforce of health, “Consider this equation, 2 + 8,758. These numbers reflect the hours spent annually by each of us on healthcare during the year. Two hours is the amount of time people spend annually in a traditional healthcare provider’s office, versus 8,758 hours spent on self-care.”

In the article “New Project? Don’t Analyze‑Act!” from the March 2012 edition of the Harvard Business review, authors Leonard A. Schlesinger, Charles F. Kiefer, and Paul B. Brown make this point regarding new endeavors:
“We acknowledge that action before analysis, learning instead of predicting, can be, well, unpredictable—and messy. And we concede that it’s antithetical to the way most organizations work. However, in the long term, taking lots of small steps actually reduces risk, which makes such an approach ideal for tackling challenges and getting fledgling initiatives off the ground, particularly in today’s skittish corporate environment.”

Perhaps with “small steps” we can create a boundary spanning workforce of health.  This newsletter describes some of the “small steps” at the Foundation. The team at NCFAHP strives to be entrepreneurial leaders. I would also call the Fellows boundary spanners in their own communities.  Finally, from the same article:

“Entrepreneurial leaders are individuals who, through an understanding of themselves and the contexts in which they work, act on and shape opportunities that create value for their organizations, their stakeholders, and the wider society. Entrepreneurial leaders are driven by their desire to consider how to simultaneously create social, environmental, and economic opportunities. They are also undiscouraged by a lack of resources or by high levels of uncertainty. Rather they tackle these situations by taking action and experimenting with new solutions to old problems. Entrepreneurial leaders refuse to cynically or lethargically resign themselves to the problems of the world. Rather through a combination of self-reflection, analysis, resourcefulness, and creative thinking and action, they find ways to inspire and lead others to tackle seemingly intractable problems…The only way to lead in an unknowable environment is through action.”
The Bernstein Fellows are entrepreneurial leaders.  In fact, Sarah Thach is the Fellow who directed me to the Harvard Business Review article.  In closing, I think it’s only fitting to end with one of her quotes:

“Just try it…. early frequent failures keep you limber!”

Thanks Sarah, and our thanks to the Fellows current and past!

-Maggie Sauer

CEO & President

A flexible workforce is essential for the future of our health care system. A massive shift in the way services are reimbursed is coming. This prompts a similar shift in how we train the workforce that keeps our communities healthy. Federally funded insurance will pay providers based on the quality of care instead of the quantity. The Centers for Medicare and Medicaid is already funding pilot projects to encourage this change. These “value-based payment” projects are causing a bloom of experiments all over the country. The goal of these experiments is to provide patients with preventative and comprehensive care that is high quality and affordable.3RNet Logo and text

It’s a big challenge. But it will be easier to manage if healthcare providers learn from each other. On August 18, the NCFAHP, Practice Sights, and 3Rnet hosted the first of many webinars to begin a national conversation on the creative models in action across the country. Rural areas, because of their small size and their unique needs, are excellent places for experimentation.

The webinar is titled “New Models of Care and their Impact on Rural Workforce.” The conversation was led by Erin Fraher, PhD, an expert on health workforce research at UNC-Chapel Hill, and representatives from three states presenting on projects in their community.

3RNet Goals List

Erin Fraher set the stage for the discussion by explaining the difference between “old school” and “new school” workforce characteristics. In conventional, fee-for-service models, the healthcare workforce is trained to operate in isolated specialties instead of in coordinated teams. The “new school” workforce reaches patients in their community, rather than in a hospital or an acute care setting. This new workforce will maximize the responsibility of medical assistants, panel managers, dieticians, and health coaches. These teams will have a different work flow to accommodate new roles.

Fraher stresses that we will have to prepare and equip the 18 million members of our healthcare workforce for this change. Medical training will also need to include an emphasis on integrated care and include rotations with teams that are following a coordinated model.

The rural health centers from North Carolina, Oregon and Colorado are piloting a variety of projects in an attempt to launch value-based care. Every state is different, but all three are creatively addressing the unique needs of their community.

Chris Collins from the North Carolina Office of Rural Health & Community Care discussed the variety of loan repayment programs to attract medical workers to underserved areas, including therapists in integrated care settings. Collins also discussed the growth of telehealth services in North Carolina and the efforts to fill the gaps.

Melissa Bosworth of the Colorado Rural Health Center presented their work on creating a data bank to show the economic impact of their programs. Those programs include reducing the number of mentorship hours for nurse practitioners and introducing mediation services to improve office culture in clinics. The Colorado Rural Health Center is also pairing health IT students with rural clinics to help them transition to changing technologies.

Scott Ekblad from the Oregon Office of Rural Health highlighted the 16 coordinated care organizations across the state. Fourteen of these organizations are rural. These organizations have a “global budget,” and are given the creative power to meet needs. They have an incentive to keep Oregon citizens well using community health teams. Medical assistants, dental hygienists and community paramedics have more responsibility and are well connected to patients in a community setting.

Practice Sights and the NCFAHP will continue the conversation on the efforts of states that are moving to value-based care. Stay tuned for the next webinar!

Ron Gaskins PortraitIt takes a cooperative and effective workforce to accomplish value-based, quality-driven care. Ron Gaskins, executive director of Access East, is an alumni of the Jim Bernstein Fellows program. Gaskins is leveraging healthcare communities in the direction of team-based care.

Access East is a nonprofit located in Greenville, NC, whose mission is to improve the health status of the underserved and indigent in eastern North Carolina through enhancing access to quality health care and implementing and coordinating healthcare delivery models. Access East is part of Community Care of North Carolina, a care network that’s evolved over 25 years, with support from the NCFAHP.

“We provide wrap around services for high-risk Medicaid patients with an interdisciplinary team focus,” said Gaskins, “We deploy care managers to the home in a timely fashion in order to keep patients out of the hospital.”

The interdisciplinary team at Access East and their partners collaborate with primary care providers in an ambulatory setting to proactively engage and manage chronically ill patients before their conditions become severe enough to merit care in higher-cost, more acute settings such as the emergency room. Access East uses a vast network of professionals (e.g., registered nurses, social workers, pharmacy technicians, pharmacists, patient advocates, health coaches, etc.) to support its initiatives, which encompass transitional care, medication management, pediatrics, chronic pain, palliative care, and behavioral health integration. The goal is to navigate patients to the right level of care.

The interdisciplinary team at Access East “Workforce development is key,” said Gaskins. “As value-based reimbursement becomes more and more prevalent, the right prescription of team-based care will be vital in effectively managing populations.” Access East has built a workforce infrastructure to ensure the transition to proactive and coordinated care. “This infrastructure requires a holistic framework around workforce diversity that taps into the many different backgrounds and experiences that professionals can bring to the job,” Gaskins added.

The constant need for more healthcare professionals looms in the background of every conversation on rural health. “More primary care physicians are needed, of course,” said Gaskins, “but to meet the demands in care that the coming decades will bring with baby boomers retiring and medicine extending lives longer will require using mid-level providers (i.e., nurse practitioners and physician assistants) to fill in the gaps. Moreover, connecting support staff such as nurses, social workers, and community health coaches with direct providers, we will begin creating team-based care models that can further assist in engaging patients and improving health outcomes.”

Gaskins gives the example of boosting the role of pharmacists in the coordination of value-based care. “The data tells us that Medicaid patients on average visit their primary-care provider two to four times a year, while they see their community pharmacy close to 20 times a year,” said Gaskins. “With this frequency of exposure to the patient, it makes perfect sense to engage the pharmacist out in the community more on chronic disease management.”

To accomplish this, Access East is partnering with Community Care of North Carolina on a project called Community Pharmacy Enhanced Services Network (CPESN) that financially rewards community pharmacists for conducting on-site education around medication management when people pick up their prescription, and reporting any important information back to the patients care manager and primary care provider. “We see the potential of expanding the medical home to more of a medical neighborhood mentality that encourages the cross-pollination of professional disciplines throughout the community,” Gaskins said. What’s needed to empower a workforce that drives value-based care?  “Strong community connections, solid care coordination, and holistic, interdisciplinary teams,” he said. “We’re piloting projects to see what works.”

The Foundation is excited to announce Ron Gaskins, Bernstein Class of 2011—2013, as the first Distinguished Fellows Award Recipient. Ron will receive this award at the 10th Annual Jim Bernstein Health Leadership Dinner on October 8th, 2015.

power-in-collaborationRural communities are characterized by community strength and expertise on their unique needs. Rural Forward NC (RFNC) taps into that strength by bringing together rural health leaders and in some cases, highlighting leadership and unidentified community assets.  The program, funded by Kate B Reynolds Charitable Trust and their Healthy Places NC initiative, supports counties in central and eastern North Carolina participating in the Initiative.  Most importantly the team works with the community to expose opportunities for collaboration and leveraging community assets.  Community organizations are critical to the identification of workforce “boundary spanners”, individuals and organizations that provide critical connections to healthcare.  These organizations can be the link between traditional healthcare setting and community self-care.

Lack of transportation, few physicians, and minimal employment opportunities make it hard for rural residents to maintain their health. Calvin Allen, Director of RFNC says, “Despite these challenges, small towns have a unique asset to build upon. People in rural communities often know each other and have established networks.” Value-based care and the opportunity for community-based workers to actively participate in the health of their community recognizes the unique knowledge and influence they contribute, something the traditional healthcare system needs to successfully improve population health.

Currently, Rural Forward NC is working in Halifax County with leaders creating a community health home.  The work is part of the Blue Cross and Blue Shield NC Foundation’s Community Health Home initiative.   Sharing data across department lines is one of the tactics that leaders in Halifax County are using to address the health of their populations, identify unmet need and create opportunities for the broader community to collaborate

During a three-hour meeting in the Halifax Regional Medical Center facilitated by the RFNC team in June, health professionals met to hash out ideas on how to get Halifax County healthier.  Representatives from the community health center, public health department and hospital attended the meeting, as well as primary care physicians. They discussed further coordination to prevent the replication of services, the idea of a mobile care unit to reach frequent or repeat EMS callers, and a new data-sharing tool that the coalition has developed.

Data-sharing is an extremely useful way for communities to work together. “When you develop an intervention, data can tell you where the greatest need is, and where the greatest potentials are,” says Allen.  “The Halifax County team discovered a family with multiple visits to the health clinic and the emergency room for respiration problems, but had no idea until they combined data that one of the parents was a smoker.” Information sharing across departments changes the intervention from treating symptoms to addressing the root cause in the household. This innovation helps departments streamline their efforts so that services aren’t replicated, which makes greater economic sense, and more importantly, patients aren’t receiving disjointed care.

Despite the benefits, sharing data like this can be very touchy. ” A level of trust has to be established to cross long-held boundaries,” says Allen.  “Our local colleagues are doing an amazing job of respecting privacy and also pooling data across department lines. Fortunately, communities like Halifax County have come a long way in establishing that trust.”

In a health climate that is slowly shifting to value-based care, rural communities, especially the health care workforce, need to work even harder to collaborate around the health of the population as a whole. “It takes creative ideas, development, good case-management, and co-operation,” says Allen, “We are seeing the value of crossing department lines when health leaders look beyond their departments and take a collective view of their community.”

integrated-careMost healthcare providers agree that mental health affects physical health and vice versa. However, integrating the two is not easy.  Providers aren’t trained to address both the mind and the body in one setting. As we transition towards value-based reimbursement, there’s a greater incentive to improve quality for patients. The Center of Excellence for Integrated Care (COE) is an example of a creative approach to improving patient outcomes.

The imminent changes to our healthcare system will result in a workforce that operates differently—and that’s where COE steps in. Housed in the NCFAHP, this small team provides the tools and training for integrating mental and physical health. “And we have our eyes on oral health specialists and pharmacists too.” says Associate Director Christine Borst.

The COE team works in a broad range of settings, and not just traditional healthcare sites. “North Carolina is one of the most diverse states in the nation when it comes to putting teams together to meet the patient where they seek services,” says Director Cathy Hudgins, “This can be a school-based clinic, a mental health or substance abuse clinic, homeless shelters, migrant worker camps and church basements.”

COE breaks down the cultural and educational barriers between health sectors. This type of workforce development, dubbed cross-training, is crucial to better patient outcomes. “It’s been exciting to work with universities,” said Borst, “Conducting trainings early on is really helpful for developing that multidisciplinary lens.”

In a healthcare practice with established workflows, cross-training requires a colossal team effort. “We work with everyone in the office, from the front desk ‘eyes and ears’ of the clinic, to the physicians and therapists in the back,” said Borst, “Regardless of what kind of specialist you are, it’s essential to work together as a team and develop a mindset of integration.”

Every care site is different. Some have a behavioral health therapist in-house; others have close connections to one. Some have no partnerships or experience with behavioral health. Borst gave the example of smoking cessation or diabetes diagnosis. “These issues really require a behavioral health intervention,” she said, “And not every clinic has the resources to provide that.” Tailoring training to meet the needs of a care setting is part of COE’s work. Every practice and every community has its assets, and COE works to create partnerships around those assets.

The biggest hurdle for integrating care is payment reform. “Everyone wants to know how to pay for it,” said Borst. COE provides some direction on navigating the billing process, but it will take policy reform to dictate how behavioral health integration will be properly reimbursed.

Effective workforce training to integrate the siloes of care is an important step towards fully implementing value-based care. “There’s a method to our madness,” Borst said, “Laying a strong foundation for a multidisciplinary approach is the first step.”

Rural areas are not the only places for which health care access is a challenge.

In urban areas like Wilmington, North Carolina, access is also an issue, especially for teens and young adults in underserved populations who face barriers like transportation, location, and insurance coverage. Jill Boesel, the Development and Outcomes Director at WHAT, or Wilmington Health Access for Teens, has been a part of closing the gap and bringing health care closer to where teens and young adults are.

blood-pressure-doctorWHAT is a community-based nonprofit health care organization that focuses on improving health care access and integrated care for adolescents and young adults between the ages of 11 and 24 in the Wilmington area.

WHAT opened its first school-based health center in 1999 and currently runs centers in three of the four local public high schools in Wilmington. The centers are located on the high school campus, open to students as walk-ins or by appointment. The centers are staffed with multidisciplinary teams that include a primary provider, mental health counselor, and registered dietician at each site.

School-based health centers have several advantages from their location. In addition to overcoming the barriers mentioned above (transportation, geography and insurance coverage), WHAT minimize lost class time for students, as students are able to simply walk down the hall to their appointment. WHAT also minimizes lost work time for parents. Parental participation in appointments is strongly encouraged, but rather than a parent having to pick their child up, take them to the doctor and back to school, parents can simply come to the school for the appointment and then return to work.

In addition to offering health care services to students in the form of one-on-one appointments, WHAT also provides the entire school with ongoing education about the health care needs of students, and WHAT providers work closely with school counselors, social workers, faculty and administration to improve the overall health of students.

Along with the school-based clinics, WHAT also runs a centrally located facility that offers adolescents and young adults, ages 11-24, access to primary care, mental health, nutrition and prevention services. Three-quarters of the population served by WHAT clinics are either publicly insured or uninsured, which provides a fair share of challenges for the clinics, especially in the rapidly shifting health care environment in the country and in this state.

jill-boeselJill Boesel came to the Wilmington area and to WHAT in 2007, and her primary role focuses on seeking and securing public and private grants and managing current grants. She is also a member of the organization’s leadership team, and believes that the key to her work is communicating very effectively the advantages of having a school-based health center situated conveniently on campus for students and parents.

“The most cherished aspect of my job is having the ongoing opportunity to develop relationships with so many incredibly talented, energetic and committed people—both within and outside of Wilmington—who are working relentlessly to pave the way for a better tomorrow here in North Carolina, despite the often seemingly insurmountable challenges we face in health care today,” Boesel says.

She points out that WHAT is focused on “whole person care”, where the traditionally separated areas of primary care, mental health care, nutrition, and other areas occur within a connected network. This enables the provider in each area to be aware of what is going on in other areas and proactive in connecting the dots when appropriate to give the patient the best overall care possible. By having different types of providers serving patients in a team-based approach in the same location, integrated care works naturally and improves the patient experience and outcome.

Boesel is a current Bernstein Fellow, and her project is very fitting with the true integrity of the Bernstein Fellowship program and the mission of Jim Bernstein: ensuring access to health care for the populations that are most vulnerable in our state. She is exploring how WHAT as an organization can improve the use of data for population health and patient engagement, within the context of an integrated school-based healthcare setting.

Boesel says: “My fellowship has afforded me the unique opportunity to connect with others doing similar work throughout other regions of the state, including my “fellow Fellows” and many others.”

Top Benefits of a School-Based Health Center

Most students in North Carolina have just started another year of school, another year of learning with teachers, friends, homeroom, and physical education classes.

For students in rural areas, good healthcare is not always easy to access.  Many parents work full-time, and it can take up to an hour (or, in some places, longer) to get to the nearest hospital or doctor’s office.  This often makes finding the time to take your kids to the doctor, for a routine check-up or a seemingly small health issue, so difficult for parents that many don’t do it.  Consequently, many students don’t receive medical attention they might need.

That’s why school-based telemedicine programs – where students have videoconference appointments from right inside their school building with doctors who are in other locations – are spreading across the country and showing successful outcomes.  One such program is right here in the western part of North Carolina.

MY Health-e-Schools is a program started in 2011 by Dr. Steve North, a family physician who saw the need for better healthcare access for students in Mitchell and Yancey counties in western North Carolina.

Amiria w/CartHow does a telemedicine program like MY Health-e-Schools work? At the beginning of each year parents can sign consent forms enrolling students in MY Health-e-Schools, which allows students to be seen during the school day by remotely located nurse practitioners or physicians.  Parents or teachers can refer students, or the students themselves can make an appointment to be seen for anything from a cold to potential symptoms of ADHD.

Many things can be done at that appointment, which is conducted via high-definition videoconferencing using specially equipped stethoscopes and cameras.  This allows a centrally located health-care provider to examine students at multiple schools without traveling, and therefore allowing more students to be seen across a large area.  When more complex processes like lab work or further tests are needed, the provider refers the student to the closest hospital or specialist.

MY Health-e-Schools providers can address issues ranging from the common earache, stomachache or cold, to chronic disease management, medication management, check-ups, sports physicals, adolescent medicine, and even telepsychology and tele-behavioral health.

North first became interested in school-based health systems while working for Teach For America in Edgecombe county before attending medical school at UNC-Chapel Hill.  Steve then moved to Rochester, NY for his residency and a fellowship in adolescent medicine, during which time he learned from the school-based health centers there.

North relocated back to North Carolina in 2006, and in 2007 became a Bernstein Fellow. During this time, he continued researching and seeking to better understand telemedicine systems and began developing the idea of a school-based telemedicine program in western North Carolina.  He received initial grant funding from the Kate B. Reynolds Foundation and the Community Foundation of Western NC, and several other sources that matched funds in the following years.

With these funds, a pilot program was begun in 2011, serving three schools in Mitchell and Yancey counties. By the second year, the program was expanded to 10 schools in the two counties and, by the third year, to 14 schools, which meant that all the schools in the two counties without their own health center had access to a primary care provider through MY Health-e-Schools.

This year MY Health-e-Schools is expanding into schools in McDowell County, and the program now allows over 8,000 students in 21 schools in the three counties to have access to trained medical providers during the school day without leaving their school building.

MY Health-e-Schools also recently received the 2014 American Telemedicine Association’s President’s Award for Health Delivery Quality and Innovation, showing that, even in only its 4th year of operation, the program is still growing and has the opportunity ahead to better health-care access for rural communities in North Carolina.

Health e-SchoolIn the meantime, MY Health-e-Schools is working to improve health care in the community, one student at a time.  North talks about the program’s impact with stories, including one of an eight-year-old student with high blood pressure who was seen at an appointment through the program.  During the appointment the provider referred him to his primary care physician and to get labs done, during which time they discovered that the student had post-streptococcal glomerulonephritis (GN), a kidney disorder that can occur after a routine strep infection.  Without the initial appointment with the MY Health-e-Schools provider, the disorder might have gone undetected for much longer and become much more severe.

North attributes the success of MY Health-e-Schools to being able to do a lot without a lot of resources, with tremendous community support.

MY Health-e-Schools is now the largest program part of North’s nonprofit organization, the Center for Rural Health Innovation.  For more information on MY Health-e-Schools, visit their website.

Special Note: The N.C. Foundation for Advanced Health Programs is pleased to announce Dr. Steve North will be joining its Board of Directors in 2015.