1. Building the Health Workforce as We Transform the Delivery System Mary D. Naylor, PhD, RN Marian S. Ware Professor in Gerontology University of Pennsylvania School of Nursing The Commonwealth Fund-Nuffield Trust 15 th International Meeting on the Quality and Efficiency of Health Care July 17, 2015

2. Initial Reflections The “high need, high cost” (HNHC) population is comprised of many subgroups with diverse trajectories but share in common the need for upfront investment and longitudinal follow-up. Health system transformation “is best conceptualized…as a process that involves concurrent redesign of the service and workers’ roles.” (Bohmer & Imison, Health Affairs, 2013, p. 2028)

3. A Population Health Framework to Guide Workforce Transformation for HNHC Patients

4. Upstream: Community-Based Care Community-based high need, high cost patients and family caregivers Risk Stratification Implementation of care plan collaboratively developed by patients/caregivers, primary care clinicians/teams Follow-Up Based on Risk Engaged patients/ caregivers, improved symptom/function, prevention of hospitalizations/ED visits/timely access to palliative care ScreeningMonitoring

5. Downstream: Acute/Post-Acute/Follow-Up Level 1 illness (primary care) Level 2 illness (palliative care) Level 2 illness (palliative care) Level 3 life (hospice) Level 3 life (hospice) Population of Acutely Ill HNHC Patients Hospital Phase Post Acute/ Rehab Phase Long-Term Follow-up Palliative Care Transitional Care Patients’/caregivers’ goals met; improved symptoms +function; reduced hospitalizations+ED visits; death with dignity

6. Common foci of international workforce transformation for this patient population: Enhanced Competencies Patient/ caregiver engagement; shared decision making; partnership Managing complexity using holistic approach; emphasis on palliative care Population health (risk stratification; evidence-based decision making; team-based, care management that optimizes technology) Performance (measurement, processes); stewardship; focus on longer term value

7. Increased Use of Teams Integrating clinical, public health and social service staff Adding new team members (e.g., community health workers) Using telehealth to improve communication and collaboration Focusing on both clinical and non-clinical staff Training to strengthen “team work” “Upskilling” current staff (e.g., palliative care)

8. A Few Examples  “Care Team Integration of the Home Based Workforce”: CMS funded California initiative designed to: 1) promote core competencies of 6000 personal health care aides supporting Medicare and Medicaid beneficiaries with disabilities, and 2) integrate aides within care team.  European HANDOVER Project: Among outcomes of a multi-nation program to improve transitions at the primary care-inpatient interface has been a “toolbox” designed by patients and healthcare professionals that can then be adapted by local educators and clinicians to “upskill” current workforce.

9. What do available innovations suggest about members of our future workforce and their roles?

10. Major emphasis on self-management Patients Substantial increase in expectations Largely “invisible workforce” Family caregivers/ direct care workers Major shift in responsibilities re: primary care, care transitions or “handovers”, and population health management, including coordination of teams managing HNHC patients Nurses Examples of role transformation related to current health system redesign

11. Increasingly, consult with other clinicians/teams or directly provide medication management services Pharmacists Diverse training, roles; have capacity to extend contributions of health professionals for most vulnerable HNHC patients Questions remain about optimal conditions for effectiveness Community health workers Increasingly, recognized as core team members because of their role in linking HNHC patients with essential services such as meals and transportation Staff in community- based organizations

12. Challenges with Current Responses Rapid proliferation of new roles may increase fragmentation and decrease productivity; value proposition needs to be examined. Limited change in overall health care practices has occurred, despite substantial advances in specific team members’ contributions. In U.S., numerous health care workforce innovations have not been linked to broader systems to assure optimal distribution and use of team members. Emphasis on “team-based care” has not been accompanied by a playbook (focus of new U.S. Center) or policies that foster and sustain teams of different backgrounds and professional pedigrees and center on the needs of HNHC patients.

13. A few “fast track” workforce development opportunities targeting HCHN patients? Encourage current workforce’s use of well-designed resources to advance population health competencies Convene international workforce leaders to: develop repository of HNHC patient centered, effective and efficient interprofessional or team-based workforce planning; and, promote rapid scaling of high-value workforce innovations Advance regulatory changes that enable all team members to function at top of their educational preparation and licenses

14. Sample Resources U.S. Department of Health and Human Services  Education and Training Resources on Multiple Chronic Conditions (MCC), http://www.hhs.gov/ash/initiatives/mcc/education-and- training/index.html http://www.hhs.gov/ash/initiatives/mcc/education-and- training/index.html  Centers for Disease Control and Prevention, http://www.cdc.gov/chronicdisease/index.htm http://www.cdc.gov/chronicdisease/index.htm National Center for Interprofessional Practice and Education (University of Minnesota) https://nexusipe.org/about https://nexusipe.org/about Institute for Patient- and Family-Centered Care, link to the Picker Institute archive, http://www.ipfcc.org/tools/picker-institute.html http://www.ipfcc.org/tools/picker-institute.html ICARE4EU, Innovating care for people with MCCs in Europe, http://www.icare4eu.org/index.php http://www.icare4eu.org/index.php

15. Direction of Future Policies Promote close alignment between health system and workforce redesign Assure adequate skill mix and supply within and across all settings that care for HNHC patients Emphasize continuity of care across multiple team members and settings Foster restructuring of roles and relationships among members of the care team focused on patient outcomes Prioritize the role of HNHC patients and their family caregivers