HWRCs' Annual Report, 2021

HWRCs’ ANNUAL REPORT

2021

IN THIS ISSUE

A Note From

INTRODUCTION 3 A Note From HRSA 4 HRSA HWRC Program

COVID-19 6 COVID-19 Research and Activities 12 Insights: The Pandemic’s Impact on Telehealth

YEAR IN REVIEW 16 Allied Health & Health Equity Workforce Research Centers 18 Behavioral Health Workforce Research Center 20 Carolina Health Workforce Research Center 22 Health Workforce Equity Research Center & Health Workforce Policy Research Center 24 Oral Health Workforce Research Center 26 UCSF Health Workforce Research Center on LongTerm Care 28 Health Workforce Technical Assistance Center 30 Spotlight: Health Equity 32 MCRR Journal Supplement

The Health Resources and Services Administration (HRSA) is committed to supporting evidence-based program planning and policy making. HRSA’s Health Workforce Research Center (HWRC) program is essential to helping HRSA meet this vision. By conducting and disseminating rigorous research, the HWRCs inform health workforce policy by illuminating workforce issues and trends.

These 9 HWRCs serve as nationally recognized experts on the US health workforce and, through their investigations into various aspects of the workforce, provide essential information and technical assistance to local, regional, state, and federal planners and policymakers. During the COVID-19 pandemic, their role became even more crucial. In addition to shifting ongoing research to better understand the impact of COVID-19 on the health workforce, many HWRCs were tapped by their local and state governments to provide workforce information and expertise, thereby assisting various jurisdictions’ responses to the pandemic in real time. Some also proactively created tools to provide timely health workforce data that was able to inform decision making processes. Since the pandemic began, the HWRCs conducted more than 50 COVID-related research projects on a wide range of topics, including pandemic impacts on care delivery, provider burnout, and the education pipeline; how COVID contributed to and exacerbated staffing challenges; and the intersection of health workforce and issues of equity and inclusion.

In the first half of 2021, the HWRCs produced more than 46 reports and journal articles based on their research, and made more than 70 presentations at national conferences. Collectively, this work addressed a wide range of workforce topics, including allied health, behavioral health, health equity, longterm care, oral health, and emerging issues related to community health, evolving health care delivery modes, and value based health care. Like every workplace this past year, the HWRCs were greatly

impacted by the pandemic. Despite having to adapt to new work environments, new technologies, priority shifts, recruitment and operational challenges, HWRCs rose to the occasion and still produced an enormous amount of cutting edge research that the country needed during this critical time.

HRSA thanks the HWRCs for their continued efforts in conducting and producing relevant health workforce research and technical assistance and their timely response to the pandemic. We look forward to their important contributions in the future.

Sincerely,

Diane Espinosa Acting Administrator Health Resources and Services Administration US Department of Health and Human Services

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HRSA HWRC PROGRAM T

he National Center for Health Workforce Analysis (NCHWA) is a national resource for health workforce research, information, and data. As a division within the Bureau of Health Workforce (BHW) at the Health Resources and Services Administration (HRSA), NCHWA supports policy makers with information and data to help inform decisions regarding health workforce education, training, and healthcare delivery (https://bhw.hrsa.gov/health-workforce-analysis/ about).

As part of these efforts, NCHWA oversees HRSA’s Health Workforce Research Center (HWRC) cooperative agreement program, which provides funding to 9 centers in the US. Collectively, these Centers offer expertise in the following arenas: 

Allied health workforce (University of Washington)

COVID-19 The COVID-19 pandemic has had signifcant impacts on the health workforce, and thus the research efforts of the HWRCs. Much of the centers’ work in

 Behavioral health workforce (University of Michigan)

the past year was focused on COVID-19—providing

 Emerging health workforce topics (George Washington University; University of North Carolina at Chapel Hill)

research and tools that could assist workforce

 Health equity in health workforce education and training (George Washington University; University of Washington)

policy decisions being made across the country as

 Long-term care workforce (University of California, San Francisco)

the pandemic raged on.

 Oral health workforce (State University of New York, Albany)

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COVID-19 COVID-19 Our team at the

University of Washington’s Center for Health Workforce Studies has also been tracking the employment effects of COVID,

specifically initial and ongoing uninsurance claims filed, by occupation within Washington state in partnership with the

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state Workforce Training and Education Coordinating Board and the Employment Security Department.

Op-Ed: It’s Time to Address Staffing at Nursing Homes In this MedPAGE Today op-ed, UW CHWS Director Frogner and Senior Deputy Director Skillman discuss the staffing challenges that nursing homes continue to face during the pandemic and call for a COVID-19 sub task force to focus on these issues.

COVID-19’s Effect on the Employment Status of Health Care Workers Redeployment, furlough, and layoff are among the terms used to describe various work statuses of health care workers during the COVID-19 pandemic.

This brief defines the range of work statuses that one can hold, identifies areas where overlap may create confusion, and discusses the potential long-term impacts of COVID-19 on employment in the health care industry.

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Supply, Distribution, Education Pathways, and State Responses to Emergency Surges in Demand: A Series on the Allied Health Professions States took varied approaches to increasing the supply of their health workforce in response to a surge in patient demand due to COVID-19. A series of briefs examine the supply, distribution, and education pathways of respiratory therapists, physical therapists, pharmacists, and clinical lab professionals, each of which played a critical role during the pandemic. The briefs also explore state responses to the pandemic for the workforce.

Is It Fair? How to Approach Professional Scope-of-Practice Policy After the COVID-19 Pandemic Director Bianca Frogner and Senior Deputy Director Sue Skillman co-authored a Health Affairs blog post that discusses how health professionals may perceive quick roll back scope-of-practice laws and regulations and suggests options for moving forward postpeak pandemic.

The Challenge in Tracking Unemployment Among Health Care Workers and Why It Matters The health care industry lost 1.5 million jobs between March and April 2020, the height of the COVID-19 pandemic in the US. Losses spread across the major health care sectors of hospitals (22.7%), ambulatory care settings (39.6%), and long-term care (LTC) facilities (37.7%). The job loss in LTC facilities (eg, skilled nursing facilities, residential care, assisted living) represents 6.2% of their workforce compared with 2.8% in ambulatory care and 2.4% in hospitals. The LTC sector has seen a steady decline in employment since the start of the pandemic, while the other health care sectors have mostly rebounded. The job loss in LTC is concerning but not surprising, given reports of high COVID-19 risk and burnout. This JAMA Health Forum article discusses how tracking unemployment among health care workers is necessary to develop a strategy to strengthen the LTC workforce and improve health care delivery.

One Change That Could Help Nursing Homes Recover From COVID-19 Fears and Become Safer Places for Aging Parents Director Bianca Frogner authored a blog post for The Conversation which discusses nursing home care and the ways COVID-19 fears could be addressed through investment in nursing home staff. She identifies the challenges that nursing homes face in maintaining a sufficient supply of staff such as certified nursing assistants and the implications to patient care. Strategies to make nursing homes safer for aging parents are also discussed.

Social Work Answers the (VIDEO) Call: Tele-behavioral Health Use During COVID-19 Through the Coronavirus Preparedness and Response Supplemental Appropriations Act signed on March 4, 2020, and 1135 waiver authority, the Centers for Medicare and Medicaid Services expanded the ability for credentialed providers to utilize telehealth services, including tele-behavioral health. Many states enacted executive orders to mandate private health insurers to follow suit and reimburse for tele-visits during COVID-19. These changes, coupled with unprecedented social, behavioral, and physical health needs, made both social workers and clients dependent upon tele-behavioral health. This brief measures the extent to which social workers were able to transition to tele-behavioral health during COVID-19 and the barriers they experienced during this change in health service delivery.

Telebehavioral Health Workforce Opportunities During the COVID-19 Pandemic Barriers to accessing behavioral health services exist across the country and create a demand for innovative service delivery, including telebehavioral health services. Behavioral health providers have increasingly adopted telebehavioral health services in recent years but the COVID-19 pandemic has caused a rapid transition to the virtual space. To better understand behavioral health workforce development opportunities for telebehavioral health and the impact of COVID-19, the BHWRC research team conducted a mixed methods study of data from behavioral health provider organizations nationwide. This report provides a summary of findings related to telebehavioral health workforce development opportunities and the impact of the COVID-19 pandemic.

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The Behavioral

Health Workforce Research Center (BHWRC) has engaged in multiple projects related to COVID-19, several of which

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RESEARCH & ACTIVITIES

focused on the behavioral health workforce’s shift to

telebehavioral health during the pandemic.

Identifying Systems-level Factors That Influence Workforce Capacity and Effectiveness The behavioral health workforce is currently experiencing a shortage of providers across the United States. This workforce shortfall has likely been affected by the COVID-19 pandemic, though it is currently unclear how policy changes and systems-level factors within behavioral health care will impact workforce capacity. This report investigates systems-level factors and service delivery following COVID-19-related state and federal regulatory changes and their impact on behavioral health workforce capacity. Results of this study can inform future behavioral health workforce planning efforts, specifically around identifying and removing barriers to maximizing workforce capacity.

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Health Workforce Research Center has undertaken multiple projects focusing on the

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preparation, deployment, and support of the health workforce in response to the COVID-19 pandemic.

Using State Licensure Data to Assess North Carolina’s Health Workforce COVID-19 Response Capacity In the initial months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages. This article describes how data was used in the early stages of the COVID-19 pandemic in North Carolina to support decisions about the deployment, surge, and maintenance of necessary health care staff.

Will Community Health Centers Survive COVID-19?

Federally qualified community health centers (CHCs) are the nation’s primary care safety net, serving a patient population of whom 68% have incomes below the poverty level, 63% identify as racial/ethnic minorities, and 82% are uninsured or publicly insured. This commentary describes the threat posed to CHCs by the pandemic, the efforts taken by HRSA to address those challenges, and the ongoing financial and workforce challenges facing CHCs serving rural communities.

The Impact and Responses of Safety Net Practices to the COVID-19 Pandemic Carolina Health Workforce Research Center researchers surveyed a national sample of safety-net health care practices across 22 states to understand how clinicians have been struggling during the pandemic, and offer recommendations for how HRSA can better support clinicians who work in safety net settings during the pandemic. This project captured the experience and observations of 1,518 National Health Service Corps frontline clinicians and other direct care personnel the last 3 months of 2020 and January 2021. A summary report was developed along with recommendations that include ensuring adequate supply of personal protective equipment (PPE), helping clinicians protect their own health and meet the needs of their families, and placing greater emphasis on the needs of clinicians as people and as professionals.

Health Care Workforce Playbooks and the COVID-19 Pandemic Along with a team from the North Carolina Area Health Education Centers (AHEC) program, the Carolina Health Workforce Research Center has generated a series of playbooks and a policy brief that are meant to provide health care systems, states, the federal government and other stakeholders with updated, state-of-the-art resources to promote local flexibility to respond to workforce challenges and shortages during the pandemic.

Contact Tracing Workforce Estimator A tool for state and local leaders to prepare for COVID-19 contact tracing in order to safely reopen and protect the health of communities.

COVID-19 County Workforce Deficit Estimator A tool to identify counties likely to experience workforce strain due to high rates of COVID-19 hospitalizations and ICU occupancy.

Emergency Vaccinator Policies for COVID-19 A tool showing states with temporary, emergency policies authorizing specific professions to administer COVID-19 vaccines.

Emergency Workforce Policies to Address COVID-19 A webinar series that includes 15 topics such as Mobilizing Health Professions Students and Social Mission of Health Professions Schools.

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The Health Workforce

Technical Assistance Center collaborated with other HWRCs on COVID-19-related initiatives.

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The Carolina

Combining our efforts helped create more robust end products to assist

those involved in workforce planning throughout the pandemic.

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In response to COVID-19,

the George Washington University Health Workforce Research Centers has 4 initiatives to provide

information on: 1) safely reopening and protecting the health of communities, 2) the critical importance of

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COVID-19

RESEARCH & ACTIVITIES

getting health workforce policies right during the pandemic, and 3) learning from the policy experimentation as it unfolds.

State Responses to Address Workforce Needs in the Initial Wave of the Pandemic States responded to the COVID-19 pandemic with a variety of approaches to ensure adequate health workforce capacity as well as strategies to expand access to care for needed services. In order to better understand pandemic issues and challenges faced by states as well as strategies they used to address them, the Health Workforce Technical Assistance Center (HWTAC) conducted 32 key informant interviews with stakeholders in 23 states. In addition, the Health Workforce Policy Research Center at George Washington University conducted a policy analysis of regulatory actions taken by states. This research brief summarizes findings on how states prepared for and responded to the pandemic. Themes include regulatory flexibility, surge capacity for acute care services, and impacts on both ambulatory care services and the health professions educational pipeline.

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COVID-19 & the Health Workforce Website As the health workforce is on the front lines of the Coronavirus pandemic, there has been a critical need to develop effective strategies to assure the availability of a sufficiently sized and well-trained health workforce to care for patients during the pandemic. Strategies to replenish workforce supply as health workers fall ill, are quarantined, or need respite have also been considered. HWTAC developed a website that is dedicated to sharing resources on efforts to develop, deploy, and replenish the health workforce in response to the pandemic.

HWTAC has monitored publications and conducted web searches daily for relevant developments relating to the impact of COVID-19 on the health workforce from April 2020 onwards. Resources are continually uploaded to the website and updates capturing key findings are sent out via email on a bi-weekly basis. Key areas of focus ofAssistance the site are: Health Workforce Technical Center  Vaccine Information  Access to Care  Changes to Organizational Policies and Guidelines

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 Health Professions Education  Regulatory Flexibility  State Workforce Strategies

and staff at the UCSF Health Workforce Research Center on Long-Term Care were asked to support Cali-

fornia’s workforce planning for anticipated surges in hospital care due to the

The Oral Health

Workforce Research Center’s (OHWRC) COVID-19 website is

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one part of a larger research project summarizing key COVID-19 impacts on oral health.

 Telehealth  Long-term Care  Health Workforce Safety

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Our faculty

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COVID-19

RESEARCH & ACTIVITIES

COVID-19 Impacts on the Dental System Website The COVID-19 pandemic has had a profound impact on all aspects of the oral health care system. Patients, dental providers, educators, and regulators were asked to rapidly adjust to the COVID-19 crisis with almost no roadmap. Early on in the pandemic, organizations, associations, and government agencies were all working on responses to the problem in their respective areas of expertise yet often with little awareness of concurrent changes in interrelated systems. To assist in these efforts, the Oral Health Workforce Research Center (OHWRC) developed a new section of its website dedicated to providing the most up-todate information about COVID-19 impacts on the dental care system. Resources are drawn from a variety of sources, are updated continually, and revolve around 4 key domains including care delivery, financing, regulation, and education. Upcoming events on the pandemic’s impact on dentistry are also included on the website to make users aware of learning opportunities.

IN PROGRESS: A Survey of Oral Health Status and Access to Care for the General Population Related to the COVID-19 Pandemic To identify and describe the factors that influenced access to oral health services for different population groups during the COVID-19 pandemic, researchers at the OHWRC desigined a series of questions about people’s need for and utilization of oral health services in 2020 for inclusion in the biannual Consumer Survey of Health Care Access, conducted by the Health Workforce Research Center at the Association of American Medical Colleges (AAMC). OHWRC researches are conducting an analysis of survey results and a will develop a report on findings.

COVID-19 pandemic.

California Health Workforce Planning In collaboration with Healthforce Center at UCSF, the UCSF Health Workforce Research Center on Long-Term Care developed:  A set of recommendations to surge the workforce  Staffing ratios and a staffing calculator to determine hiring needs for newly-opened COVID-19 hospitals  Job action sheets for alternate care sites  Orientation and training materials for alternate care sites They also collaborated with other state leaders to guide changes in nursing education to ensure that students could gain appropriate clinical experiences and enter the workforce.

All resources are available on the Healthforce Center COVID-19 Health Workforce Surge Planning website.

Utilizing Nontraditional Healthcare Delivery Practices: Alternative Care Sites During the COVID-19 Pandemic

Several states and cities established alternate care sites in locations such as convention centers and dormitories, to provide sub-acute care for people with SARS-Cov2 infection. This policy brief examines the roles of these sites, their staffing mix, their recruitment and deployment strategies, and their training approaches.

IN PROGRESS: Community Paramedic Roles in the COVID-19 Response

This study in progress is aiming to identify and describe models that communities can use to engage their community paramedic workforce to support local pandemic response.

IN PROGRESS: Multiple Job-holding Among Long-term Care Workers

Some front-line workers in long-term care hold multiple jobs because they are unable to support themselves and their families with the low wages and part-time hours of many long-term care jobs. This issue has been magnified due to the COVID-19 pandemic. UCSF researchers are currently using publicly-available data to assess the extent to which long-term care workers hold multiple jobs and the factors associated with multiple job-holding. A report on findingswillbedevelopedonceanalysisiscomplete.

IN PROGRESS: Teledentistry in a Post-COVID-19 World: Assessing Adoption, Integration, and Policy Assessing the rapidly evolving use of teledentistry and supports needed at the state and national policy level will be critical to enhancing use of these services to improve the safety and access to needed dental care in the post-COVID-19 world. This project will review policy changes and practices using interviews and policy reviews in up to 7 states.

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Insights The Pandemic’s Impact on Telehealth: The Behavioral Health Workforce’s Shift to Telebehavioral Health

By Angela J. Beck, PhD, MPH Director, Behavioral Health Workforce Research Center, University of Michigan, School of Public Health areas with existing provider shortages.

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rior to the COVID-19 pandemic, telebehavioral health services were widely underutilized despite evidence in support of the effectiveness of telehealth services. The COVID-19 pandemic spurred rapid and widespread use of telebehavioral health modalities following the federal government’s recommendation in March 2020 of its use to mitigate public health risks. To facilitate telebehavioral health adoption and delivery, the Centers for Medicare and Medicaid Services adjusted regulations and reimbursement requirements for telehealth to provide greater access to care across the US, including emergency department and therapy services, and 30 states passed emergency orders to permit expansion of telehealth services. Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) were also given authorization to serve as distant telehealth sites and provide telehealth services to patients in their homes, broadening access to care in

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In the state of Michigan, 2 executive orders were issued to permit defined expansions of some providers’ statutory scope of practice and relief from restrictions and requirements that previously limited telebehavioral health service delivery. The Medical Services Administration, Michigan’s Medicaid authority, released new Medicaid guidance in March 2020 in line with federal changes to further support telehealth expansion, and several bills were passed to expand regulation and definition of telehealth services. These policies facilitated immediate change in behavioral health service delivery in order to grant access to care for individuals seeking treatment for mental health and substance use disorders (SUD), and adoption of telebehavioral health services increased significantly across care settings.

“The COVID-19 pandemic spurred rapid and widespread use of telebehavioral health modalities.”

To better understand provider experiences with telebehavioral health, the BHWRC conducted a study in summer 2020 to assess the impact of telehealth policy changes on behavioral health service provision based on the experiences of n=31 psychologists, nurses, clinical social workers, professional counselors, SUD counselors, and peer support providers in Michigan. Key informant interviews revealed a significant increase in the use of telebehavioral health since March 2020, the effects of which positively impacted continuity of services for clients and improved access to mental health care. The majority of providers reported telebehavioral health services improved access to mental health care and decreased patient no-show rates as a result of reduced transportation barriers and time constraints. Reported quality of care and patient satisfaction with telebehavioral health services varied by service type and patient characteristics, with some providers reporting an improved sense of patient security, comfortability, and rapport. However, providers also identified some patient subgroups for whom quality of care seemed to worsen following the transition to telebehavioral health, including older adults, younger children, and individuals with a SUD,

(...Continued from page 12) serious mental illness, and/or language and speech disorders. Barriers to effective telebehavioral health adoption, including inadequate access to technology or internet, remain a challenge in service provision.

All key informants supported continued telebehavioral health expansion beyond the pandemic, with many recommending a hybridized in-person and telehealth model.

Recommendations of methods for sustaining and further improving access to care included authorization of payment for audio-only telehealth when other forms of care are not feasible, improvement of telebehavioral health coverage for all persons, and removal of certain procedural barriers for providers offering telebehavioral health services.

“The majority of providers reported telebehavioral health services improved access to mental health care and decreased patient noshow rates as a result of reduced transportation barriers and time constraints.”

Q&A What are some new directions that health workforce research and planning are taking?

A special issue of Health Services Research in 2017 provides a summary and examples for how health workforce research is evolving. Washko and Fennell summarize 4 main themes, including (1) the changing roles of health care providers, (2) the changing combinations of different providers who work together to deliver care, (3) the impact of these workforce changes on quality of care and access to care, and (4) advances in methodological challenges inherent in the study of evolving health workforce changes.

HRSA-funded HWRCs conduct and disseminate rigorous research that strengthens evidence-based policy and enhances government’s and the public’s understanding of issues and trends in the health workforce to help inform health workforce planning and policy.

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COVID-19

Workforce Strategies in Response to the Pandemic

YEAR IN REVIEW HWRC Research Dissemination:

70+ Presentations  37 Conferences and Meetings  25 Published Journal Articles  10 Webinars  3 Podcasts 

The Health Workforce Technical Assistance Center has developed a resource dedicated to sharing data and information on efforts to develop, deploy, and replenish the health workforce in response to the pandemic.

UPDATED DAILY

www.healthworkforceTA.org/COVID-19 14

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Work From the

Allied Health & Health Equity Workforce Research Centers What Commute Patterns Can Tell Us About the Supply of Allied Health Workers and Registered Nurses

Examining the Racial and Ethnic Diversity of Associate Degree in Nursing Programs by Type of Institution in the US, 2012–2018

Information on the supply of workers in a local job market is important when determining whether there are qualified workers to fill health care jobs in demand. The American Community Survey (ACS), a publicly available annual survey of over 3.5 million households conducted by the US Census Bureau, has been a regular source of information for mapping the geographic distribution of a wide range of occupations, describing the time, duration, and distance of workers’ commutes, and identifying common forms of transportation for commuting.

Increasing nursing workforce diversity is essential to quality health care. Associate Degree in Nursing (ADN) programs are a primary path to becoming a registered nurse and an important source of nursing diversity. While public institutions contribute the highest total number of diverse ADN graduates, private for-profit institutions have the highest percentage of non-white graduates.

This article published in Nursing Outlook provides details on ADN graduates by race/ethnicity and how these findings correlate to financial aid between 2012 and 2018.

This report explores what the ACS can tell us about commuting patterns among selected allied health occupations and registered nurses as well as how these patterns may inform discussions of health workforce supply.

Variation in Employment of Therapy Assistants in Skilled Nursing Facilities Based on Organizational Factors Therapy assistants represent approximately half of the therapy workforce in skilled nursing facilities. Employment of therapy assistants enables skilled nursing facilities to provide more therapy services at lower costs. As new payment mechanisms provide incentives for therapy in skilled nursing facilities, employment of therapy assistants may be a cost-effective way to continue to provide services when necessary.

This MCRR article examines the relationships between organizational characteristics of skilled nursing facilities and employment of therapy assistants.

Therapy Staffing in Skilled Nursing Facilities Declined After Implementation of the Patient-driven Payment Model The Patient-Driven Payment Model (PDPM) is a new reimbursement policy for skilled nursing facilities (SNFs) that was implemented by the Centers for Medicare & Medicaid Services in 2019. PDPM disincentivizes provision of intensive physical and occupational therapy, which has caused concerns that declines in therapy staffing may negatively impact patient outcomes. Therapy staff includes physical therapists (PTs), occupational therapists (OTs), physical therapy assistants (PTAs), occupational therapy assistants (OTAs), and therapy aides.

Little is known about the employment of therapy staff within SNFs relative to market needs.

Assessing the Size and Scope of the Pharmacist Workforce in the US Pharmacists are increasingly recognized as crucial members of the health care team. To date, no single source of information exists that best characterizes the increasingly complex nature of the pharmacist workforce. Improving awareness of the potential roles of pharmacists would help to more effectively incorporate them into the health care team and improve care.

This report identifies the many different settings where pharmacists work, their current and emerging roles, and the barriers and facilitators to greater involvement of pharmacists in patient care.

This JAMDA article compares wages and patterns of employment among SNF therapy staff to estimate immediate and gradual effects of PDPM implementation.

Find these reports and more on their website at

depts.washington.edu/fammed/chws/ 16

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Work From the Behavioral Health Workforce Research Center

A Systematic Review of the Roles and Contributions of Peer Providers in the Behavioral Health Workforce Approximately 1 in 5 adults experience a mental illness, a number that is expected to rise due to a shortage of mental health and substance use disorder (SUD) providers. One way to address this need for behavioral health services is through the use of peer providers. Peer providers are individuals who have been successful in the recovery process who help others experiencing similar situations, often acting as recovery catalysts. Peer support services can reduce the likelihood of relapse and prevent chronic mental illness, long-term disability, and substance overdose.

This article published in the American Journal of Preventive Medicine better defines the roles of peer providers and their unique contributions to behavioral health care.

Medicaid Financing for Behavioral Health Services: The Use of Flexibilities and Authorities Medicaid is the largest single payer for behavioral health services, and managed care is the predominant delivery system for Medicaid enrollees. However, states have the flexibility to decide if behavioral health providers and their services are reimbursable and subject to same-day billing restrictions. The state-specific nature of the Medicaid program, overwhelming use of managed care organizations (MCOs), and the dominance among waiver programs of the behavioral health waivers calls for attention on state Medicaid Plans, Medicaid MCOs, and Section 1115 waivers to examine payment rates for behavioral health services providers.

This report aims to determine the variation in behavioral health provider reimbursement rates per unit of service under feefor-service (FFS) and MCO in states with Medicaid waivers for behavioral health, and in non-waiver states, determine if there are fewer behavioral health providers available in Medicaid FFS and MCO programs.

A Mixed-method Comparison of Physician-reported Beliefs About and Barriers to Treatment With Medications for Opioid Use Disorder Coverage of Buprenorphine Medications That Treat Opioid Use Disorder by State Medicaid Programs Buprenorphine is shown to be an effective medication for the treatment of opioid use disorder. It promotes long-term recovery and decreases the risk of mortality. Although Medicaid programs largely cover buprenorphine products, many continue to apply prior authorization (PA) requirements.

This report studies how state Medicaid programs apply PA requirements to buprenorphine products.

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There is demonstrated evidence that medications used for treating opioid use disorder—such as buprenorphine, methadone, and extended-release naltrexone—are effective at treating opioid use disorder (OUD) and reducing associated harms. However, these medications are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications.

This article discusses physicians’ comparative beliefs about medications used to treat opioid use disorder and their perceived barriers to prescribing them.

Find these reports and more on their website at

www.behavioralhealthworkforce.org

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Work From the

Carolina Health Workforce Research Center What EHRs Tell Us About How We Deploy Health Professionals to Address the Social Determinants of Health Increasing awareness of the social determinants of health (SDOH) has prompted health systems to implement strategies to screen for and address patient SDOH. With the increased awareness comes the question of what workforce is needed to implement SDOH screening and related interventions? To answer this question, we must ask which healthcare workers screen for SDOH, who actually addresses needs related to patient SDOH, and how to incorporate screening and intervention into the clinic workflows.

The Evolving Role of Medical Assistants (MAs) in Primary Care Practice: Divergent and Concordant Perspectives From MAs and Family Physicians Medical assistants (MAs) are a flexible and lower-cost resource for primary care practices and their roles are swiftly transforming. This article surveyed MAs and family physicians for evidence of role confusion between MAs and physicians, physician resistance to delegate tasks to properly trained MAs, or MA reluctance to pursue training to take on new roles. Although no strong evidence was found for role confusion, 3 areas emerged where the gap between the potential and actual implementation of MA roles could be narrowed—population health and panel management; patient education, coaching, and counseling; and scribing.

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This article reviews how population changes over time in different geographical regions have impacted the market structure and availability of general surgeions in the United Sates.

Despite a growing body of research on the evolving roles of medical assistants, nurses, social workers, pharmacists, nurse practitioners, and physician assistants, there is currently a lack of knowledge regarding different team configurations in primary care practices.

The Evolving Sex, Race and Ethnic Composition of the Surgical Workforce: North Carolina Is a Bellwether of National Change

This article examines the gradual diversification of the surgical workforce in North Carolina to more closely reflect the population diversity of the State.

Clinical setting and geographic location affects access to surgical services and potentially the quality of care. Through examining the distribution of general surgeons across billing entities and within hospital referral regions (HRRs), UNC researchers found that a trend towards practice in larger medical organizations from traditional hospital settings is emerging.

Primary Care Teams: Past, Present, and Future

This research brief uses electronic health records (EHR) data to describe the mix of professionals identifying and addressing patient SDOH.

North Carolina, as a state with a significant Black population and fast-growing Hispanic population, is reflective of national demographic changes. In part due to these demographic changes, the US is currently facing challenges to recruit and retain a general surgery workforce that mirrors the population.

Place and Population Matter in General Surgeon Location and Practice Structure

This article reviews data from the American Board of Family Medicine (ABFM) examination application to explore what types of professions are working together in practice.

The Supply and Distribution of the Preventive Medicine Physician Workforce Social Work Workforce Development and Medicaid Expansion: Mapping Areas of (Mis)alignment Despite efforts to dismantle the Affordable Care Act, Medicaid expansion has increased access to primary care, as well as the availability of behavioral health services, including treatment for both mental health and substance use disorders.

However, increasing the availability of health and behavioral health services requires an increase in practitioners. Several federal programs support training providers to meet the growing need of a trained health workforce.

This article evaluates whether a program on specialized social work training in integrated health care settings is aligned with state Medicaid expansion.

Preventive medicine physicians work at the intersection of clinical medicine and public health. Previous reports on the state of the preventive medicine workforce revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates in recent years.

This article describes trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty, as well as the age, gender distribution, and geographic distribution of this workforce.

Overall Work and Practice Satisfaction of Licensed Clinical Social Workers in the National Health Service Corps Loan Repayment Program Little is known about the job satisfaction of licensed clinical social workers (LCSWs) participating in the National Health Service Corps (NHSC) federal Loan Repayment Program (LRP).

Employee satisfaction in organizations is important for organizational well-being and to decrease turnover.

This article examines the work and practice satisfaction of LCSWs participating in the NHSC LRP. Findings have the potential to inform the NHSC’s strategies in managing and retaining LCSWs.

Mapping Co-Location: Using National Provider Identified Data to Assess Primary Care and Behavioral Health Co-Location Evidence supports that integrated behavioral health care improves patient outcomes. Co-location, where health and behavioral health providers work in the same physical space, is a key element of integration, but national rates of co-location are unknown.

This article establishes national co-location rates and analyzes variation by primary care provider (PCP) type, practice size, rural/urban setting, Health and Human Services region, and state.

Find these studiess and more on their website at

go.unc.edu/CHWRC

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Work From the

Health Workforce Equity & Policy Research Centers Understanding Why Nurse Practitioner and Physician Assistant Productivity Varies Across Community Health Centers: A Comparative Qualitative Analysis Advanced practice clinicians (APCs)—nurse practitioners and physician assistants—that are in the 90th percentile of community health centers (CHCs) provide about 1,840 adjusted-visits per year; whereas APCs in the 10th percentile of CHCs provide about 978 adjusted-visits per year. Several important conditions were found among high productivity CHCs, including scheduling APCs and physicians for the same number of visits, parity in terms of any financial incentives, and formal education programs for new APCs during onboarding/transition to practice.

Optimal Staffing in Community Health Centers to Improve Quality of Care As quality incentives are further integrated into payment systems, community health centers (CHCs) will need to optimize their workforce configuration to improve quality. Given the relative efficiency of advanced practice clinicians in producing quality, further hiring of these professionals is a cost-effective investment for CHCs. This article explores optimal workforce configurations in the production of care quality in CHCs, accounting for interactions among occupational categories, as well as contributions to the volume of services.

This article explores why the productivity of APCs varies across CHCs, as measured in their marginal contribution to overall patient visits.

Does Distance Learning Facilitate Diversity and Access to MSW Education in Rural and Underserved Areas?

Distance learning in social work has proliferated in recent years. It is increasingly promoted as a strategy for diversifying the social work workforce and expanding access to graduate education for individuals in rural and under-served communities. Findings indicate that online and blended education is associated with practice in rural and underserved areas.

This article examines the effects of distance learning in social work education.

Independent Freestanding Emergency Departments and Implications for the Rural Emergency Physician Workforce in Texas Independent freestanding emergency departments (IFEDs) have increased rapidly over the last decade, especially in Texas. This growth calls for a closer look into the implications of these new models of health care organizations.

This article examines the IFED physician workforce composition and changes in emergency physician workforce supply across states and in rural Texas.

Does Community College Attendance Affect Matriculation to a Physician Assistant Program? A Pathway to Increase Diversity in the Health Professions

The Impact of Nursing Staff on Satisfaction Scores for US Hospitals: A Production Function Approach

Community colleges (CC) are an important pathway to the physician assistant (PA) profession, with 3 of 4 matriculants having a CC background. However, lower matriculation rates among similarly qualified applicants who transferred from a CC to a 4-year university compared to applicants with no CC background suggest that PA programs are missing important opportunities for increasing student diversity and thereby the profession.

Hospitals have increasingly relied on nurse assistants to support nurses in the provision of patient care, yet knowledge about their contributions to the patient experience in US hospitals is limited. Although registered nurses are more impactful, nurse assistants are the more underdeployed staffing category. Given their lower labor costs, further employment of nurse assistants may be warranted.

This article explores whether CC applicants were a significant contributor to the diversity of matriculants to PA programs and whether CC applicants were less likely to matriculate to PA programs than non-CC applicants.

This article explores the impact of nurse assistants and registered nurses on an array of patient satisfaction measures from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems.

Do Nurse Practitioner-led Medical Homes Differ From Physician-led Medical Homes?

The patient-centered medical home (PCMH) is an enhanced model of primary care.

Nurse practitioner (NP)-led PCMHs differ from traditional physician-led PCMHs, though it is unclear to what extent. There are possible differences in capabilities, priorities, and needs of the population served across practices, but studying this can be an important guide for policymakers to track the adoption of PCMHs. This article examines the extent to which NP-led PCMHs differed from traditional physician-led PCMHs.

Find these studies and more on their website at 22

www.gwhwi.org/hwrc.html

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Work From the

Oral Health Workforce Research Center Contributions of General and Specialty Dentists to Provision of Oral Health Services for People With Special Needs

How Evidence-based Is US Dental Workforce Policy for Rural Communities?

The Oral Health Workforce Research Center (OHWRC) completed a study to evaluate the attitudes and willingness of general and specialty dentists to treat people with special needs and to identify the barriers to greater participation by dentists in the care of these patients. The research project was a collaboration with the Health Policy Institute at the American Dental Association (ADA).

Populations residing in rural America have lower rates of dental care utilization, higher rates of dental caries, less water fluoridation, and fewer dentists per capita when compared to those living in urban environments.

Dental workforce shortages in rural communities are endemic, despite the research on best practices for enhancing the rural workforce.

This report examines the contributions of general and specialty dentists, especially pediatric dentists, to oral health care for people with special needs. Researchers focused on variations in the provision of oral health services by specialty, source of training, and geography.

Dental Workforce Trends: A National Study of Gender Diversity and Practice Patterns Between 2010 and 2016, the proportion of women working in dentistry increased from 24.5% to 29.8%. Overall, female dentists were more racially/ethnically diverse, more likely to be foreign-trained, and more likely to work in pediatric dentistry than male dentists. Gender diversification in dentistry and other factors, including generational differences and changes in public policy, continue to reshape the delivery of oral health services.

This study analyzed gender differences in dental practice using the American Dental Association’s 2010-2016 Masterfile and the 2017 Survey of Dental Practice.

Authorization Status of Dental Therapists by State Dental therapists (DTs) are primary dental care practitioners that have been deployed in many countries around the world. There is increasingly strong evidence supporting the safety and effectiveness of DTs, including their ability to promote community-based services and enhance oral health equity. Following the approval of education standards by the Commission on Dental Accreditation (CODA) in 2015, dental therapy gained increasing acceptance in the United States with states and tribal nations authorizing dental therapy. Dental therapy is rapidly becoming an established, growing profession in the US, although there is variation in legal authority across states and jurisdictions.

This report examines the alignment of policy and infrastructure with evidence-based workforce strategies to increase access to oral health services for rural populations. Research focuses on best practices as well as the barriers and facilitators to effective implementation of workforce strategies to increase the availability of oral health services.

Application of Silver Diamine Fluoride by Dental Hygienists Silver Diamine Fluoride (SDF) is a topical medicament that can be used to treat dental caries across the age spectrum. Research supports the use of SDF in pediatric dentistry and in the elderly population as a simple, inexpensive, and effective way of preventing dental caries initiation and progression.

State dental boards and regulators have recognized SDF in various ways, impacting the ability of dental hygienists (DHs) to apply it. Many have directly addressed the topic in regulations or board opinions. Some indicate that SDF is a fluoride, a desensitizing agent, etc. falling under those DH scope of practice permissions and limitations, while others have remained silent on SDF. A recent US study of SDF safety was completed by expanded practice dental hygienists providing services in Head Start programs in Oregon.

This interactive infographic describes specific requirements in state laws and regulation that impact the ability of dental hygienists to apply SDF.

This interactive infographic describes the status of dental therapy in the US and details the specific requirements in state laws and regulations that define dental therapy practice.

Find these studies and more on their website at

oralhealthworkforce.org

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Work From the

UCSF Health Workforce Research Center on Long-Term Care The Impact of Nurse Delegation Regulations on the Provision of Home Care Services: A 4-State Case Study Increased training and input from registered nurses is needed to identify appropriate health maintenance tasks to delegate to home care workers and to support development of training strategies. Using a qualitative case study approach, 4 states were selected with varying levels of restrictions in their nurse delegation regulations to conduct interviews. The researchers spoke with state leaders, agency leaders, and home care workers to learn how these policies affect the home care workforce’s ability to perform care tasks for their clients in order to allow clients to remain in their own homes.

This article explores how home care workers and the agencies that employ them interact with their state’s nurse practice act in the provision of care.

Medical Care Delivery in US Nursing Homes: Current and Future Practice The delivery of medical care services in nursing homes is dependent on a workforce that includes physicians, nurse practitioners, and physician assistants. Each of these professions operates under a unique regulatory framework while adhering to common standards of care. Nursing home provider characteristics and their roles in care delivery can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications.

This article provides an overview of what is currently known about medical provider practice in nursing homes and organizational models of practice. Links to quality, both conceptual and established, are presented, as well as policy recommendations.

Medical Staffing Organization and Quality of Care Financial Vulnerability and Worker Well-being: A Comparison of Long-term Services and Supports Workers With Other Health Workers Over 1.5 million new jobs for medical assistants, nursing aides, and home care aides need to be filled by 2026. Many of these providers will work in the long-term services and supports (LTSS) sector.

This article discusses a study that utilized 16 years of data from the American Time Use Survey, which examines the financial vulnerability of high-skill and low-skill LTSS workers in comparison with other health care workers, and provides insight into their well-being by measuring time spent on work and non-work activities.

Racial Disparities in Financial Security, Work and Leisure Activities, and Quality of Life Among the Direct Care Workforce Personal care, home health, and nursing aides provide the majority of care to chronically ill and disabled older adults. This workforce faces challenging working conditions, resulting in high turnover and workforce instability that affect the quality of care for older adults.

This article examines financial security, work–life balance, and quality of life of Black, Hispanic, and workers of other race/ethnicity among these professions compared to White workers.

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Medical providers are significant drivers of care in post-acute long-term care settings, yet little research has examined the medical provider workforce and its role in ensuring quality of care.

This article examines the impact of nursing home medical staffing organization dimensions on the quality of care in US nursing homes. Respondents who reported having a formal process for granting privileges and nursing homes with direct employment of physicians reported significantly fewer emergency visits. The results of the impact of nursing home medical staffing organization dimensions were mixed, with many domains not having any significance or having negative relationships between provider characteristics and quality measures.

Personal Care Assistance in Rural America Personal Care Aides (PCAs) play a vital role in ensuring people with disabilities can remain in their homes and communities.

PCAs provide essential services for people with self-care disabilities (eg, difficulty dressing, bathing, and running errands) and yet are not sufficiently available where there are higher numbers of people with self-care disabilities.

This StoryMap online resource explores where people with disabilities who need help with self-care and daily activities live, and compare that to where PCAs are located. This will help to better understand if there are enough PCA workers available where they are needed.

The Role of Schedule Volatility in Home Health Nursing Turnover Despite considerable research on nursing turnover, few studies have considered turnover among nurses working in home health care. Between 2016 and 2019, the average annual separation rate of home health nurses was over 30%, with most separations occurring voluntarily. Schedule volatility and turnover were positively associated for full-time nurses, but not for part-time nurses.

This article examines turnover among home health nurses, focusing on the role of schedule volatility.

Find these studies and more on their website at

healthworkforce.ucsf.edu

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Work From the

Health Workforce Technical Assistance Center Small Area Analysis

Community Health Needs Assessment

Small Area Analysis (SAA) is a research technique used to analyze variations in health service utilization and resource allocation among neighboring communities. SAA focuses on specific areas or populations to identify significant differences and needs among well-defined small areas within a larger geographic boundary.

A community health needs assessment is a collaborative analysis of the population, resources, services, health care statuses, health care outcomes, and other data in a defined community or service area that helps identify potential health issues for improvement. Certain federal and state funders require periodic community health needs assessments, including federal grants for primary care offices and maternal and child health programs.

This web page provides answers to common questions about SAA through a series of podcasts. It also provides access to helpful SAA tools, resources, and related articles.

This section of the HWTAC website is dedicated to guidance on conducting community health needs assessments and is updated on a periodic basis. Resources include infographics and podcasts on community engagement, data collection and analysis, and prioritizing community needs.

State Health Workforce Data Collection Inventory The State Health Workforce Data Collection Inventory describes findings from a survey about data collection on health workforce supply (eg, demographic, education, and practice characteristics of health professionals), demand (eg, vacancies and employer recruitment and retention difficulties), and the education pipeline (eg, graduation rates and trainee/graduate characteristics). The data collection survey is ongoing and the inventory is continually being updated as more responses are received. The most up-to-date information can be viewed on the Data Collection Inventory page of the HWTAC website.

Health Professions Regulation in the US A key goal of health reform in the US is to improve population health through expanded access to health insurance. Demand for high-quality, cost-effective, basic health services is anticipated to grow, particularly for underserved populations. However, there is also growing concern about the impact of health professions scope of practice on access, quality, and cost of health services. Since health professions regulation falls under state jurisdiction, the legal scope of practice for a health profession is typically defined in a state-specific scope of practice act. These acts describe the services that professionals can provide and under what conditions they can be provided. Scope of practice acts also define the requirements for education and training, certification and licensure, and supervision. Restrictive legal scopes of practice often serve as a barrier to effective and efficient delivery of health services.

This webpage on the HWTAC website is updated on a quarterly basis to provide the most upto-date information in regards to scope of practice and regulation for health professions.

NSSRN Webinar Series Implications of Weighting Issues Associated With the 2018 NSSRN This webinar examines weighting issues associated with the 2018 National Sample Survey of Registered Nurses (NSSRN). Implications for conducting research using the 2018 NSSRN are discussed.

NP Research Using the NSSRN This webinar focuses on nurse practitioner (NP) research using the NSSRN. The first presentation examines evidence that registered nurses (RNs) are becoming NPs faster today than in the past and discusses the implications of that finding. The second presentation compares NPs that completed residencies to those who did not.

RN Research Using the NSSRN This webinar focuses on RN research using the NSSRN. Topics include the path to registered nursing; the validation of estimates of state-level RN distribution by hospital employment setting; and characteristics of RNs in long-term care.

GIS Tutorial How to Create a Travel Polygon to Evaluate Access to Health Care Providers This tutorial demonstrates how to create a travel polygon in ArcGIS that can be used to evaluate access to health care providers.

Find these resources and more on their website at 28

healthworkforceTA.org

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Spotlight: HEALTH EQUITY

HEALTH EQUITY WEBINAR SERIES Examining the Drivers and Outcomes of the US Dental Therapy Movement Through a Health Equity Lens Presenter: Elizabeth Mertz, UCSF HWRC on Long-Term Care; Moderator: Patricia Pittman, GW Health Workforce Equity and Policy Research Centers Dental therapists (DTs) are primary care dental providers, which are used globally, and were introduced in the United States in 2005. This webinar focuses on the dental therapy movement and examines the role of health equity in its adoption.

Providing Behavioral Health Care During the COVID-19 Pandemic: Social Workers’ Rapid Transition to Tele-behavioral Health

The aim of health equity is to ensure that everyone in the US has the opportunity to be as healthy as possible. Sometimes this requires the removal of barriers such as poverty and discrimination to achieve this goal. Health equity is increasingly recognized as an important consideration in health workforce planning. One key to achieving health equity is to have a diverse and knowledgeable health workforce. A diverse health workforce that reflects the population it serves and is knowledgeable about the obstacles many individuals face in reaching their full health potential can help overcome barriers to care.

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Presenter: Brianna Lombardi, University of Pittsburgh; Moderator: Susan Skillman, University of Washington Center for Health Workforce Studies The COVID-19 pandemic disrupted access to and the delivery of behavioral health services for both patients and social work providers. This webinar describes how practicing social workers transitioned to tele-behavioral health services during the pandemic. Presenters discuss challenges, practice innovations, and ethical/equity-focused implications to increase the use tele-behavioral health beyond the pandemic. Recommendations to ensure reimbursement parity, workforce preparation, and supports to engage patient use of tele-behavioral health are also highlighted.

Evaluating a Course on Implicit Bias in Clinical and Learning Environments: Provider Bias-awareness, Patient-centeredness, and Reflections Presenter: Janice A Sabin, University of Washington School of Medicine; Moderator: Bianca Frogner, University of Washington Center for Health Workforce Studies Implicit race bias has been associated with poor patient/provider communication, less trust and confidence in the provider, and poor patient-centered communication, particularly with Black patients. This webinar explores an online course on implicit bias for academic teaching faculty and others developed by the University of Washington. Presenters discuss providers’ pre- and post-course bias awareness, pre- and post-patient centered communication, and their reflections on the impact of the course on teaching and clinical practice.

First Generation College Students in the Health Professions Presenter: Laura M. Wagner, UCSF School of Nursing; Moderator: Patricia Pittman, GW Health Workforce Equity and Policy Research Centers Increasing the diversity of health professionals enhances efforts to address underlying determinants of health, as providers from underserved backgrounds are more likely to provide care to patients who are at highest risk for disparities in access to health care. This webinar explores a career development program at the University of California, San Francisco School of Nursing. The FirstGenRN Program focuses on a learning community for nursing students, faculty development, and a visibility campaign. Research is presented to support how first generation college health professions students are essential to improving our nation’s healthcare.

Which Rurality Definition?: The Relative Performance of 8 Federal Rural Defiinitions in Identifying Rural-urban Dispariities Presenters: Paul Delamater, University of North Carolina at Chapel Hill; Julia Long, Cecil G. Sheps Center for Health Services Research; Moderator: Davis Patterson, University of Washington Center for Health Workforce Studies There are large variations in the level of agreement among areas that are identified as “rural” under various rurality definitions. Rural-urban disparities are sensitive to the specific defiinition and which population characteristic that is being considered. This webinar explores 8 federal rural defiinitions and the degree to which they identify the same areas as rural. Rural-urban disparities across socioeconomic, demographic, and health access and outcome measures are also evaluated.

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COVID-19 and the Health Workforce Describes the articles included in the health workforce research supplement and how the issues raised by the authors relate to the COVID-19 pandemic and rapidly changing health care environment

The Evolving Role of Medical Assistants in Primary Care Practice: Divergent and Concordant Perspectives from MAs and Family Physicians Surveys MAs and family physicians for evidence of role confusion between MAs and physicians, physician resistance to delegate tasks to properly trained MAs, or MA reluctance to pursue training to take on new roles

The Impact of Nurse Delegation Regulations on the Provision of Home Care Services: A 4-State Case Study Explores how home care workers and the agencies that employ them interact with their state’s nurse practice act in the provision of care

MCRR JOURNAL SUPPLEMENT This collection of research articles authored by staff from HRSA-funded Health Workforce Research Centers (HWRCs) are published together as an open access supplement in the Medical Care Research and Review journal, providing a comprehensive picture of the US health care and health support workforce today.

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Understanding Why Nurse Practitioner and Physician Assistant Productivity Varies Across Community Health Centers: A Comparative Qualitative Analysis Explores why the productivity of APCs varies across CHCs, as measured in their marginal contribution to overall patient visits

Variation in Employment of Therapy Assistants in Skilled Nursing Facilities Based on Organizational Factors Examines the relationships between organizational characteristics of skilled nursing facilities and employment of therapy assistants

Dental Workforce Trends: A National Study of Gender Diversity and Practice Patterns Analyzes gender differences in dental practice using the American Dental Association’s 2010-2016 Masterfile and the 2017 Survey of Dental Practice

VIEW THE FULL SUPPLEMENT ONLINE! https://journals.sagepub.com/toc/mcrd/78/1_suppl

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