CEO Perspectives on Factors Determining Medical Staff Configurations in CHCs

OBJECTIVE While financial incentives to adopt team-based care are mounting, little is known about how leaders of primary care organizations make decisions regarding medical staff configurations. This study explores perceptions of CEOs of community health centers (CHCs) that have a variety of staff configurations. DATA/SETTING We used the 2012 Uniform Data System to identify a maximum variety sample of CHCs with unusually high proportions of advanced practice providers, nurses, medical assistants, case managers, or community health workers. DESIGN/METHODS We conducted semistructured interviews with CEOs at 19 selected CHCs about factors that influenced their medical staff configuration decisions. RESULTS We found that CEOs considered two major dimensions in their decisions: choice and balance of providers (physicians versus nurse practitioners [NPs] and physician assistants [PAs]) and configuration of clinical support staff. Across these decision domains, CEOs consider contextual issues (e.g., local labor supply, wage gaps between professions, scope of practice regulations, local payment policies, and institutional history), as well as their own perceptions of individual attributes, the quality of specific professions, and the likelihood of retention. Strong preferences emerged for a balance among physicians and NPs/PAs and the inclusion of nurses with stackable degrees. CONCLUSIONS This study provides a preliminary framework for understanding how CEOs at CHCs weigh staffing options in a variety of contexts. This framework can serve to inform research on the comparative effectiveness of different staffing configurations and improve national and state workforce projection models

Perceptions of Electronic Health Records Effects on Staffing, Workflow, & Productivity in Community Health Centers

Significant Federal investments under the Health Information Technology for Economic and Clinical Health Act of 2009 and the Affordable Care Act have motivated many community health centers (CHCs) to implement electronic health records (EHRs) in the past few years. Evidence suggests that EHR implementation causes significant changes in how primary care clinicians spend their time and may be associated with changes in staff and facility level productivity. However, the mechanisms to explain these changes were mostly speculative. The goals of this project were to understand how, from the perspective of clinicians, support staff, and administrators, CHCs’ implementation of EHRs has changed staffing models, staff roles, and workflow, as well as the mechanisms by which EHRs influence staff productivity, coordination between providers, and quality of care. Key Questions How has EHR implementation changed staffing models in CHCs? How has EHR implementation changed staff roles and workflow in CHCs? How have these changes influenced CHC productivity and quality of care

Health professions education as a national industry: framing of controversies in nursing education and migration in the Philippines

During the past few decades, the nursing workforce has been in crisis in the United States and around the world. An aging work force and high rates of burnout and turnover has caused a global shortage of nurses of unprecedented proportions. Many health care organizations in developed countries have resorted to recruiting nurses from other countries in order to maintain acceptable staffing levels. The Philippines is the largest source country for foreign-trained nurses in the United States and an important supplier of nurses worldwide. Exporting nurses has been a long-standing economic strategy for the Philippine government, despite the fact that the Philippines' domestic health system is weak and existing supplies of health workers are poorly distributed. The Philippine nursing profession is now aimed more at global markets than supplying domestic needs. Despite longstanding awareness of the "internationalization" of the Philippine nursing profession, the logics and thought processes that underlie the phenomenon are poorly understood. This study aims to uncover the discursive construction of nurse migration by various stakeholders ("migrant institutions") through case studies of two recent controversies in nursing education and migration in the Philippines: a leakage of answers on the nursing licensure exam and the inclusion of nurses in a trade agreement with Japan. It employs frame analysis of the newspaper coverage of the two controversies and key informant interviews of government, health sector, education and professional organization representatives to examine how the priorities of economic development, migrants' rights and professional development of nurses are debated in the Philippines. The study finds broad support for interpretations of the controversies that position Filipino nurses as export products on the global market, which are linked to their professional development and often minimize concerns about their rights as migrants. It demonstrates the domestic importance of protecting the Philippine "brand" of nurses, links nursing professional development to Philippine economy and nation building, and challenges "brain drain" understandings of health professional migration. It also makes a case for approaches which account for the role of migrant institutions in shaping public understanding and policy decision-making related to migrants and migration

Using a New Evidence-Based Health Workforce Innovation Research Framework to Compare Innovations in Community Health Center and Other Ambulatory Care Settings

In the United States, changing demographics, rising costs, and the impact of new regulations and payment models arising from the Affordable Care Act have placed unprecedented pressures on healthcare providers to increase access to care, improve quality and to control costs. To meet these challenges, some providers are forming accountable care organizations (ACOs) while others are pursuing medical homes or other novel payment and care delivery models designed to help meet these challenges. Within established organizations such as federally funded community health centers (CHCs), healthcare leaders are exercising significant latitude in developing innovative solutions for meeting their patients’ needs more effectively and efficiently. One important way they are accomplishing this is through novel workforce arrangements that place health workers in new or expanded roles, new team arrangements or new locations. Key Goals To develop a framework that can be used to describe the drivers/motivators, mechanisms and outcomes of health workforce innovation so they can be used to guide future research in this area. This framework can help to identify patterns in emergent workforce arrangements, and can help researchers and planners to formulate hypotheses and study the implications of health workforce innovations in different contexts. To use the framework to compare and contrast health workforce innovations in community health centers and other ambulatory care settings. This information can help HRSA and other policymakers to understand the implications of health workforce changes for planning, education, and labor market projections, both in CHCs and in ambulatory care more generally

Do Years of Experience with Electronic Health Records Matter for Productivity in CHCs?

OBJECTIVE Community health centers’ (CHCs) patient panels are expected to increase in the coming years. This study investigated to what the years of experience with an electronic health record (EHR) was related to the productivity of CHCs. DATA/SETTING We primarily drew from the 2012 Uniform Data System, an annual reporting system of 1198 CHCs receiving federal Section 330 grants. We also used the “Readiness Survey” to categorize CHCs by years of experience with an EHR. DESIGN/METHODS We estimated a log-linear model of average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. We compared the productivity of each type of medical staff by presence of an EHR, EHR vendor, and years of EHR experience. RESULTS Physician productivity significantly improved in CHCs with three to four years of EHR experience. Nurses experienced a notable negative productivity impact in the early years of EHR adoption, although the trend was not statistically significant. CONCLUSIONS Attention should be paid as to whether nurses are diverted away from clinical duties to manage administrative tasks related to EHRs, and whether staffing levels are sufficient to support the implementation of EHRs. CHCs may need additional support and training especially for nurses in order to maintain the CHCs’ current patient panel, and even more so if the patient population expands as Medicaid coverage expands under the Affordable Care Act

Internationally Educated Nurse Hiring: Geographic Distribution, Community, and Hospital Characteristics

Since the1990S, the confluence of several trends — population and nurse workforce aging, increased acuity and complexity of hospital care, and difficult working conditions — has caused a growing global shortage of registered nurses. As hospitals in the United States cope with persistent nursing shortages, many have begun to look overseas to fill vacant staff positions (Aiken, Buchan, Sochalski, Nichols, & Powell, 2004). As the largest importer of internationally educated nurses (IENs), the United States is considered to be the epicenter of global nurse migration (Aiken, 2007; Kingma, 2007). While IENs compose a relatively small portion of the total U.S. nursing workforce, their numbers are growing; data from the National Sample Survey of Registered Nurses (NSSRN) provided by the Health Resources and Services Administration (HRSA, 2006, 2010) suggest the proportion of IENs in the U.S. workforce increased from 3.5% to 5.4% (100,791 to 165,539 nurses) between 2004 and 2008. The number of IENs who passed the nursing licensure exam (NCLEX-RN) grew by 53% (from 14,954 to 22,879) between 2004 and 2007 (National Council of State Boards of Nursing, 2005, 2009), although not all IENs who pass the NCLEX-RN are hired by U.S. health care organizations (Aiken, 2007)

Immigration policy and internationally educated nurses in the United States: A brief history

Since the 1980s, U.S. policy makers have used immigration policy to influence the supply of nurses by allowing or restricting the entry of internationally educated nurses (IENs) into the U.S. workforce. The methods pursued have shifted over time from temporary visa categories in the 1980s and 1990s to permanent immigrant visas in the 2000s. The impact of policy measures adopted during nursing shortages has often been blunted by political and economic events, but the number and representation of IENs in the U.S. nursing workforce has increased substantially since the 1980s. Even as the United States seeks to increase domestic production of nurses, it remains a desirable destination for IENs and a target market for nurse-producing source countries. Hiring organizations and nurse leaders play a critical role in ensuring that the hiring and integration of IENs into U.S. health care organizations is constructive for nurses, source countries, and the U.S. health care system

Nurses, Inc.: Expansion and commercialization of nursing education in the Philippines

Exporting nurses has been a long-standing economic strategy for the Philippine government, despite the fact that the Philippines' domestic health system is weak and existing supplies of health workers are poorly distributed. This study explores the role of nursing schools as "migrant institutions" in expanding and commercializing nursing education and perpetuating the link between nursing education and migration. Data were collected primarily via in-depth interviews of key informants (nursing school administrators and policymakers) in the Philippines. Results suggest that nursing schools have expanded migration opportunities by making nursing educational available to more students and more diverse student populations. Also, some nursing schools have acted to control the licensure and recruitment processes by establishing commercial relationships with licensure exam review centers and recruitment agencies. These activities perpetuate the culture of migration in the country's nursing profession and indirectly contribute to declining quality of nursing education, misuse of scarce resources, corruption in the nursing sector, and exacerbation of existing health workforce imbalances.Philippines Nursing education Migration