November 2015
Using a New Evidence-Based
Health Workforce Innovation
Research Framework to
Compare Innovations in
Community Health Centers
and Other Ambulatory Care
Settings
AUTHORS:
Leah Masselink, PhD
Patricia Pittman, PhD
Calire Houterman
Mullan Institute Health
Workforce White Paper No. 1
Prepared By
The George Washington University
Fitzhugh Mullan Institute for Health Workforce Equity
Questions
For questions regarding this report, please contact
Patricia Pittman at ppittman@gwu.edu.
Suggested Citation
Masselink L, Pittman P, Houterman C. Using a New Evidence-Based Health Workforce
Innovation Research Framework to Compare Innovations in Community Health Center
and Other Ambulatory Care Settings. Washington, DC: Fitzhugh Mullan Institute for
Health Workforce Equity, George Washington University; 2015.
Funding
This white paper was supported by the Bureau of Health Workforce (BHW), National
Center for Health Workforce Analysis (NCHWA), Health Resources and Services
Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as
part of an award totaling $450,000, with zero percent financed with non-governmental
sources. The contents are those of the author[s] and do not necessarily represent the
official views of, nor an endorsement by HRSA, HHS, or the U.S. Government.
1
f
November
2015
Using a New Evidence-Based Health Workforce Innovation Research
Framework to Compare Innovations in Community Health Centers and
Other Ambulatory Care Settings
Table of Contents
INTRODUCTION ............................................................................................................................... 2
METHODS ........................................................................................................................................ 3
FINDINGS ......................................................................................................................................... 4
DISCUSSION ..................................................................................................................................... 8
LIMITATIONS ................................................................................................................................. 10
CONCLUSIONS ............................................................................................................................... 10
REFERENCES .................................................................................................................................. 12
2
f
November
2015
INTRODUCTION
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.
The goal of workforce innovation within healthcare organizations—sometimes referred to as “skill
management” or changing “skill mix” or “staff mix” (Sibbald et al. 2004, Dubois & Singh 2009)—is to
improve the effectiveness or efficiency of healthcare by changing individual staff members’ skills or
competencies or changing the mix of staff members in a single discipline or in multidisciplinary teams. In
the past decade researchers have sought to both define workforce innovation in healthcare and to create
frameworks to evaluate the impact of such innovations on outcomes, including gains in population health
(Sibbald et al. 2004, Dubois & Singh 2009, Friedman et al. 2014).
Innovation has been defined as “the intentional introduction and application within a role, group,
or organization, of ideas, processes, products or procedures, new to the relevant unit of adoption,
designed to significantly benefit the individual, the group or wider society” (West 1990). Weberg (2009)
has defined healthcare innovation as “something new, or perceived new by the population experiencing
the innovation, that has the potential to drive change and redefine healthcare’s economic and/or social
potential”. Weberg’s study of the concept of healthcare innovation also highlights the importance of
studying the consequences or outcomes of healthcare innovations in context (e.g. existing financial and
human resources, leadership, culture).
This body of work offers specific ideas about the mechanisms of workforce change and insight
into how both institutional context (regulations, funding, culture) and organizational context (internal
procedures, technology, human resources) can impact changes to staff mix, expansion of staff skills or
other “innovative” workforce arrangements such as formation of interdisciplinary teams. But it has been
difficult to translate the theoretical literature into a framework that describes the entire process of
innovation and can be used easily to develop clear, answerable research questions. For example, another
recently published typology of primary care workforce innovations by Friedman et al. (2014) paid more
attention to why healthcare organizations introduced innovative health workforce arrangements, but its
categories were difficult to operationalize for research (e.g. “transformative” vs. “non- transformative”
innovations). The existing work on skill mix or staff mix (Sibbald et al. 2004, Dubois & Singh 2009) has
clearer categories of innovation mechanisms, but does not seek to integrate what motivates healthcare
organizations to pursue workforce innovations in the first place.
With this in mind, the research team set out to integrate the various streams of work in this area
to develop a new, comprehensive, evidence-based framework for describing and analyzing health
workforce innovation. They also sought to test the application of the framework in a context of specific
interest to HRSA by using it to compare health workforce innovations in community health centers with
those in other ambulatory care settings.
This project had two goals:
1.
To develop a framework that can be used to describe the drivers/motivators, mechanisms and
outcome measures 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,
3
f
November
2015
and can help researchers and planners to formulate hypotheses and study the implications of
health workforce innovations in different contexts.
2.
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.
METHODS
Framework Development
The researchers began by conducting a literature search to aid in developing a typology describing
the range of innovations in workforce or staffing arrangements that could be implemented in a healthcare
organization. They drew on the work of Sibbald et al. (2004) and Dubois & Singh (2009) to develop a
typology of mechanisms of innovation at the center of the framework, drawn from their concepts of “skill
mix” or “staff mix” change—seeking to improve effectiveness or efficiency of healthcare by changing
individual health workers’ skills or competencies, changing the mix of health workers in multidisciplinary
teams, etc. They organized the mechanisms into three broad categories of who does certain activities in
a healthcare organization, how health workers work together and where health workers work.
Next, the researchers used data from the AHRQ Innovations Exchange to test the relevance of the
innovation mechanisms in the initial typology and to add categories of drivers/motivators and outcomes
of
health
workforce
innovation
to
the
framework.
The
AHRQ
Innovations
Exchange
(https://innovations.ahrq.gov/) is a repository for profiles of “innovative” activities that lead to “new and
better ways of delivering healthcare.” The Exchange is a particularly useful resource for framework
development and testing because its profiles come from published reports or grey literature, and some
are self-submitted case studies. It also includes profiles from across the health sector, including hospitals,
outpatient facilities, long- term care facilities and community organizations. The researchers examined of
a subset of profiles (n=171) that were classified in the database as “Staffing” and/or “Team Building”
innovations, assuming that these classifications were most likely to describe health workforce
innovations.
The researchers conducted a qualitative analysis of information from the “Staffing” and “Team
Building” profiles, using the field titled “Snapshot: Problem Addressed” to identify the domains of factors
that motivate healthcare organization to pursue new health workforce arrangements (key drivers or
motivators). They also analyzed the field titled “Did it Work?” to identify the levels and types of outcomes
that have been measured to document the impact of health workforce innovation.
Finally, the researchers situated the drivers/motivators, mechanisms and outcome measures in
their external and organizational contexts (Anderson et al. 2014, Dubois & Singh 2009). They also added
“feedback” arrows from outcomes to institutional and organizational context to account for the fact that
outcomes of health workforce innovations can change the external or organizational context for
subsequent innovation efforts.
Comparison of Workforce Innovations in CHCs and Other Ambulatory Care Settings
To After finalizing the framework, the researchers used it to compare health workforce
innovations (documented in the published or grey literature or the Innovations Exchange) set in
community health centers with those in non-CHC primary care or ambulatory care settings. The
researchers gathered 19 examples of CHC-specific workforce innovations and 34 examples of other
ambulatory care setting workforce innovations from these sources, and they used the framework to
classify innovations in each setting according to the following characteristics:
1.
Key driver(s) or motivators of innovation
4
f
November 2015
2.
Mechanism(s) of change
3.
Outcome(s) measured to evaluate the impact of innovation
After classifying the innovations, they used this information to make comparisons between the
two sets of innovations to identify commonalities and differences between CHC and other ambulatory
care workforce innovations.
FINDINGS
The final health workforce innovation framework is shown in Figure 1. The final framework
included four domains of key drivers or motivators of health workforce innovations:
1.
Access to care
•
Enhancing patients’ ability to receive necessary services through cultural
competence, patient education or other outreach efforts.
Cultural competence for underserved populations (enhancing facilities’
ability to care for diverse populations—e.g. interpretation, culturally
tailored programs)
Patient education (enhancing patients’ ability to care for themselves by
providing information or training about their disease or other health needs)
2.
Quality of care
•
Enhancing facilities’ ability to provide appropriate and well-coordinated care, avoid
errors, or improve processes.
3.
Patient health issues
•
Improving patients’ health by preventing disease or reducing its impact.
4.
Costs/efficiency
•
Reducing costs to the organization of staff burnout or turnover.
•
Reducing costs to the organization and/or health system of patients’ use of expensive
services.
Figure 1: Health Workforce Innovation Framework
5
f
November
2015
The literature review and AHRQ Innovations Exchange profiles demonstrated that these
categories of drivers/motivators were often linked to each other, and organizations pursuing workforce
innovations often considered them together. Improving access or quality were the most reported
immediate goals, with the ultimate aim of improving health outcomes and/or reducing costs. For example,
organizations might seek to make workforce changes to improve quality of care for frail elderly patients,
with the goal of holding down future costs. They might seek to add or change staff to improve access to
care for a difficult-to-reach population with the hope of improving their health and reducing overall costs
(e.g. fewer emergency room visits for chronic conditions).
The typology of workforce innovation mechanisms included the following categories:
Who does certain activities
•
Adding new types of health workers
New health worker roles that do new activities (not done before by any other health
worker)
New health worker roles that take on existing activities (previously done by other
health workers)
•
Changing roles of existing health workers
Existing health worker roles that take on new activities (not done before by any other
health worker)
Existing health worker roles that take on existing activities (previously done by other
health workers)
How health workers work together
•
New models involving multiple health workers (e.g. changes to workflow, team composition)
•
New tools or strategies to improve communication and “teamwork” between multiple health
workers (e.g. huddles, interdisciplinary quality improvement teams)
Where health workers work
•
Having health workers do the same activities in a different venue (within the health sector)
•
Shifting activities to different health workers in a different venue (within the health sector)
•
Shifting activities of health workers to a non-health sector venue (e.g. churches)
As demonstrated in some of the workforce innovation examples included in the study,
innovations designed to change one dimension (e.g. who does certain tasks) can also influence another
dimension (e.g. how staff members work together). For example, an initiative that has emergency medical
technicians (EMTs) providing mental health screenings in patients’ homes (existing health workers taking
on a new activity) also involves changes to where staff members work (shifting mental health screenings
from an outpatient setting to patients’ homes and from behavioral health providers to EMTs). Similarly, a
program adding community health workers to a chronic disease care team could also change how
members of that team work together.
The final framework also included four levels of outcome measures that healthcare organizations
could use to gauge the impact of workforce innovations:
1.
Employee-level outcomes
•
Employee satisfaction
6
f
November
2015
•
Employee burnout
•
Employee turnover
2.
Organization-level outcomes
•
Productivity (volume of visits, time per visit, etc.)
•
Costs (balance of amount spent and/or saved by the organization implementing the
innovation—e.g. added or reduced staff costs, reductions in utilization)
3.
Patient-level outcomes
•
Access to care (e.g. number of visits/encounters, waiting time)
•
Quality of care (e.g. rate of guideline adherence)
•
Coordination of care (e.g. number of referrals, utilization)
•
Patient experience (e.g. patient satisfaction with care)
•
Health outcomes (disease markers such as HbA1c levels, blood pressure, CD4 count)
4.
System-level outcomes
•
Population health outcomes (large-scale measures of disease markers, utilization)
•
Costs (amount spent/saved by the health system because of other outcomes of the
innovation—e.g. improved population health outcomes, changes in utilization)
As healthcare organizations often pursued workforce innovations for multiple related reasons,
they often measured their impact on more than one outcome domain. For example, new approaches
designed to improve health outcomes for patients by improving staff teamwork and communication might
also increase health workers’ satisfaction and/or reduce turnover. (In turn, reduced turnover might lead
to lower long-run costs to the organization, even if it incurred some costs implementing the innovation.)
Employee-level outcomes such as satisfaction and turnover were not cited as key drivers or motivators of
health workforce innovation, but organizations sometimes measured them as another way to assess the
impact of the innovation and speculate about the potential organization-level consequences such as
reduced turnover costs. Most system-level outcomes were difficult to measure in the studies or
Innovations Exchange profiles of health workforce innovations, as most of them took place in single
organizations or networks. However, many of the profiles or articles mentioned these as possible
“downstream” impacts of the innovations, so the researchers included them here although they are rarely
measured explicitly.
Comparison of Workforce Innovations in CHCs and Other Ambulatory Care Settings
The workforce innovation examples in community health centers were most frequently motivated
by goals of improving access to care. In all, 13 of the 19 examples had primary goals of improving access
(some with secondary emphases on cultural competence or patient education). Another 4 examples
focused on both access and quality (mostly coordination of care), and only 2 examples had improving
quality of care as their primary goal.
Among the access-focused workforce innovations, the researchers found several examples that
added new health worker roles such as navigators, peer specialists, volunteer educators or cultural
liaisons. Several other examples showed CHCs using new team models involving multiple health workers
to improve access for patients with chronic diseases or other significant needs—e.g. a multidisciplinary
HIV clinic, a patient self-management program for diabetes patients, and a lactation education program
for minority mothers. Several CHCs also used new team models involving multiple health workers to
improve cultural competence such as a community clinic for refugee women.
While access and cultural competence were the most frequent key drivers of health workforce
innovation in CHCs, they also used new team models to improve quality of care—for example, an initiative
involving clinical pharmacists in the care teams for patients in need of medication management. Two
7
f
November
2015
examples also showed CHC staff members performing the same activities in new venues to improve access
and quality of care, including a program that placed case managers in emergency departments and
another that moved primary care providers into a mental health center. Other than these, relatively few
CHC workforce innovations had a primary focus on improving quality of care. The only other example,
which involved adding a new type of health worker (“practice enhancement assistants”) to help facilities
improve their guideline adherence rates, was only included in the study because it took place in a network
that included CHCs, but the CHCs were not the only participants.
Likely because so many CHC workforce innovations focused on enhancing access to care, many of
the innovation examples used relatively “soft” outcome measures—for example, volume of encounters,
screening rates, number of patient education sessions provided. (This is not surprising because of the
difficulty of collecting more “downstream” measures such as health outcomes or costs within the same
time frame and context as the workforce innovation.) A few examples included patient-level measures
such as satisfaction, mental health and emergency department visits. Not surprisingly, most of the
innovations located in CHCs received evidence ratings of “suggestive” (non-experimental or qualitative
evidence—8 innovations) or “moderate” (at least one systematic evaluation using a quasi-experimental
design—9 innovations) from AHRQ. The smaller group of innovations that focused on improving quality
of care (which included one of the two innovations with a “strong” evidence rating from AHRQ for its
randomized design) had more specific measures such as guideline adherence or disease markers like viral
load and CD4 count for HIV patients or glycemic control for diabetes patients.
The key drivers of workforce innovations in the non-CHC ambulatory care settings were more
balanced between access to care and quality of care than in CHCs: 18 of the 34 examples were designed
to improve access to care (including cultural competence and patient education), and 16 were intended
to improve quality of care (including both coordination and process improvement). Fewer access-focused
innovations in non-CHC ambulatory care settings included cultural competence dimensions, but several
examples were aimed at helping patients with limited English proficiency. Most of the access-focused
innovations changed the roles of existing health workers (e.g. community health workers supporting
Latino families of children with asthma) or implemented new team models involving multiple health
workers (e.g. a multidisciplinary clinic for frail, vulnerable elderly patients). Another example—a program
to have emergency medical technicians conduct mental health and medication management screenings
in patients’ homes—demonstrated how changing roles (EMTs doing screening) in a new venue (patients’
homes) could be combined to improve access to care.
The prevalence of quality-focused innovations among the non-CHC ambulatory care examples
relative to CHCs was one of the most striking differences between the two settings. A few quality-focused
innovations included new roles (e.g. health coaches, screening volunteers), but many more involved new
roles for nurses and nurse practitioners. Nurses and nurse practitioners served as case managers for
patients with chronic diseases across settings and (in one case) managers of a “transitional care program”
designed specifically to manage the transition between inpatient and outpatient care. Other examples
created new team-based models of care involving other clinicians such as pharmacists or specialist
physicians (e.g. geriatricians), often in the context of care for patients with chronic illnesses. The non-CHC
ambulatory examples also included one that used a multidisciplinary team to conduct a Six Sigma-inspired
process improvement effort, which did not appear in any of the CHC examples in the study.
Likely because of the greater representation of quality-focused innovations, more of the
workforce innovations in non-CHC ambulatory care settings had specific, quantitative ways of measuring
outcomes than the CHC innovations—e.g. disease markers, hospitalizations, emergency department
visits, or readmission rates. Nearly all of the quality-focused innovations used these “hard” measures
(sometimes along with others). Several of the access-focused innovations used similar “upstream”
measures to those used in similar examples within CHCs—e.g. encounters, services provided—but also
8
f
November
2015
like the CHC examples, a few found ways to measure “downstream” outcomes such as falls, mental health,
glycemic control or blood pressure. A larger proportion of non-CHC health workforce innovations had
evidence ratings of at least “moderate” from AHRQ relative to those introduced in CHCs: 21 received
ratings of “moderate” and 5 received ratings of “strong”.
Most of the innovations in both settings fit into the “who” or “how” categories of innovation
mechanisms; both settings had relatively few examples of changing where staff members work. The
examples in CHCs were mostly physical relocations of staff members to other sites rather than through
telemedicine or other use of technology—e.g. placing case managers in the emergency department or
placing primary care providers in a mental health clinic. The researchers found more examples of using
technology to relocate staff members’ activities in non-CHC ambulatory care settings—e.g. staffing an
online clinic, conducting electronic consultations or being part of virtually connected teams—than CHCs.
DISCUSSION
This study uses a comprehensive, evidence-based framework for describing and studying health
workforce innovations to make a preliminary, qualitative comparison of health workforce innovations in
CHCs and other primary care or ambulatory care settings. The findings highlight the fact that healthcare
organizations are using workforce innovations to address a wide range of related issues: access to care,
quality of care, patient health outcomes and costs of care (both to the organization and to the health
system).
As demonstrated here, the framework can be useful for comparing the drivers and mechanisms
of health workforce innovations across settings, as well as assessing the effectiveness of different types
of innovations in achieving their goals of improving access, quality, patient health outcomes and costs. Its
outcome measure categories can also be used to assess the evidence for workforce innovations, make
comparisons and identify gaps that could be addressed in future studies of health workforce innovations.
It can also be used to pose new research questions that can be used to design new observational or
experimental studies of health workforce innovations incorporating variables from the institutional and
organizational context domains. For example, how do different leadership styles impact the ability of CHCs
to add new roles or create new team models to address quality improvement? What drives innovation in
CHCs vs. other ambulatory care settings? Does the effectiveness of different approaches (e.g. adding staff
roles to enhance cultural competency vs. developing new multidisciplinary team models to improve
coordination of care) vary according to the health needs or economic context of the patient population?
For planners and managers, it is also important to understand how certain contextual factors—
either in the broader institutional context or specific to the organization—can facilitate the adoption of
certain innovative approaches, or how factors such as culture, incentives or organizational resources can
mediate or moderate the association between different innovative workforce approaches and the
outcomes they are intended to address. For example, does the impact of certain new team models using
existing workers on health outcomes differ in the presence or absence of specific additional resources
(e.g. technology)? Or does the impact of adding a new role to a facility (e.g. a social worker) change
depending on the existing culture or leadership style within the organization? The framework can also be
used to examine how changing payment incentives influence both organizations’ choices and the
effectiveness of different workforce innovations—or even study how these evolve over time as incentives
change. (If we assume that outcomes of innovation change the context for subsequent innovation
attempts, how can we see this the next time an organization seeks to make a change to its workforce?)
New data sources such as a revised version of the National Ambulatory Medical Care Survey
(which includes questions about staff roles and tasks for the first time) will present an opportunity for
larger scale empirical studies of the prevalence and distribution of some of the “innovative” workforce
approaches in CHCs and other ambulatory care facilities examined in this study. But this study also
demonstrates the utility of using of case studies and other more qualitative methods to capture the