California faces serious shortages in its health workforce, which makes it difficult for too many people to access the care they need. For example, in the next decade, California will face a shortfall of 4,100 primary care clinicians, will need an additional 600,000 home care workers, and will only have two-thirds of the psychiatrists we need. These shortages will exacerbate the existing deficit of health professionals from communities of color and will directly impact millions of Californians already living in communities facing shortages of health professionals, including the Inland Empire, San Joaquin Valley, Los Angeles, and most rural areas.
A report released by the California Future Health Workforce Commission provides recommendations for the state to address these challenges. Healthforce Center research faculty, including Janet M. Coffman, Joanne Spetz, and Susan A. Chapman, in addition to Director Sunita Mutha, contributed to the development of the following Commission recommendations:
1. Establish and scale a universal home care worker (UHCW)
This requires the development of a UHCW family of jobs with career ladders and associated training, helping to meet the need for an estimated 600,000 home care workers by 2030, and potentially reducing spending on unnecessary emergency department visits and hospitalizations by more than $2.7 billion over 10 years due to enhanced training and care.
Currently, there are different regulations regarding home care worker training and scope of practice in California, depending on whether the worker is hired directly by a client, employed through the Medi-Cal In-Home Supportive Services Program, placed in a client’s home by a home care agency, or certified as a home health aide. The multiple job categories, limited scope of practice for some categories, lack of opportunities to obtain training, and lack of recognition or compensation for higher skills cause confusion for those who need services. These restrictions also contribute to high turnover rates for workers, and cap job growth. Currently, many home care workers struggle to make ends meet, with many of them earning at or below the poverty line. There is no clear career pathway that supports home care workers’ professional development to a higher paying or more highly skilled position.
To solve this problem the commission recommends that a well-coordinated family of jobs be established with a clear progression of training, scope of practice aligned with workers’ skills, and compensation and professional advancement. The UHCW role would have three levels with increasing skills and levels of training—from proficiency in activities of daily living to paramedical service for the most complex individuals (e.g., people with dementia). This addresses a critical need for a stable and qualified workforce that supports the rapidly growing population of aging adults in California. Evidence indicates that the expansion of home health and home care aide scope of practice, particularly with regard to the administration of medication and treatment plans, allows more well-rounded care, improves patient satisfaction, and in some cases, brings supervision to formerly “underground” practices. The job family could also include certified nursing assistants, who are unlicensed assistive personnel commonly giving care in nursing homes. If implemented, this new policy would increase home care worker job satisfaction, client satisfaction and worker retention. This recommendation builds upon Healthforce research exploring the needs of the long-term care workforce and the need for a pipeline of adequately trained long-term care workers.
2. Expand the number of primary care physician and psychiatry residency positions
Expanding these positions is expected to yield an increase of 1,872 primary care physicians and 2,202 psychiatrists by 2030. In conjunction with maximizing the scope of practice of nurse practitioners and increasing supplies of primary care nurse practitioners and psychiatric mental health nurse practitioners, this recommendation would eliminate California’s projected shortage of primary care physicians and nearly eliminate the shortage of psychiatrists.
The recommendation would increase the number of first-year residents in primary care residency programs in California by 20% between 2018 and 2024 and maintain that increase from 2024 to 2029. This increase in the number of graduates of primary care residency programs, coupled with migration of primary care physicians from other states to California, would result in an increase in the number of full-time equivalent (FTE) primary care physicians in California in 2030.
The recommendation would also meet 75% of projected demand for psychiatrists in 2030. The number of first-year residents in psychiatry residency programs would increase by 152 to 527 per year, which would yield a 247% (375 residents per year) increase in graduates of psychiatry residency programs between 2018 and 2025. This increase in the number of graduates of psychiatry residency programs, coupled with migration of psychiatrists from other states to California, would result in an increase in the number of psychiatrists in California in 2030. These projections build off of previous Healthforce Center research on primary care and behavioral health care workforce shortages and associated policy recommendations.
3. Scale the engagement of community health workers, promotores and peer providers
This should be done through certification, training, and reimbursement to broaden access to prevention and social support services in communities across the state. Community health workers and promotores (CHW/Ps) and peer providers can help meet an increasing demand for team-based, integrated primary and behavioral health care. CHW/Ps draw on shared culture to support better outcomes, and peer providers draw on lived experience to promote recovery and self-sufficiency for people with mental illness and substance use disorder.
Community Health Workers and Promotores
The American Public Health Association defines community health workers and promotores(CHW/Ps) as “frontline public health workers who are trusted members of and/or have an unusually close understanding of the community served.” Integrating CHWs and promotores into more traditional clinical care models is proving to have direct impact on addressing social determinants of health, enhancing patient care, and improving access to health care and social services. Creating a sustainable community health workforce will require institutional and cultural change in health care systems. Direct investment in community health to enhance the health and well-being of marginalized communities is also necessary.
Peer providers are individuals who provide services in behavioral health settings, both for mental health and substance use disorders (SUDs) treatment; they use their own experience of recovery from mental illness or addiction and skills obtained from formal peer provider training to serve their patients. Their inclusion in care models marks the transformation from behavioral health care to a “recovery-oriented” model of care. Healthforce Center research indicates that peer providers are uniquely positioned to support the long-term recovery of people with mental health and substance use disorders. The US Department of Veterans Affairs hires peer specialists to help patients identify and achieve specific life and recovery goals, and a number of organizations in California use peers in transitional settings to serve as navigators and mentors for the formerly incarcerated and those recently discharged from a psychiatric hospitalization.
4. Maximize the role of nurse practitioners (NPs) as part of the care team
This recommendation will fill gaps in primary care, helping to increase the number of NPs to 44,000 by 2028, and provide them with greater practice authority, with particular emphasis in rural and urban underserved communities.
Healthforce Center has published a robust body of work examining NPs’ ability to provide care in low-income and rural areas; their affect on medication adherence compared with primary care physicians; and the impact of lifting restrictions on NP scope of practice.
5. Sustain and expand the Programs in Medical Education (PRIME) program across UC campuses
These programs will train highly motivated, socially conscious graduates who will become licensed physicians practicing in underserved communities. Under this priority, the goal is to secure state government support of PRIME’s current student enrollment of 354 students and increase enrollment by 40 students a year.
UC’s PRIME program is a good example of training that focuses on meeting the needs of California’s underserved populations in both rural communities and urban areas. The curriculum combines specialized coursework, structured clinical experiences and advanced independent study. Expanding PRIME and implementing similar programs at private medical schools may help to increase the number of physicians who practice in underserved areas.
6. Increase postbaccalaureate program slots for students reapplying to medical school from underserved communities
This recommendation proposes that from 2021 to 2030, an additional 100 postbaccalaureate slots per year would be funded for qualified California students from disadvantaged backgrounds, designated shortage areas, and underserved communities who applied to medical school previously but were not admitted. Priority would also be given to students with demonstrated interest in the Commission’s three priority areas: primary care, behavioral health and aging. Scholarships would be provided to cover 100% of tuition charged by postbaccalaureate programs.
Postbaccalaureate programs increase the number of successful medical school applicants from disadvantaged backgrounds, including underrepresented populations. Programs typically provide intensive preparation for the Medical College Admission Test, courses in basic sciences that are required for medical school admission and guidance regarding the medical school admission process. Persons from underrepresented racial/ethnic groups who participate in postbaccalaureate programs in California are much more likely to be admitted to medical school than persons from underrepresented groups who do not participate in a postbaccalaureate program.
Developing the Leaders of Tomorrow
Implementing these recommendations will require a legion of effective leaders throughout the state who can coalesce around this vision, work with multiple stakeholders, and drive change in hospitals, health systems and health care organizations so that Californians receive the care they need. If you or your organization needs support training leaders or developing agents of change, please contact us and learn more about our leadership programs. Read the full commission report and executive summary and view this address from Janet Napolitano, UC president and co-chair of the California Future Health Workforce Commission:
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