U.S. Department of Health & Human Services
HRSA Press Office: (301) 443-3376
Remarks to the Fall Conference of the Northwest Regional Primary Care Association and the Community Health Association of Mountain/Plains States
October 15, 2012
Thanks, Julie (Hulstein, Executive Director, CHAMPS) for that introduction, and to the NWRPCA and CHAMPS for inviting me to this conference. I want to thank all of you for your dedication to providing access to health care for those who are poor, isolated or medically vulnerable.
John (to Colorado Gov. Hickenlooper), we all know about your lifelong commitment to the medically underserved, starting back in your student days at Wesleyan and as mayor of Denver. Your enthusiasm and support are very important to everyone in this room and to everyone who works to serve the disadvantaged.
I also would like to introduce Margaret Davis, director of the North Central Division in our Bureau of Primary Health Care – Margaret, if you’re out there – and any other HRSA staff present – please stand up. They’ll be happy to answer any questions you may have later.
I also want to mention our regional office here in Denver – led by Pat Gillies – along with all our regional offices that are led and staffed by folks who are available to you for issues and programs I’ll be discussing today.
Later this morning Dan Hawkins will describe how the Supreme Court’s ruling on the Affordable Care Act affects community health centers. And I know you’ve been getting updates from Jim Macrae, head of HRSA’s Bureau of Primary Health Care, on the work his bureau has been doing with you, and how the ACA has impacted your own work.
So I would like to give you a HRSA update on the broad impact the ACA has had on the primary health care workforce. And specifically, the ACA’s broad impact on the training and deployment of the health care workforce, along with the changing roles of primary clinicians in our country’s rapidly evolving health care system, within the context of the nation’s community health center system.
But before I continue, I want to make sure everyone understands the many different things we do at HRSA, and the many partnerships that can be leveraged between community health centers and HRSA workforce programs. You can also go to HRSA.gov on the web to see what HRSA is doing in your state and ways other investments can potentially align with your work.
I’m sure I don’t need to explain the role of the Bureau of Primary Health Care for this audience. As I think you know, HRSA is the safety net agency, charged with ensuring access to high-quality, culturally effective, primary care for all Americans – and the Community Health Center program is one of our highest-visibility enterprises.
But not everyone knows that HRSA has a portfolio of 80 different grant programs, and that most of these programs go toward expanding primary care and extending health services to those who are low-income, medically vulnerable, or geographically isolated.
Among the programs and activities we support in addition to community health centers are some that you are already partnering with, and others you might think about:
Speaking of organ donation, I always ask every group I speak with to consider signing up or help sign people up and become organ donors. This year, we kicked off our “Fifty Plus” campaign targeting people over 50. I’m over 50, and that little red heart is on my driver’s license. I hope it’s on yours, too, regardless of your age.
Another component of HRSA’s work that is directly linked to workforce is the National Center for Health Workforce Analysis, which was created by the ACA to provide long-term planning to enable federal and state policymakers to better prioritize workforce investments.
Among other things, the National Center has just awarded a contract for an analysis of the impact that the ACA’s expansion of coverage has had on primary care shortages. The data and information being produced will be of great value to states, and hopefully to you.
Among the portfolio of programs I just mentioned, a key focus of our work involves the monitoring and leveraging of the primary health care workforce.
In order to achieve our mission, we need an adequate supply and distribution of clinicians with critical competencies practicing in systems that maximize their individual and collective contributions to the health of patients.
This is such a high priority for us that it is one of three strategic priorities on whose progress I report monthly to HHS Secretary Kathleen Sebelius: that is, strengthening the primary care workforce to better meet the health needs of the nation.
The characteristics of the health care workforce impact health care delivery everywhere. Those characteristics include the supply and distribution of clinicians, as well as the quality and orientation of their training. And they include the competencies clinicians acquire and the skills they apply. Obviously, those characteristics greatly influence the care delivered through the nation’s network of community health centers.
You may have heard that I’m from North Dakota, and I began my nursing career working in small hospitals serving rural patients. From my experience, I can tell you, accessing basic health care isn’t always very easy for rural patients -- although that can certainly be true for individuals in communities in metropolitan areas as well.
The Affordable Care Act aims to improve that. And as you know, the ACA invests over $455 million to support the training of new primary care providers by 2015. It also provides continued funding for the National Health Service Corps. In FY 2012, the Corps made more than 4,260 loan repayments and more than 220 scholarship awards, through a total $212 million in ACA funds.
The Corps is the largest HRSA program that boosts the supply and distribution of primary care clinicians. Today the Corps has nearly 10,000 primary care professionals practicing in medically underserved areas nationwide. That’s nearly triple the number in the field (3,600) four years ago.
There are nearly 1,500 Corps clinicians working in the states of Regions 8 and 10 today, and more than three out of four of them are being funded by the ACA. That’s a critically important ACA footprint in your part of the country.
By the way, the National Health Service Corps’ new interactive Jobs Center was recognized last month by HHS Secretary Kathleen Sebelius as one of the three top innovation awardees for offering “new solutions to solve critical problems” in recruiting health care professionals to underserved communities and community health centers.
The Jobs Center is accessible from any computer, smart phone, or tablet and allows doctors, nurses and other providers to take “virtual visits” to prospective rural and urban communities seeking to hire clinicians. Providers can tour community health centers, rural health clinics, and Indian Health sites. Job seekers can also learn about nearby schools for their kids and employment opportunities for their spouses.
So please make sure to update your profiles on the NHSC Jobs Centers website, if you haven’t already. We have hundreds of NHSC clinicians already using it. You can see it on our home page under “National Health Service Corps.”
Some of those NHSC applicants are returning veterans. And through community health centers and the NHSC, HRSA is working to help them connect with job opportunities here at home. Veterans of the U.S. military have skills and experience that can work for your health center.
Health centers are certainly doing their part. More than half the health centers who responded to a survey two months ago reported hiring at least one veteran in the past year. And 1 in 10 of the more than 2,000 new hires in health centers were veterans.
I am grateful to all community health centers for their collaborative efforts in this challenge, and I urge you to continue participating in this important initiative by making the extra effort to find vets seeking employment and inviting them to take part of your team.
By the way, digressing from the topic of employment for just a moment, we are also working to expand health care delivery to veterans living in rural areas.
Three states with the highest proportions of veteran residents — Virginia, Montana and Alaska — will each receive about $300,000 to implement or upgrade telehealth capabilities for veterans who must otherwise travel long distances to access medical, mental and behavioral health care.
The grants, administered by ORHP’s Office for the Advancement of Telehealth, will be used for telehealth equipment and to develop electronic health records that are compatible with the VA’s Veterans Health Information Systems and Technology Architecture system.
In addition, the VA is piloting a collaboration project with HRSA and the Substance Abuse and Mental Health Administration to increase access to mental health services for veterans and their families using local providers, including community health centers.
At HRSA, we’re also energizing this focus in different ways. For example, we certainly appreciate the importance of helping veterans who have medical training transition back into civilian life.
Over the past two months, we gave funding preference for vets applying to PA training programs when we issued awards of more than $2.5 million to 13 PA education programs.
Eleven of them have strong recruitment, retention, and education programs for veteran applicants and students – including academic recognition of medical training and experience gained during military service. Three of the 13 grantees are in Regions 8 and 10.
We are seeing similar results with our veterans’ initiative for nursing education programs.
Now while the number of PA students has been growing steadily, so has the shortage in clinical preceptors, particularly in rural primary care and community-based settings. And yet like primary care nurse practitioners, PAs are highly qualified members of the health care team.
So I want to encourage you to think about whether your health center can get more involved in the training of our physicians assistants: You can help reduce the growing shortage of clinical preceptors for our nation’s PA students.
Affordable Care Act funds will produce an estimated 600 physician assistants by 2015. But physician assistant educational programs need additional community-based clinical sites, such as community health centers, to support continued expansion.
Health profession training programs need to work with community health centers to develop rural community training sites and rural community preceptors to serve as teachers and role models for students.
Alongside physicians and PAs, nurses obviously play a very important role in the provision of health care at community health centers. And HRSA’s Nurse Loan Repayment Program, for example, has seen its budget more than double since 2009 to almost $83.1 million today.
Under this program, nurses who work for two years in a facility with a critical nursing shortage can get 60 percent of their school debt paid off. These facilities include FQHCs, critical access hospitals, Indian Health Service Health Centers, and rural health clinics. We currently have more than 2,500 nurse loan repayors working through this program nationwide.
And in response to Secretary Sebelius’ interest in strengthening our primary care workforce, HRSA has taken steps to ensure that more nurse practitioners take advantage of this loan repayment program.
Last year, we released guidance that reserved half of available 2012 funds to repay the loans of nurse practitioners. As with primary care physicians and primary care physician assistants, we want nurse practitioners in the workforce as quickly as possible, and this will help them go to school full-time.
For its part, the Office of Rural Health Policy is also involved in the development of our rural health care workforce. One of its more recent activities supports the recruitment and retention of primary and allied health care providers in rural communities.
Two community health centers in your regions are currently in their third year of the program: Plains Medical Center in Limon, Colorado and the Kodiak Island Health Care Foundation in Kodiak, Alaska.
The Plains Medical Center is networking with Lincoln Community Hospital, Morgan Community College and two area AHECs to target and train Certified Medical Assistants and LPNs to serve populations along a 90-mile stretch of Interstate 70 east of Denver.
In addition, ORHP has a Rural Training Track Technical Assistance cooperative agreement with the National Rural Health Association to support the 23 active Rural Training Track family medicine programs (including in Colorado, Washington, and two in Idaho) to work with new entities that want to start these programs.
This is a unique training model, as the residents do their first year in an urban setting, and then spend the next two years in a rural hospital or clinic. Studies show that 70 percent of the graduates of these programs end up practicing in rural areas.
The focus on the distribution and supply of primary health care clinicians has been joined by a very strong focus on building a health care workforce that is well trained to provide high-quality, culturally and linguistically appropriate care, using a more efficient and interprofessional team-based approach.
This reflects a growing recognition – codified in the Affordable Care Act – that team-based health care represents an essential strategy for improving quality care, delivering patient-centered care, and keeping costs in check. In other words, improving health care also must include efforts to ensure that health professionals are taught to work collaboratively in teams and that health care settings are designed to deploy an effective use of a complement of health care providers.
The importance of this approach was reinforced just last month, when the Institute of Medicine estimated that $750 billion – or about one-third of total U.S. health care costs – was wasted in 2009 on unnecessary services, excessive administrative costs, fraud, and other problems.
The IOM explicitly mentioned care coordination as a key focus area and recommended, among other things, that providers need to improve coordination and communication within and across organizations.
Specifically, the IOM said that provider organizations and clinicians need to partner with patients, families and community organizations to develop coordination and transition processes, data sharing capabilities and communication tools to ensure safe, seamless patient care.
To achieve this necessary shift in our business models requires both health professional educators and clinical leaders working together across disciplines to create appropriate training and care models.
I think we all recognize that change really begins “upstream,” with new ways to educate the health workforce to deliver care that has quality and safety – and their requisite attributes of care coordination and team engagement – at its core.
And this means much more than having different disciplines in the same setting. It means entirely different ways of engaging across the team and with the patient.
For example, anyone who has watched 6-year-olds learning to pass the puck in hockey scrimmages knows that teaching to produce not just individually competent hockey players, but hockey players who are also able to function competently as part of teams – achieving that competency can take a long time and requires a lot of practice, skills and knowledge.
My point is that this isn’t easy work – to achieve optimally coordinated care across interprofessional team members – care that contributes to eliminating unnecessary re-hospitalizations, medical errors, or patient confusion about managing their own care. Care that contributes to a host of other things that can go wrong when we don’t have continuity of care coordinated across providers and settings.
To further this goal, Secretary Sebelius recently announced a continuing HRSA grant to the University of Minnesota Academic Health Center to be the site of a new Coordinating Center for Interprofessional Education and Collaborative Practice. The center will facilitate movement of the health care delivery system to one characterized by integrated care and services. It will act as a one-stop resource on interprofessional education and practice that also supports research, data collection, and analysis. This new five-year, $4 million initiative will pilot projects at 11 affiliated academic sites around the country.
As just one indication of how groundbreaking this initiative is, four private philanthropies have committed an additional $8.6 million to support the Center’s projects – the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the Gordon and Betty Moore Foundation.
Now one area that does not always receive adequate attention is behavioral health. So in partnership with the Substance Abuse and Mental Health Services Administration, we are operating the Center for Integrated Health Solutions.
This is a national technical assistance and resource center that promotes the development of integrated primary and behavioral health services to better address the needs of individuals with behavioral health and substance abuse conditions, including in older adults.
The Center provides training and technical assistance to 64 community behavioral health organizations, including community health centers, that have collectively been awarded more than $26.2 million in Primary and Behavioral Health Care Integration grants.
It is the first “national home” for information, experts, and other resources that you can use to help integrate behavioral health and primary care. You can go to “integration.samhsa.gov” for webinars, listserv information, and learning resources.
And HRSA is taking steps to promote interprofessional practice and education in two of its nursing programs. This fiscal year, the Nurse Education, Practice, Quality and Retention Program is soliciting projects to develop interprofessional collaborative practice.
In addition, the Advanced Nursing Education Program is seeking interprofessional courses and learning experiences to build skills in health care technology among advanced practice nurses.
These new approaches to training and education are being put into practice through programs that align clinicians’ training with innovative models of care. They include the evolution of community health centers into patient-centered medical homes, where care delivery is redesigned for enhanced access, better coordination and team-based care.
Research shows that medical homes make a difference in patient outcomes, and health centers are key providers in implementing this important sea change.
Just last month, we announced awards totaling more than $44 million in ACA funds to support existing health centers in their efforts to become patient centered medical homes and improve quality of care. More than 100 of the awardees are in Regions 8 and 10.
In many parts of the country – including right here in Denver – health centers are leading the way in these efforts. At present, 13 percent of health center grantees have been officially recognized as patient-centered medical homes, and many more are in the process of gaining recognition.
In particular, health centers in two states, Oregon and Colorado, stand out for supporting clinical networks through their primary care associations, where they collaborate and share best practices related to patient-centered medical homes. Allow me a special shout-out to Oregon, where 18 out of 25 health center grantees (72 percent) have achieved state-based patient-centered medical home recognition, the highest percentage of all 50 states.
Of course medical home models can target specific patient populations – and there is no population group that is growing faster right now than the elderly. With that focus in mind, in November of last year HRSA and CMS began a 3-year demonstration project – the FQHC Advanced Primary Care Practice Demonstration – to support health centers that serve as integrated health homes for Medicare beneficiaries.
This partnership between CMS and HRSA was one of the first projects announced after the CMS Innovation Center was formed through the Affordable Care Act. Under this demo, 500 participating health center sites are transforming to “advanced primary care practices” that provide targeted, accessible, continuous, and coordinated family-centered care for Medicare patients.
The other new model of care you are surely familiar with is Accountable Care Organizations, which build on integrated care models by holding groups of providers accountable for both the quality and the cost of all care provided to a specific patient population. ACOs have the potential to improve the quality and value of health care by promoting accountability, coordination of care, and investments in infrastructure and redesigned care processes.
Health centers that participate in ACOs could potentially realize a number of benefits, including 1) easier access to specialty and hospital care for patients; 2) access to electronic health record and referral systems; and 3) opportunities to share in the savings that primary-care focused models of care produce in the form of reduced use of specialty care, hospitalizations, and ER visits.
I know that currently there is no ACO program under Medicaid, which is an important issue for you. HRSA staff is working closely with CMS to explore options to help health centers participate in ACOs under Medicaid.
We are also considering how health centers’ needs may differ from those of traditional providers when forming ACOs, and how the Medicaid program can help with these issues.
Within these new models of care, community health centers have a very important role to play in providing more comprehensive, coordinated and integrated care. They also have important roles to play as training grounds for the next generation of clinicians, especially given our shared interest in ensuring that vulnerable populations have access to health care clinicians and ensuring substantive experience in ambulatory primary care settings.
But I’m preaching to the choir, and before going any further, I want to congratulate the NWRPCA and CHAMPS for your work on the Education Health Center Initiative. This is a very important partnership with tremendous potential for leveraging clinical expertise and partnerships to integrate clinical training with practice – a model that could ultimately be very useful at the national level.
We could all learn a lot from efforts toward the goal of achieving what you call the “continuum” in the professional development of doctors, PAs and nurses. As you may know, the Affordable Care Act invests $230 million over five years in the teaching health center program.
Currently, there are 22 Teaching Health Centers training 143 primary care medical and dental residents in the areas of Family Medicine, Internal Medicine, Pediatrics, Obstetrics/Gynecology, General Dentistry, and Psychiatry. And we just received a new set of applications to add more THC sites and new primary care residents to this program.
Additionally, HRSA’s Teaching Health Center Graduate Medical Education program provides GME payments to support the expansion of primary care medical and dental residency training in community-based ambulatory patient care settings such as health centers, including health centers operated by the Indian Health Service or an Indian tribe or tribal organization.
In a related area, HRSA is leveraging public and private partnerships to advance health profession education through projects such as the Interprofessional Oral Health Core Competencies in Primary Care project. This initiative is developing and implementing a standardized set of core oral health clinical competencies for primary care providers and strategies to enhance oral health primary care team approaches to patient care.
The next steps will involve presenting our findings to the Advisory Committee on Training in Primary Care Medicine, creating a report for public distribution, replicating the best models, and supporting implementation of oral health clinical competencies in community health centers.
Also, the Primary Care Faculty Development Initiative, for its part, helps increase primary care residency faculties’ teaching, assessment, and leadership skills so that primary care residents will be prepared to engage in team-based patient-centered practice in medical homes. A contract to conduct a pilot with teams of faculty from family medicine, general internal medicine, and general pediatrics residency programs was recently awarded, and work will soon be under way.
The challenges posed by our changing health care system, and the requisites of interprofessional team-based care, raise the issue of enhanced workforce flexibility, which several Federal Advisory Committees have addressed.
For example, both the Council on Graduate Medical Education and the National Advisory Council on Nurse Education and Practice have made recommendations to enhance access to primary care by exploring ways to reduce barriers to health professionals practicing at the top of their license.
Specifically, the new report focused on care provided through the construct of a patient-centered health home. The committee views teams in these settings as central to eliminating health care disparities and attaining accessible, high-quality and affordable health care.
This report continues the steady drum beat from the previous report that identified interprofessional education as a central component to achieving a prepared workforce that is able to fulfill the primary care needs of patients.
The committee also noted that institutional leadership is required to create an environment that is supportive of care teams. At the institutional level, this means that practice re-design and educational reform are mutually reinforcing activities. That statement alone reflects much of the complexity of all this.
So we come at workforce issues from a multidimensional perspective – only some of which I’ve had the time to comment on here.
One of the things that makes the Affordable Care Act so innovative is that it doesn’t address any one program or initiative in isolation, but rather in the context of a web of policy imperatives involving hospitals, clinics, individual practitioners, health centers, colleges and universities, state PCAs and PCOs, foundations and insurers – both public and private.
Change often isn’t easy, and challenges are to be expected along the way. But I think the opportunities to strengthen and improve the health of people in your states and regions have never been greater.
To get this agenda right, we really need the best thinking from everyone and, to that end, I’m asking for your active participation. We look forward to hearing your very best ideas.
Thank you for inviting me here today.