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National Association of Counties ­ October 2010

Counties and Healthcare Workforce Investment

Importance of Healthcare Workforce Investment

According to the U.S. Department of Labor, the healthcare industry will create 3.2 million new jobs between 2008 and 2018, significantly more than any other industry.1 In 2009, establishments providing healthcare and social assistance accounted for nearly 1 in every 8 jobs, the highest of any type of employer.2 Major job growth is predicted not only for physicians and nurses, but also for clinical lab technicians, emergency medical technicians, home health aides, physician assistants, pharmacy technicians, and other similar occupations.3 In fact, ten of the 20 fastest growing occupations are healthcare related.1 Healthcare workforce investment is a significant opportunity for both economic and health infrastructure development. County leadership that is aware of and actively engaged in healthcare workforce investment are better prepared to begin and/or facilitate these important efforts.

Effects of Healthcare Workforce Investment

As unemployment rises from layoffs in other industries, training in the healthcare field not only places county residents immediately in employment demand, but also provides long-term job stability as the demands for a trained healthcare workforce increase.

Case Study: Idaho County, Idaho

Idaho County, Idaho, with an estimated population of 15,448 residents in 2008, is located in the north central portion of the state.8 The National Center for Rural Health Works in partnership with NACo conducted a study in 2009 to determine the impact of health services on the economy of Idaho County.9 From 1998 to 2006, Idaho County witnessed increases in: health services employment (37.5%), health services payroll (108.2%), and health services as a percent of total county employment (15.0% in 1998 to 18.9% in 2006). The health services sector employed a total of 687 full- or part-time workers, with an estimated payroll including benefits of $28.2 million. The secondary economic impacts of the health services sector employment were determined through the use of income multipliers. Combining the income multipliers from all health services, the total secondary economic impact of health services on Idaho County was calculated to be $6.9 million. Based on the results of the income multipliers, an existing 6% county sales tax was expected to generate over $600,000 from healthcare services income. The full report titled "The Economic Impact of Health Services on the Economy of Idaho County, Idaho", in addition to similar reports for Fulton County, Pennsylvania and Sumter County, Alabama can be found at: www. ruralhealthworks.org/dl_naco.html

Support for this publication was provided by the U.S. Department of Labor

National Association of Counties ­ October 2010

The healthcare workforce is not only a determinate of health outcomes, but it is also an economic development issue.4 If a resident must go to another area to receive needed healthcare; dollars and jobs are lost from the resident's local economy.5 An adequate healthcare system that is locally available will attract new county residents and retain aging county residents as their healthcare needs increase. As an export industry, the healthcare industry exports medical goods and services to other communities, bringing outside dollars, including Medicare and Social Security, to local health providers.6 In addition, health care organizations and their employees are direct purchasers of goods and services within the local community. The existence of health services within communities serves to attract other residents and businesses to the community, further enhancing the local economy. The economic effects of investing in the healthcare system can be measured, allowing county officials to showcase the importance of these endeavors with concrete data. One study found that one physician generates locally approximately $1.5 million in rev-

enue, $0.9 million in payroll, and creates 23 jobs.5 Given that 58.9% of all healthcare visits are made to primary care physicians, physician assistants, or nurse practitioners, investments in a primary care workforce beyond merely physicians can also produce a sizeable contribution to local health and the local economy.7

Before You Begin Healthcare Workforce Investment

Understanding the diverse issues involved is a crucial step in beginning healthcare workforce investment.

Know your stakeholders.

Knowing what organizations are currently working in healthcare workforce investment, which organizations are interested in becoming involved, and what organizations can enhance current/future efforts will aid in the establishment of programs and services; and, encourage the success of the investment. While county leaders will most often not directly provide workforce investment services, their unique position as representatives of community needs and abilities, as policy makers, and as leaders in community development allows them to foster collaboration among all involved parties. Regional collaboration with key leaders from the public, private, and non-profit workforce development sectors can help formulate strategies that will make the best use of the competitive assets of the region as a whole.10 A networked approach can link different strategies with common, objective information regarding the state of activities in the region, a common knowledge of the key issues, and a cooperative plan for addressing these issues. A few common healthcare workforce investment stakeholders are outlined below:

Local Example: Chester County Health Care Partnership

Chester County, Pennsylvania

The Chester County Health Care Partnership is comprised of over 30 organizations including hospitals, continuing care facilities, acute rehabilitation facilities, educational institutions, and county development offices. The partnerships with these key stakeholders in the healthcare economy of the county allows the Chester County Health Care Partnership to pursue its' goal of sharing information, ideas, programs and funding to stabilize and strengthen the local workforce. Programs implemented by this organization have included: presentations to Chester County high schools and other organizations describing nursing and other health career opportunities; healthcare facilities and educational settings hosting Health Care Career Showcases to provide students with a thorough overview of how healthcare organizations and facilities operate; and hosting of a Health Care Career Awareness Day held each November. Visit www.chestercountyhealthcare.org for more information about the Chester County Health Care Partnership including upcoming training and workshops, healthcare employment opportunities within the county, and other resources.

Hospitals, Clinics, and Other Healthcare Organizations

As these organizations are the employers for healthcare workers (present and future) throughout the community, strong knowledge of and strong relationships with the current, local healthcare providers is critical. Training new and existing healthcare workers to serve the commu-

National Association of Counties ­ October 2010

nity is a fruitless endeavor if there are not job opportunities available following the completion of their training. Understanding the needs of these employers can help county officials link employer needs with the abilities and resources of workforce organizations. Furthermore, county officials can communicate resident priorities to the healthcare and workforce organizations that can address these needs.

County public health providers across the nation have reported difficulties recruiting health educators, nutritionists, epidemiologists, dental hygienists, dental assistants, laboratory personnel, and home health aides.11 County officials can help pair public health providers with healthcare workforce development efforts to fill vacancies and gaps within the county health workforce.

Workforce Investment Boards

Workforce Investment Boards' (WIBs) financial resources, established workforce development programs, and facilities serving the local community make these boards a dominant player in any healthcare workforce investment. While participation of county elected officials in and with these boards varies greatly across the nation, county officials can establish/maintain supportive relationships with the boards serving county residents; and, help communicate resident and healthcare organization needs and opportunities for local healthcare workforce investment. One-stop career centers operated by WIBs are an extremely powerful resource for potential healthcare workers. The American Recovery and Reinvestment Act of 2009 (ARRA) funding of Workforce Investment Act (WIA) supported training programs identified the healthcare industry as a training priority for adult and dislocated workers.19 County officials can facilitate the efforts of one-stop career centers in directing adult and dislocated workers to healthcare careers through supportive policy making that helps retain these workers in the local community and/or increases the capacity of local education system to provide healthcare training opportunities.

Community Colleges and other training resources

As the demand for the limited training slots at community colleges continues to increase, measures must be taken to prevent any decline in the number of healthcare training slots available; and, if possible prioritize a greater portion of or increased funding for healthcare training programs. The high demand for skilled healthcare workers provides a solid platform for making sure that these training programs are given appropriate and needed funding.

Local Example: Lifespan Takecare Program

Butler County, Ohio

The Lifespan Takecare Program of Butler County, Ohio provides a care manager/educator to work with the Butler County Department of Job and Family Services Temporary Aid to Needy Families recipients. These recipients have a work exception because of caring for a family member. The goal of the Lifespan Takecare Program is to train these individuals so they can establish their home as a valid and safe workplace. Under this program, caring for a family member meets the requirement for work activities under the Ohio Works First Program. The case manager conducts an initial assessment of the caregiver's role and responsibilities, as well as the state of the care recipient. Following the assessment, the case manager develops an individualized education and care practice plan that fits the caregiver's needs and abilities. The caregiver then completes a comprehensive 75-80 hour formalized training program for employability as a Home Health Aide. This training equips the participants to work in a health care organization under professional supervision and plan of care. Visit www.lifespanohio.org for more information about this activity and other health services being provided by this program.

Local Public Health System

The local public health system is often a great source of health and healthcare data for counties. Proper targeting of healthcare investment will ensure that county officials obtain the best health returns possible on any investments made in the healthcare workforce. Data-driven healthcare workforce investment augments these programs with enhanced credibility, allowing county officials to communicate why specific training endeavors were pursued and the effectiveness of these programs to constituents, interested parties, and local, state, and national officials.

National Association of Counties ­ October 2010

Given the high demand and limited funding for the community college system, county officials can encourage the pursuit of other innovative training initiatives. Programs such as registered apprenticeships, mentorships, and web-based learning have shown success in providing cost-effective training of healthcare workers at various levels of education. By enacting policies that support the formal recognition of persons trained in alternative programs, county leaders can support healthcare organizations' hiring of and patient/employer confidence in these workers.

dents. Data showing a rapidly aging population may demonstrate an imminent need for qualified assisted living and nursing home health workers. High prevalence of renal failure throughout a county would call for increased training for dialysis technicians.

Identify Gaps in Healthcare Service

Outlining local healthcare organizations, their provided services, and proximity to the county residents they serve will identify any gaps in healthcare service coverage. Resources such as Geographic Information Systems (GIS) may provide a visual representation of healthcare service coverage gaps in your county. Coupling current county health information with healthcare service coverage can demonstrate exactly where resources are not meeting resident health needs.

Know your healthcare workforce needs.

Local workforce investment organizations may already be fully aware of all employment needs and opportunities within the area. County officials can evaluate all available information to determine if healthcare workforce investment in their community should be a priority; and, whether current workforce development efforts are addressing the local residents' need.

Identify local healthcare employer needs

Understanding local healthcare employer needs can ensure a smooth continuum from healthcare worker training to employment with these organizations. While previous assessment may have identified gaps in dialysis center capacity and coverage, dialysis providers may be unable to hire needed, trained staff because of lack of insurance reimbursements.

Identify community health needs

Working with the local public health system can help inform the current health needs of the county resi-

Local Example: Welcome Back Center of Suburban Maryland

Montgomery County, Maryland

The Welcome Back Center of Suburban Maryland's mission is to build a bridge between the pool of internationally trained health workers living in Montgomery County and the need for linguistically and culturally competent health services in the local community. The nurses served by this program are local residents, committed to working in local area following program completion. Furthermore, these nurses are already highly-skilled and highly educated: 53% of the 76 nurses that are within the program have more than 6 years of nursing experience in their native countries, and nearly half have at least 4 years of nursing education. Through a combination of guidance and support, academics, practical exposure to the U.S. healthcare system, and mentoring, this program decreases the challenges and barriers foreign-trained nurses encounter when obtaining the Registered Nurse (RN) license in Maryland. The program currently helps foreign-trained nurses navigate the state's registered nursing licensure process, participate in college courses to prepare for licensure, and gain clinical exposure to the U.S. health care system through paid placements in hospitals. Nurses that completed the program experienced a 155% increase in wages from when they started the program. Partners for this program include the local Montgomery College, the Montgomery County Workforce Investment Board, the Montgomery County Department of Health and Human Services, the Maryland Department of Labor, the Maryland Hospital Association, and three local hospitals that provide the on-the-job training and exposure. Visit welcomebackinitiative.org for more information about other International Health Worker Assistance centers throughout the nation. For additional information regarding the Welcome Back Center of Suburban Maryland, contact Carmen Saenz, [email protected], 240.777.4796.

National Association of Counties ­ October 2010

Identify Where Healthcare Workforce Investment will be Most Effective

This is the culmination and synthesis of the previous activities. Understanding county resident health needs, healthcare service gaps, and local healthcare employer needs will inform where healthcare workforce investment is needed and where healthcare workforce investment will be most effective. These assessments may have already been completed at various times and for different organizations/stakeholders.

seeing decreases in available funding for workforce development. In California, for example, the 20092010 WIA and ARRA funding provided a total of $967 million to the workforce investment system. However in 2010-2011, $470 million provided the previous year through ARRA not only has expired, but overall WIA funding for California was reduced by $37 million.12

Policy Obstacles

By identifying problematic policies, local elected officials can work to remove/modify obstructive local policies, help local healthcare workforce investment programs learn to successfully navigate these policies, or help create new local policies that can support these efforts. For example, faculty-to-student ratios of 1-to-10, mandated by many state nursing boards, make it difficult for many communities to find enough clinical sites to train prospective nurses.13

Know your challenges.

Identification of obstacles hindering local healthcare workforce investment is vital to create/support these efforts. Proper identification of all obstacles to programming must be identified and eventually addressed through the most effective avenues.

Funding Shortages

With the expiration of the ARRA funding and steady decline of WIA funding, many states/localities are

Retention of Healthcare Workers

High employee turnover carries significant monetary, time, and investment costs. From January to December 2009, the healthcare industry had the highest monthly median employee turnover rate compared to all other industries.14 The financial cost of losing a single nurse has been estimated to be equal to twice that nurse's annual salary.15 For each percentage point increase in nurse turnover, the averClark, Lincoln, Nye, and Esmeralda Counties, age hospital loses an estimated $300,000 per Nevada year.16 Retention is a problem not only of the Workforce Connections, a Workforce Investment partnercurrently employed workforce, but also of ship including county commissioners from the four counties any newly trained healthcare workers. Local served, recently provided funding for the Southern Nevada healthcare workforce investment will not be successful without recognizing the reasons Healthcare Industry Education, Training and Employment for current high employee turnover in local Project for Clark, Lincoln, Nye, and Esmeralda County resihealthcare organizations and enacting necesdents. The Area Health Education Center of Southern Nevada sary measures to address these problems. (AHEC) in partnership with the College of Southern Nevada

Local Example: Southern Nevada Healthcare Industry Education, Training and Employment Project

(CSN) and the Southern Nevada Medical Industry Coalition (SNMIC) will combine the workforce development experience, educational, and employment resources of its partners to create training opportunities for participants in the program in Emergency Medical Technician (EMT), Phlebotomy, Certified Nursing Assistant (CNA), Supportive Services and Health Unit Coordinator. The project will serve unemployed, underemployed, recipients of public assistance, low-income individuals, seniors, veterans, and/or the disabled. Visit www.nvworkforceconnections.org for more information about Workforce Connections' programs and activities.

Types of Healthcare Workforce Investment

While healthcare workforce investment has taken a variety of programmatic forms, these programs generally fall into one of several categories: Healthcare workforce planning: Programs within this category include the formation of healthcare workforce taskforces and commissions; collection and analysis of local and state healthcare workforce data; as well as the

National Association of Counties ­ October 2010

establishment of state grant programs to encourage local areas to undertake specific healthcare workforce initiatives (i.e. nursing shortages). Programs to promote healthcare careers: Programs that promote healthcare careers address this problem by exposing youth and dislocated/incumbent adult workers to the healthcare industry, enabling them to make educated decisions and clarify perceptions of a healthcare career. Health career ladder advancement: Encouraging healthcare workers in entry-level positions to pursue training for more skilled healthcare labor provides numerous advantages.14 As these workers are already members of the healthcare field, these individuals do not require orientation to healthcare work; or, to the value and need of healthcare work. Building health workforce educational capacity: An education system that can support the influx of new workers seeking healthcare training is central to the success of any healthcare workforce development.

Despite the need for increased numbers of healthcare workers, many educational institutions have not grown sufficiently to provide training to interested, qualified applicants.13 Health workforce retention: High employee turnover in the healthcare industry not only exacerbates healthcare employee shortages; it also carries significant monetary and time costs. Perhaps most importantly, retaining experience healthcare workers who provide direct patient care is critical for improving the quality of care.17 One-stop center referrals for health workforce jobs and education: In good economic times, workforce investment focuses on job-placement; however, in an economic downturn workforce investment needs to focus on job-training to make workers more competitive in a tight job market.18 For clients lacking specialized healthcare skills, the role of one-stop career centers is to help clients access the available healthcare training and education resources.

Resources

Employment and Training Administration, United States Department of Labor, 2010

Using Registered Apprenticeship to Build and Fill Healthcare Career Paths www.doleta.gov/oa/pdf/Apprenticeship_Build_ HealthCare_Paths.pdf This report, developed by the Department of Labor's Office of Apprenticeship, discusses how Registered Apprenticeship can be a critical contributor to the building the healthcare workforce by increasing skill levels without significant cost increases. The model helps professionalize entry-level healthcare occupations and prepares individuals for higher-level health careers.

Local Example: Lancaster County Center of Excellence in Long Term Care Practice

Lancaster County, Pennsylvania

The Center of Excellence in Long Term Care (COE-LTC) provides input to the Lancaster County Workforce Investment Board on workforce issues facing the long-term care industry in Lancaster County. COE-LTC plays an essential role in the selection, piloting, evaluation, and approvals of Lancaster WIB initiatives. COE-LTC provides research-based, state-of-the-industry programs and best practices that are carefully monitored and evaluated to meet the needs of the local long-term care industry. COE-LTC has synthesized local long-term care facilities, home health agencies, hospitals, assisted living/personal care facilities, hospice, government agencies, nonprofit agencies, and educational institutions to collaborate on solutions to pressing issues faced by employers. Through the collaborative effort, COE-LTC helps provide opportunities and programs that would be cost-prohibitive for local employers to pursue on their own. Visit www.coeinlongtermcarepractice.com for more information on programs, publications, and other resources from COE-LTC. For information on other Lancaster County WIB programs, services, and resources, please see www.lancastercountywib.com.

Bureau of Labor Statistics, 2010

Career Guide to Industries 2010-2011 Edition: Healthcare www.bls.gov/oco/cg/cgs035.htm This site provides an overview of employment in the healthcare industry, working conditions, current employment in healthcare occupations, training and advancement opportunities, earnings, and healthcare job outlook.

National Association of Counties ­ October 2010

National Center for Health Workforce Analysis, 2004

Effects of the Workforce Investment Act of 1998 on Health Workforce Development in the States bhpr.hrsa.gov/healthworkforce/reports/wia/wia.htm This report provides a solid summary of the Workforce Investment Act, implementation structure, funding streams, and how WIA has been used to support health workforce development. Types of healthcare workforce development are coupled with state program examples from 2004.

Local Example: Workforce Central

Pierce County, Washington

Workforce Central, formerly named the Tacoma-Pierce County Employment and Training Consortium), supports many healthcare workforce development initiatives in Pierce County, Washington. Workforce Central awarded funding to provide healthcare training for over 300 incumbent healthcare workers. These incumbent healthcare training initiatives include training for claims reporting, web-based training for medical records, medical records management, one-to-one physical therapy, and others. The Career Coaching Program is a unique public and private partnership that provides career coaching and planning, interest and aptitude assessment, financial aid, and training information to healthcare employees with a desire to obtain additional training for advancement in high demand healthcare careers. This program has provided career guidance, funding for training, workshops and other resources to over 4,000 Pierce County Hospital employees. The Pierce County Health Careers Council, a service of WorkForce Central (Tacoma-Pierce County Employment & Training Consortium), was developed to develop, implement, and oversee collaborative strategies that support: a sufficient supply of trained healthcare workers, health services workers' skill sets for quality care provision, Pierce county resident access to healthcare training that results in employment and career progression in health services, retention of healthcare industry staff, and awareness of healthcare careers and training opportunities. The Pierce County Health Careers Council has offered services providing extensive information on healthcare careers and training programs, career development coaching and career mapping assistance, career assessment resources and educational planning support, financial aid resources and application assistance, assistance with educational budgeting and cost planning, and financial assistance/ scholarships for qualified applicants. For information on other services, upcoming events, and workforce development resources, visit www. workforce-central.org. Information on the Pierce County Health Careers Council can be found at www. healthjobs4you.com.

National Association of County and City Health Officials, 2010

The Local Health Department Workforce: Findings from the 2008 National Profile of Local Health Departments www.naccho.org/topics/infrastructure/profile/upload/ NACCHO_WorkforceReport_FINAL.pdf This report provides a great snapshot of the current public health workforce including trends on specific occupations, local health department executives, staff recruitment and retirement, workforce development, and changes in staff size based off of information collected from the 2008 National Profile of Local Health Department study.

Health Workforce Information Center

www.hwic.org This center provides a substantial amount of health workforce information including toolkits, data, publications, news, and lists of funding opportunities for both individuals and organizations. Information has been sorted by both health workforce topic and healthcare profession for easy access to needed resources.

National Association of Counties ­ October 2010

(Endnotes)

1. Bureau of Labor Statistics, U.S. Department of Labor, Career Guide to Industries, 2010-11 Edition, Healthcare, on the Internet at www.bls.gov/oco/cg/ cgs035.htm (visited July 21, 2010 ). 2. Bureau of Labor Statistics, U.S. Department of Labor. (2010, June). Occupational Employment Statistics (OES) Highlights: An Overview of U.S. Occupational Employment and Wages in 2009. Retrieved July 21, 2010, from www.bls.gov/oes/highlight_2009.htm 3. Lacey, T. A., & Wright, B. (2009). Occupational employment projections to 2018. Monthly Labor Review, 132 (11). 4. Fonkert, J. (2007). Rural Minnesota's Health Care Workforce: Demographics, Geography & Strategies. Rural Minnesota Journal, 2 (1). 5. Eilrich, F., Doeksen, G., & St. Clair, C. (2007). The Economic Impact of a Rural Primary Care Physician and the Potential Health Dollars Lost to Out-migrating Health Services. 6. Scorsone, E. (2001). Health Care Services: Three Critical Roles in Rural Economic Development. Economic and Policy Update, 1 (13). 7. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center of Health Statistics, "National Ambulatory Medical Care Survey, 2004 Summary," No. 374, June 23, 2006. 8. U.S. Census Bureau; 1990 & 2000 Census Population; 2007 & 2008 Census Population Estimate (www.census.gov [March 2009]). 9. National Center for Rural Health Works. (2009). The Economic Impact of Health Services on the Economy of Idaho County, Idaho.

10. Carlson, P., Holm, R., & Uhalde, R. (2009). Building Regional Partnerships for Economic Growth and Opportunity. 11. Bureau of Health Professions, Health Resources and Services Administration. (2005). Public Health Workforce Study. 12. Legislative Analyst's Office. (2010, June 7). Workfoce Investment Act (WIA) - Discretionary Fund Expenditure Plan. Retrieved August 2, 2010, from www.lao.ca.gov/handouts/Conf_Comm/2010/WIA_ Discretionary_Funds.pdf 13. Cleary, B., McBride, A. B., McClure, M., & Reinhard, S. (2009). Expanding the Capacity of Nursing Education. Health Affairs, 28 (4), w634­w645. 14. The Bureau of National Affairs, Inc. (2010). Job Absence & Turnover: 4th Quarter 2009. Human Resources Surveys and Reports, 40 (839). 15. Atencio, B., Cohen, J., Gorenberg, B. (2007). Nurse retention: is it worth it? Nursing Economics, 21. 16. PriceWaterhouseCoopers (2007). What works: healing the healthcare staffing shortage. PriceWaterhouseCoopers, LLP. 17. Benner P. From novice to expert: the Dreyfus model of skill acquisition. Am J Nurs. 1982;82(3):402407. 18. Corporation for a Skilled Workforce. (2010). The Critical and Emerging Role of Workforce Investment Boards: How Federal Policy Can Incite Workforce Innovation. 19. U.S. Department of Labor. (n.d.). DOL Information Related to the American Recovery and Reinvestment Act of 2009: Implementing the Recovery Act. Retrieved July 21, 2010, from http://www.dol.gov/ recovery/implement.htm

About the National Association of Counties

The National Association of Counties (NACo) is the only national organization that represents county governments in the United States. Founded in 1935, NACo provides essential services to the nation's 3,068 counties. NACo advances issues with a unified voice before the federal government, improves the public's understanding of county government, assists counties in finding and sharing innovative solutions through education and research, and provides value-added services to save counties and taxpayers money. For more information about NACo, visit www.naco.org.

25 Massachusetts Avenue, NW l Suite 500 l Washington, DC 20001 202.393.6226 l fax 202.393.2630 l www.naco.org

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