Health Policy Forum: The Future of D.C.'s Healthcare Workforce

Earlier this year, CareFirst BlueCross BlueShield (CareFirst) sponsored the DC Chamber of Commerce Health Policy Forum entitled "The Future of DC's Healthcare Workforce—Capacity and Pipeline Challenges and Solutions." The virtual event brought together policymakers, healthcare institutions, the provider community, human resource professionals and private sector companies to explore the future of Washington, D.C.'s healthcare workforce. CareFirst President and CEO Brian D. Pieninck moderated the event.

Here are highlights from the discussion

Healthcare workforce shortage

The pandemic changed how people seek and receive care. The adoption of digital health and telehealth services increased the scope of work for many practices. It also changed how many licensed and unlicensed healthcare workers work. Stressors like these, and the emotional toll of the pandemic, led some healthcare workers to retire sooner than expected, leave clinical roles for administrative positions or leave medicine altogether. But nursing shortages and workforce challenges within healthcare have been a problem for decades.

"Between 2019 and now, we've probably lost about 20% or more of our home health aide workforce here in the District of Columbia. And when you talk about who that health workforce takes care of –some of our most vulnerable communities— in their homes— that's substantial. And there are higher vacancy rates in long-term care, behavioral health and the disability-serving provider community," explained panelist LaQuandra Nesbitt, M.D., MPH, D.C. Department of Health director and board-certified family physician.

Since the onset of COVID-19, more people acknowledge how their lives have been touched by emotional distress and social isolation and are looking for help—pinching an already thinning line of behavioral health providers.

While many providers continued to deliver mental health services or addiction treatment services in person, other practitioners adapted to telehealth technologies. The technologies accelerated access to care, but they also accelerated interstate competition for that workforce. A reduced staff, coupled with fallout rates for infections and exposure due to COVID-19 surges, meant more practices were using overtime and expensive temporary staffing services to stay afloat.

"After each surge, we have more workers that are disabled, more workers that are unmotivated, just too exhausted, really to meet basic performance expectations, and more workers leaving the workforce permanently. So cumulative workforce attrition is what we have to talk about, not just what happened at the worst moment of COVID, but that each wave exacerbates this experience. And that's not just limited to our heroic frontline staff, but also includes lost experience and skills in critical management and administrative positions," said panelist Mark LeVota, Executive Director of the DC Behavioral Health Association.

“The nursing shortage would be less severe if nurses weren't running around doing a whole bunch of administrative duties in addition to their clinical and nursing duties. The behavioral health disorders would probably be less severe if we could think about how behavioral health services are delivered in a more creative way. All these things are intimately connected in terms of care delivery models, scope of practice, and team-based care. All those things will help us better leverage the assets that we have.“

LaQuandra Nesbitt, M.D., MPH, D.C. Department of Health director

Keeping the healthcare workforce engaged and focused

"We have healthcare industry employers at the table. We have the educational system at the table. We have the public health cluster at the table … because we all [must] work to address this. Folks recognize that if we are not working together and thinking about sustainability, we're not going to move forward," said panelist Jacqueline Bowens, President and Chief Executive Officer of the DC Hospital Association (DCHA).

"We've got to increase capacity on the training side, but employers have to be more engaged in creating pipelines and pathways for sustainable careers. On any given day, we probably have 1100 vacancies in our hospital system alone. That can be from the nurse to the track worker. So how do we redefine and reimagine careers in healthcare? Working together is, I think, clearly how we're going to get there," said Bowen.

"The short-term solutions probably sound more familiar, but they're also meaningful areas of compensation, benefit design, workflow reconfigurations, and new workforce wellness strategies. Think about recruitment and retention, bonuses, targeted promotions, and better explanations of total compensation. It's not just pay. It's also insurance benefits, retirement benefits, free clinical supervision, free coaching and free license exam prep, said LeVota.

“We're going to have to be different in our approach as employers and upskilling managers with better supervision skills and developing better team-based approaches to getting work done. While we also work on the pipeline and the pathway, work on the long-term solutions that we know also need critical investment and attention.“

Mark LeVota, Executive Director of the DC Behavioral Health Association

"If we keep driving up wages in certain employee employment categories by competing on incentives and signing bonuses, etc., that will price certain employers out, further exacerbating their vacancy rates. And then it creates an unsustainable expectation for employment, fringe benefits, etc., that we won't be able to hang on to in the long term," said Dr. Nesbitt.

"Loan repayment or recruitment and retention incentives [keep us in competition] with the rest of the country. We can't graduate that many people very quickly. They must move through the pipeline. We could do some things that would graduate people in certificate and diploma programs, and we could upskill existing people and look at scopes of practice. We could look at reciprocity. We could look at licensure. All things may help, but some of those may still be very temporary measures. We've done some of those things during the pandemic. And all it does is shift the workforce around. So, we've got to make sure that these solutions that we keep looking at as real solutions that will give us the long-term gain are, in fact, that. Or whether they are a Band-Aid while implementing those long-term and sustainable solutions," she added.

"How do we align the employer's needs along with the training? That's really been a disconnect. And how do we bring the right incentives to the table? Compensation is critical. Absolutely. But I want to reinforce that's not going to be the only piece. I think all our employers understand it is not simply posting a job with skills and saying, we're ready to receive you. It must be that whole comprehensive approach to readiness, access and equity," said Bowens.

"The other piece is thinking through those workforce wellness strategies. This is an essential piece of addressing our workforce's emotional distress from their own lives, stress, grief, loss, and working with the people they serve," LeVota said.

"I think we all have dealt with this in a quiet sort of way, but we have to really elevate and balance out the importance of investing in our behavioral health—our mental health. That's going to be so important," said Bowen Pipeline response.

"Most educational institutions, if they believe there will be jobs in a particular area, will add educational capacity. In the U.S., nurses have grown from about one million nurses in 1982 to over 3.2 million nurses currently. So, the supply side has been growing. We had shortages, to begin with, and the pandemic has heightened or advanced the retirement of many people, the attrition, the burnout. So, we need to ramp up the production more and look at worker satisfaction and worker burnout and what we can do," said panelist Edward Salsberg, MPA, Lead Research Scientist at Milken Institute School of Public Health, the George Washington University.

Salsberg recommends the following strategies to meet the healthcare workforce needs of Washington, D.C.:

  • Career ladders: Offer entry-level workers—workers that may have come in with a high school degree or community college degree—opportunities for career advancement that makes those entry-level jobs more attractive and provides a steady stream of workers for the higher-level jobs.
  • Ensure adequacy of salaries and working conditions and benefits: Home health aides and certified nurse assistants, and many frontline workers face some of the most significant challenges with the pandemic and its negative impact. We have to look at how wages and benefits kept pace with this workforce.
  • Get the data: Track where our workers come from, where they're going and the degree of attrition.

"There's more we can do to link the educational institutions with the service providers to support the production of workers that match the needs. We have an educational community that will work, that wants to be responsive, and would be open to greater collaboration with the delivery system," he concluded.

Collecting the data

Effectively collecting and using data-driven insights is an essential step in measuring disparities and improving the health of a community. Data informs appropriate planning and action. And being present in communities and conversing with residents to understand their perspectives and needs is equally important.

“What we find in our research is connections to the community matter. Having open dialogue matters.“

Yesim Sayin Taylor founding Executive Director of the D.C. Policy Center.

In Washington, D.C., data sources make it difficult to determine how many licensed practitioners are providing services in the region. The D.C. Department of Health keeps a main list of all licensed practitioners, but the American Community Survey (ACS) and Bureau of Labor Statistics (BLS) report on the number of clinicians or health practitioners in two different formats. And when these sources are compared, there are significant variances.

In November 2020, D.C. Policy Center looked at the population of a Ward to try to estimate the need for primary visits. They compared the information in the sources mentioned above and considered demographics and statistical data regarding health outcomes. They found that the presence of practitioners met only 2% of the need in Ward 7 and 4% of the need in Ward 8. In other words, the communities with the highest-risk residents have the most limited access to care.

"We learned a lot about racial inequities in health and through our research. But one thing that was interesting to me is at the beginning of the pandemic, there was difficulty engaging African-American and Hispanic residents, not just in D.C. but elsewhere in the country, in trials and vaccination. There were questions about why. 'Why aren't we finding representation not just in our healthcare provision but also in participation in finding solutions?' So, there's discussion about the Tuskegee Syphilis Study. We know this story. We know that this has a very bad outcome for the Black communities and has shaped their thinking. So, doctors were curious, is this still what's in people's minds? So, they went out and did a survey. They surveyed folks in D.C. and Baltimore. They went to Tuskegee and asked these questions. And it turns out that it is not this experiment that's shaping people's perceptions of the healthcare sector. It is what happened at their doctor's office last week or the week before," reflected Yesim Sayin Taylor founding Executive Director of the D.C. Policy Center.

"And when you look at the big discrepancies between the, for example, primary visit needs and the availability of practitioners nearby, you can understand why people are frustrated. They may have to get on the bus or drive a long distance to go to a place that's not their neighborhoods," she adds.