NYAPRS Note: Much has been speculated about workforce development in light of Medicaid reforms in NY, but one thing that is certain is that the traditional workforce will have incentives (or in other words, be forced at the risk of losing their jobs) to retrain and/ or take new positions providing outreach and preventive care to the community. The inclusion of these workers in how that is done and how the new roles are defined and valued is crucial to continuity and standardization across not only the workforce, but consumer expectation and empowerment. There is an opportunity for the recovery field to develop intervention strategies and partner with large systems that are retraining staff toward prevention and rehabilitation.
Defining Health Care Jobs
Crain’s Health Pulse; 4/5/2015
As Crain’s reported this week, DSRIP will facilitate the retraining of 118,000 health care workers and 25,000 new hires. One issue for this workforce retraining is how different roles will be defined. The descriptions of care coordinators, care managers, community health workers, patient navigators and several other variations are inconsistent across the state. Area colleges would like to play a part in the retraining but have difficulty devising curricula with little guidance. “I’m going to educate a care manager in Syracuse who’s not going to look like a care manager who was educated in Queens,” said Patrick Coonan, dean of Adelphi University’s School of Nursing and Public Health. Mr. Coonan is part of the DSRIP Project Approval and Oversight Panel, which approved and amended PPS scores in February. He said a committee within that 19-member panel could be asked to devise some of those definitions with input from the Department of Health. Providers might want to take the lead themselves, though. “The folks doing the work directly, and the labor representatives, can probably do the best job of defining things,” said Dr. David Cohen, executive vice president and chairman of Maimonides’ Department of Population Health.
How Market Reforms are Remaking the City’s Medical Workforce
Crain’s Health Pulse; Jonathan Lamantia, 4/5/2015
Jean Nurse sat in a downtown Brooklyn classroom, listening to Carol Oster’s lesson of the day: what to do when a crisis strikes a patient with a serious mental illness or a chronic disease like HIV, diabetes or asthma. Ms. Nurse, 46, is a case manager with 19 years of health care experience, but she’s being retrained for a type of job in high demand because of major changes in how care is delivered to 5.3 million Medicaid recipients in New York state. Many health care jobs no longer will be based at hospitals. Instead, they will require workers to reach the most complex patients in their homes.
“Some people are used to the hospital setting, but we go into projects where there’s feces in the elevators,” Ms. Nurse said. “It’s definitely an adjustment.”
A $6.4 billion overhaul of the Medicaid program is set to begin this year in New York, and the reforms will be hugely disruptive for thousands of health care workers, both inside and outside hospitals. Some will be retrained. Many will earn a fraction of their former salaries. Thousands will be laid off.
From a worker’s perspective, “there’s always fear and concern about jobs,” said Helen Schaub, policy and legislative director at 1199 SEIU Healthcare Workers East. To workers who could lose their jobs she says: “Prepare early rather than wait to get a layoff notice.”
An estimated 2,200 workers will lose their jobs statewide—a figure that may go as high as 8,300, according to 1199 SEIU, the union most affected by the reforms. Providers have promised to spend $420 million over five years on retraining, redeployment and recruiting. Retraining on such a massive scale won’t be easy. By union estimates, some 25% of retrained employees in some health networks could end up in jobs that pay 75% to 95% of their former salaries.
At the Puerto Rican Family Institute, Ms. Nurse cared for patients with mental illnesses. Now she is a care coordinator there, responsible for managing a caseload of 40 New Yorkers with complex mental or medical conditions. She is learning how to intervene when a crisis—an eviction, perhaps—disturbs the delicate state of her clients’ lives.
The goal: With this retraining, Ms. Nurse can keep her patients from seeking care unnecessarily at an emergency department. Her job is, in many senses, the job of the future in health care, one that workers displaced by the coming reforms are likely to take up. Instead of caring for people when they are sick, the new system aims to keep them well by coordinating their care through a team of providers, social workers and care managers.
“The system is dependent on an army of frontline workers reaching out to the community,” said Bill Ebenstein, senior fellow at the John F. Kennedy Jr. Institute for Worker Education at the City University of New York.
The Medicaid reforms, he added, “probably will fail or succeed on the basis of that workforce.”
The nature and extent of job cuts will not be clear until the end of the year, when health care organizations that are participating in the Medicaid reform program formalize restructuring plans that affect 700,000 employees, or 9% of the state’s private-sector workforce. A labor battle could be brewing.
“Labor and management must be willing to have the conversation about what’s best for the system overall, and how can we minimize any ill effects on worker compensation,” said June Keenan, senior vice president for delivery-system transformation at Westchester Medical Center. “There’s going to be some hard conversations for everyone involved.”
The five-year Medicaid reform initiative, known as the Delivery System Reform Incentive Payment program, or DSRIP, aims to reduce avoidable hospital admissions by 25%. There are 25 new state health care delivery networks of hospitals and community-based organizations created under DSRIP. They collectively plan to retrain 118,000 workers and hire another 25,000.
The reforms aim to slow spending in the state’s $58 billion Medicaid program. But union officials are concerned that organized labor will pay the price. In its public comments about the new program, 1199 SEIU wrote that community-based care should cost less because it keeps people healthier, “not because it relies on cheap labor or high caseloads.”
Ms. Nurse is among the first wave of health care workers undergoing retraining by the union’s Training and Employment Funds, which has been hired by nearly half of the new networks. The funds will coordinate training with colleges, such as CUNY, so some workers can receive college credit—and higher wages.
Advertised rates for care coordinators and case managers are $15 to $17 an hour, with outreach workers at $10 an hour, according to 1199 SEIU.
Ms. Nurse, as a care coordinator, recently helped a client fill out a housing application, a half-day’s work that left little time for others. Accompanying someone to a doctor’s appointment takes up a similar amount of time. Her colleagues help with food-stamp applications.
“You’re giving 40 clients quite a bit of time, and there’s just a limited amount time in the course of a day,” Ms. Nurse said.
One of her classmates is Renny John, 37, an outreach worker whose job is to get permission from Medicaid recipients to coordinate their care. Each month he’s given a list of 150 Medicaid recipients to contact. When he can’t reach them by phone, he says, he travels to some of “Brooklyn’s most dangerous housing projects” to find people who would benefit from care coordination. But because Medicaid often provides inaccurate addresses, he must rely on word-of-mouth to track down people.
“For care coordination to have clients, we have to get them,” said Mr. John.
He once was a claims examiner for an auto insurance company. “I just like helping people. I’ve been through the system,” he said. “I’ve been on food stamps. I’ve had Medicaid. I know how to navigate the system.”
Ms. Nurse and Mr. John will play a key role in the Medicaid reform plan. Their jobs require exceptional interpersonal skills to motivate the neediest patients to seek treatment and stay out of hospitals. Thousands more workers will need to acquire those skills for the reform program to succeed.
“Hospital jobs will not go away as a result of this,” said Westchester Medical Center’s Ms. Keenan. “Hospital jobs and roles may change as hospitals get much more involved in reaching out to the community.”
Maimonides Medical Center has trained about 400 health care workers in care coordination as part of previous Medicaid reforms. Its method includes a care-coordination fundamentals class, followed by individualized courses for care managers, care navigators and outreach workers.
“Workforce issues are just too important,” said Dr. David Cohen, executive vice president and chairman of Maimonides’s department of population health. “We must create new titles and also new opportunities, career ladders and reasonably paying positions to replace those that are lost.”
Care managers and mental-health professionals will make up 1,315 of the 1,500 new hires in the Brooklyn hospital’s network, Dr. Cohen said. “We’re going to try some things that are going to succeed terrifically, and some things that are going to fail. We’re going to have to keep retooling.”