I. Welcome and Introductions
In response to concerns about the growing shortage of HIV health care providers, and the subsequent impact on access to quality care, the HRSA’s (HRSA’s) HIV/AIDS Bureau is working to study the phenomenon and develop a plan for action. In pursuit of its goals, HRSA convened a stakeholder meeting of clinicians, workforce and other health researchers, State Health Department officials and health care funders to discuss major factors contributing to the decline in HIV clinicians, learn about promising workforce development strategies being implemented in local communities and States, and suggest potential short-, medium- and long-term solutions to the problem.
The meeting was held September 15-16, 2008 in Rockville, Maryland. Attendees were welcomed by Deborah Parham Hopson, Associate Administrator of the HIV/AIDS Bureau. Parham Hopson told those assembled that the Bureau had initiated discussions on the topic in 2006, as part of a broader strategy to identify and address emerging issues in the epidemic. It was determined that a stakeholder meeting would prove helpful in determining an appropriate, effective role for HRSA and others in addressing the issue. Parham Hopson acknowledged the leadership of her Deputy Chief and Chief Medical Officer, Laura Cheever, in helping to define a plan for moving forward.
II. Overview of HRSA's Strategy
Dr. Cheever explained that the role of HRSA's workforce initiative is to "determine strategies to support an appropriate workforce to provide high quality, compassionate care today and in the future in Ryan White programs." Cheever emphasized that the Bureau's intent is to focus not only on the HIV/AIDS workforce, but to consider its work in the context of broader workforce shortages in primary care and care to the underserved, and to consider a variety of health professions, including nursing, medicine, dentistry and pharmacy.
To learn more about workforce shortages and their impact at the local level, HRSA has contracted with Mathematica, a health policy research organization, to develop case studies of local systems of care that have innovative approaches to addressing workforce challenges. The stakeholder meeting, explained Cheever, would be used to help generate an agenda for what can be done in the short- and long-term to improve the capacity of the HIV workforce. Some of the factors that HRSA has identified as having a strong influence on the workforce include: 1) Increases in the demand for care and services due to the fact that clients are living longer; 2) Constraints in Ryan White grantee capacity due to increases in client caseloads without significant increases in budgets; 3) Fiscal constraints within Medicaid and other funding systems that affect provider reimbursements; 4) Increasing pressure on providers to deliver a broader spectrum of prevention and primary care services; 5) Impact of fiscal constraints on provider productivity requirements, which can lead to increased burnout; and 6) Potential implications of routine testing.
Cheever urged stakeholders to keep these issues in mind as they work together to construct a process for addressing the workforce shortage.
III. Plenary Sessions
Overview of Domestic Workforce Issues
The Lewin Group
There is a growing consensus that the supply of health care is not keeping up with demand, said Tim Dall, Vice President of the Lewin Group. At the same time, there are diverse opinions about the factors affecting supply and demand, which have in turn led to an array of forecasts regarding workforce trends. Some believe more clinicians are needed. Others believe the current supply of clinicians is not being used efficiently. Dall's presentation sought to highlight data on workforce shortages and what they indicate.
Often it is asked, said Dall, how a complex health care system comprised of 800,000 nurses, 300,000 physicians, and thousands of other clinicians in a variety of specialties, as well as a range of health care plans, employers, facilities and regulations can be modeled. Several approaches prevail.
One is known as the inventory model. It starts with the demographics of the current workforce, adds the number of new entrants to the field, subtracts the number of retirees or those exiting the field, and produces a number used as the starting point for the following year's projections. In applying the model to the current physician workforce, Dall has found:
Modeling data from the Association of the American Medical Colleges (AAMC), said Dall, shows that many physicians work longer and more consistently than they expect. The data also show that women and men tend to retire at the same ages, but given men's shorter lifespans overall women physicians actually spend more time in the workforce.
Dall then presented data on pharmacists. In applying the inventory model, he found that a large number of pharmacists in the United States are between the ages of 45 and 50, there are growing numbers of women moving into the field, and in the next 15-20 years women will comprise two thirds of all pharmacists, if current trends hold. As with physicians, labor force participation for both men and women pharmacists starts to decline significantly after age 60.
Dall used sample survey data collected by HRSA to model the nursing workforce. The results showed a substantial drop in the number of new nurses entering the profession, coupled with high attrition rates. About 95 percent of the nursing workforce is female, although the number of male nurses is growing. Labor force participation by nurses decline between the late 20s and early 40s, and picks up around age 45. It then remains fairly constant until age 60, after which it drops off again. Labor force participation rates are higher now than they were in previous years, possibly due to higher wages. Because many nurses tend to be second-earners in their households, said Dall, labor force participation rates for nurses tend to correspond with economic cycles; better economic conditions are often accompanied by reductions in the nursing workforce, while the supply of nurses increases during economic downswings.
There is a lack of consensus regarding what future needs will be for different types of physicians. Dall suggests that demand-based forecasting models yield the most accurate data, predicting demand and supply in the context of existing system inefficiencies. They use current patterns of health care utilization and service delivery to extrapolate into the future, taking certain trends into account.
Another approach to forecasting is called benchmarking, used by Jonathan Weiner in the mid-1990s to predict the future supply of physicians for HRSA. Wiener's data was published in the Journal of the American Medical Association and was used by, among others, the Council on Graduate Medical Education to develop funding policy for graduate medical education. In addition, educational institutions used the data to determine which specialties would be emphasized. The problem, explained Dall, is that Weiner's model was predicated on the notion that managed care would drive staffing patterns for the long term. When that proved not to be true, the projections were no longer valid. Dall cautioned on the use of models that depend on the consistency of one trend. Researchers, he said, "better be sure that trend materializes, [and] if not, they should do a sensitivity analysis so that people realize what could happen if the trend doesn't hold."
Many current forecasts for physicians, nurse practitioners and physician assistants, according to Dall, are drawn from a trend model developed by Richard Cooper. Cooper has correlated the physician/population ratio with gross domestic product as an indicator of economic well being. Using the model, he has predicted a physician shortage of 200,000 by 2020, mostly in the area of specialty practice. Based on these results, Cooper suggests that the major trend affecting the demand for physician services is the economy.
To examine the use of specialists by those with HIV/AIDS, Dall and his colleagues first looked at information from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Care Survey. They examined data for patient visits to inpatient or outpatient hospitals in which HIV/AIDS was indicated. What they found in those settings is that non-Hispanic Whites represented 38 percent of all office visits, non-Hispanic Blacks represented 43 percent, Hispanics represented 15 percent and non-Hispanic others were 4 percent.
They then looked at the types of doctors providing care to those particular patients. The results indicated that the clinician was an infectious disease doctor in 23 percent of office visits, a family practitioner in 16 percent of office visits, and an internist in 57 percent of office visits. Hematologists/oncologists, obstetricians, gynecologists and ophthalmologists were used to a lesser extent. Dall then took this data and forecast the future demand for physicians within these areas of practice.
Using this data, Dall projected that the total demand for physician services will increase 25 percent by 2025. At that time, the nation will be short 35,000 - 44,000 adult care generalists practicing in family and internal medicine.
Dall then presented data on other clinicians. With regard to nurses, he explained that an increased emphasis on expanding nurse education programs coupled with better nursing salaries had improved the outlook regarding future supply. However, despite these efforts and based on current trends, there will likely be a shortfall of several hundred thousand nurses by 2025.
In 2000, it was estimated that the vacancy rate for pharmacists was 8 percent and growing rapidly. Since that time, the supply has increased due to higher pay scales and expansion of training programs. If trends continue, said Dall, there should be a modest shortfall by 2025.
He Stated that the supply of nurse practitioners and physician assistants is growing pretty steadily and that there is some question about whether those professions will hit a saturation point. That is clearly not the case at the present time, said Dall.
Demand for dental services continues to grow at a significant rate. Barriers to care are largely related to geographic maldistribution of services and lack of access by certain populations, including the medically underserved.
In concluding, Dall presented some considerations for engaging young clinicians in HIV care based on what the data says about their interests and priorities.
What We Know About the Workforce in HIV/AIDS
HIV Medicine Association
The HIV Medicine Association (HIVMA) represents more than 3600 physicians, nurse practitioners, and physician assistants working in HIV medicine. The organization works to promote an alternative pathway that supports the training and certification of primary care providers as HIV experts. In pursuit of this goal, HIVMA developed the Minority Clinical Fellowship Program in 2006 to increase minority representation in the HIV workforce. The program provides Latino and African-American medical residents with mentoring and 1 year of clinical training in a center of excellence with a mentor.
Christine Lubinski, Executive Director of HIVMA, said that most of the HIV care provided in the United States, particularly in public settings, is delivered by multidisciplinary teams. Each member of the team is critical, she said.
She referenced a 2005 study of Ryan White HIV/AIDS Program Part C clinics that showed 20 percent of patients had the majority of their care provided by physician assistants or nurse practitioners. These clinicians, said Lubinski, maintained average patient panels of 100, and while they tended to see younger patients with fewer HIV complications, they scored as well as infectious disease doctors and HIV experts on quality measures. In addition, they often scored better than internists without HIV expertise or training.
Lubinski also presented data from the HIV Cost and Service Utilization Survey (HCSUS), conducted from 1996-98. The survey showed that 14 percent of persons with HIV/AIDS in care had unmet dental needs, and those who were uninsured or had Medicaid were three times more likely than those with insurance to go without needed medical or dental care.
"I would venture to say, given what I know has happened to Medicaid since the late 90s, that even fewer people with HIV now have an adult dental care benefit," she said. She expressed growing concern about the availability of dental services to those with HIV, especially in light of recent dental school closures due in part to insufficient reimbursements for care.
Lubinski said HCSUS data on the physician workforce, collected between 1998-99 from a sample of 372 physicians, showed that one third had annual incomes below $100,000, the majority were White men, and 20 percent were gay and providing care to 18 percent of patients. In addition, 40 percent were infectious disease physicians and 56 percent were general practitioners.
In general, Lubinski said, numerous studies document that health outcomes are better for HIV patients when physicians see more HIV patients and keep up with current treatment standards. This is true for all clinicians providing care to people living with HIV/AIDS. Further, formal training in HIV care is usually in infectious disease programs, although other specialties offer structured training experiences. There are a host of informal opportunities for non-infectious disease physicians to receive HIV clinical experience and mentoring. Doctors in training, including those being trained in Ryan White HIV/AIDS Program-funded clinics, perform an important role in providing HIV care.
As treatments have moved to outpatient settings, said Lubinski, medical residents have received less exposure to HIV patients. Data she presented from a 1998 survey of residents at academic health centers that found 22 percent of internists and 58 percent of family medicine residents felt "somewhat or very unprepared" to take care of people with HIV/AIDS.
Antiretrovirals have significantly increased the lives of those with HIV/AIDS, said Lubinski, and as a consequence HIV primary care providers are now expected to provide a broader range of services, such as risk reduction, diabetes screening, management of hypertension and other conditions associated with aging. Earlier in the epidemic, studies indicated that HIV patients were frequently referred to HIV specialists by their general practitioners. Current data suggests a trend in the reverse direction; infectious disease physicians are increasing referrals to internists for the management of general medical conditions.
In 2004, HIVMA conducted a survey of 729 first-year medical residents in internal medicine programs in ten States with the highest HIV prevalence. The average debt level was $108,000. The results showed that a majority (70 percent) planned to do specialty training upon completion of their medical residencies. Forty percent were interested in working in HIV medicine or research, and 79 percent indicated a preference for a year of focused training rather than a 2-year fellowship. Half of respondents (51 percent) felt their residency had not prepared them to practice HIV medicine.
Lubinski also presented results from a Workforce and Capacity Survey conducted by HIVMA and the Forum for Collaborative HIV Research. Responses came from 252 Ryan White HIV/AIDS Program Part C programs serving 135,000 patients in 2007. Forty-one percent were located in the south and 61 percent were in metropolitan areas. Ryan White provided funding for 69 percent of all primary care staff.
Results showed that the clinics served an average of 650 patients each. Twenty percent had experienced more than a 25 percent increase in their caseloads in the previous 3 years, 51 percent had experienced up to a 25 percent increase in their caseloads, and the remainder had experienced stable or decreasing caseloads. Many clinics in the south and rural areas reported rapid growth in patient caseloads. The range in panel size per physician was substantial, from 8-1250. The ranges for physician assistants were equally broad (4-600) as were the ones for nurse practitioners (5-750). Appointment times for new patients ranged from 15 to 240 minutes.
The majority of respondents indicated that it was very difficult to recruit primary care providers to HIV. Less than 10 percent said it was easy or very easy. Clinics in the west and south, and to a lesser degree the Midwest, reported the most difficulty. Recruitment of nurse practitioners and physician assistants was also challenging.
Top recruitment challenges identified by respondents included the overall lack of clinicians in their geographic areas (and lack of HIV clinicians in particular), as well as low reimbursement rates. Clinics in the northeast, south and west reported clinician shortages as barriers to recruitment. In the south and northeast, physician workloads were also a factor. To a much larger degree than in other regions, clinics in the south reported that physician pay scales and provider aversion to treating patients with HIV presented barriers to recruitment.
Wait times for first appointments for newly diagnosed HIV patients were significantly longer in the south (1.7) than in the northeast and Midwest (1.1 weeks). Wait times were also significantly longer in hospitals and academic centers than they were in publicly funded health centers or health Departments.
Lubinski concluded her comments by urging more study on the status of the HIV workforce and development of viable practice incentives. She said regional differences, as well as challenges unique to rural versus urban areas, must be addressed. The Bureau, she added, could take the lead in developing productivity standards that address optimum panel sizes and appointment times, and advancing practice models that respond to needs of patients and clinicians.
"If we are going to address this issue," said Lubinski, "then it has to be integrated into broader discussions, including on national health care reform and into the formation of a comprehensive national AIDS strategy."
Question and Answers
Michelle Lopez of New York asked Tim Dall if he had data on emergency-room visits for minority populations. Dall said there was a lack of data on racial and ethnic characteristics of patients. There are some surveys, he said, but they tend to be small with modest sample sizes. His findings did indicate that a significant percentage of patients with HIV/AIDS who seek care in emergency rooms are non-Hispanic Blacks. Data on the characteristics of physicians providing care in those settings is not available, in part because many of them provide care in multiple settings and it is hard to know what proportion of their time is spent in emergency rooms.
Keith Rawlings of Dallas asked if the presenters had data showing the percentage of licensed physicians in the United States who were practicing medicine versus the percentage working in other fields. He further asked about the criteria being used to define HIV expertise.
Christine Lubinski cited anecdotal evidence suggesting that physicians are moving into the private sector, including the pharmaceutical industry. With regard to defining experience, she said studies suggest HIV experts are those who have treated at least 20 patients and have participated in national and regional conferences on practice standards. The emphasis is on intensity of practice rather than duration.
Michael Horberg from Kaiser Permanente asked Lubinski whether she had any data suggesting that patients seeking care at Ryan White clinics were doing so because their physicians were no longer treating HIV. Lubinski said the HIVMA survey did not request that information, but that anecdotally she has heard many patients go to public clinics because their physicians no longer provide care or have closed their practices.
David Reznick of Atlanta asserted that physician reluctance to provide HIV treatment must be considered in efforts to expand the workforce. He then asked Dall if he had data on the number of clinicians working in the public versus private health care settings, adding that his belief is that clinicians are leaving public health because they feel the reimbursements are too low. Dall said he has some data on nurses working in public versus private settings, but it has not received the attention it deserves.
IV. Panel I: HRSA Programs and Their Potential Contribution
Bureau of Health Professions (BHPr)
Deputy Associate Administrator
Diana Espinosa, Deputy Associate Administrator of BHPr, highlighted several ways in which BHPr focuses on workforce challenges, including:
Espinosa highlighted several efforts within the Bureau that hold relevance for HIV/AIDS. The Nursing Education and Practice program emphasizes care to underserved and high-risk populations, which includes those with HIV/AIDS. State oral health grants include Puerto Rico, which focuses on the provision of culturally competent oral health services to people with HIV/AIDS. Espinosa mentioned that the primary care component of the statute has a special emphasis on high-risk populations.
The Area Health Education Centers (AHECs), which support innovation in health professions education, help increase the number of clinicians in underserved areas. Twenty-three of the program's 50 grantees provide HIV training and education to students, faculty and practitioners. The Preventive Medicine Residency Program has focused on increasing linkages and improving the quality of care.
A new program, the patient navigator, provides funding to community-based organizations to develop programs that increase care coordination and linkages.
BHPr also awards student loans and scholarships to primary care providers who work in underserved and minority communities.
Bureau of Primary Health Care (BPHC)
Public Health Analyst
Amanda Reyes of BPHC presented information on BPHC's community health center program, which served 16 million patients in 2007 through a network of 1,000 health centers. Health centers are located in high-need communities and must provide a broad portfolio of primary care and support services. Many are found in the same communities as Ryan White clinics; in 2007, 164 community health centers received Ryan White HIV/AIDS Program Part C funding. Health centers employ a broad range of health professionals to ensure high quality medical homes for those who would otherwise go without care.
While not required by legislation, said Reyes, nine out of ten community health centers directly provide HIV testing and counseling services. In 2007, more than 500,000 clients received HIV testing and counseling services at health centers.
The legislation prohibits health centers from denying access to services based on ability to pay. There is a sliding fee scale for those at 200 percent of poverty and below.
Reyes suggested that collaboration with the health centers program can be useful in addressing HIV workforce issues, and added that BPHC-funded primary care associations can provide entrée to this extensive system of care.
Bureau of Clinician Recruitment and Service
The Bureau of Clinician Recruitment and Service (BCRS) was created in 2007 to consolidate all programs in HRSA that provide funding to individual clinicians.
The programs are as follows.
BCRS' Mike Berry explained that BCRS also oversees the J1 visa waiver for clinical care, which in 2007 provided support to 10 clinicians serving as primary care physicians in rural clinics or Native American areas. Five of those who received J1 visas served in community health centers.
Division of Training and Technical Assistance, HIV/AIDS Bureau
HIV Education Branch
The mission of the AIDS Education and Training Center (AETC) program is to improve the quality of life for patients living with HIV/AIDS by providing education and training to health care professionals. AETCs serve as the clinical training arm of the Ryan White HIV/AIDS program.
Physicians, physician assistants, nurses and advanced practice nurses, oral health professionals, and pharmacists constitute 80 percent of those who receive training through the AETCs. The remaining 20 percent are allied health professionals.
Providers who receive training care for the medically underserved, include those in health centers, Ryan White clinics, rural health clinics, and correctional facilities.
The program maintains 11 regional centers with more than 130 local sites. Funding is for 5 years. There are also four national centers: 1) the AETC National Resource Center; 2) the National Minority AETC; 3) the National Clinician's Consultation Center; and 4) the AETC National Evaluation Center.
From 2006-2007, AETC faculty provided more than 46,000 hours of training to clinicians, 25 percent of whom were nurses and 21 percent physicians.
Questions and Answers
Lucy Bradley-Springer of Denver asked Mike Berry if he had data on the percentage of scholarship or loan repayment recipients that remain in their assigned communities after meeting their service obligations. He said current data show that 53 percent of program participants who met their obligation between one and 15 years ago are still working in their assigned communities.
Berry added that participants in the loan repayment program tend to stay in the communities where they first serve more often than scholarship recipients. The list of approved scholarship sites is limited because the program is legislatively mandated to send recipients to areas of greatest need. In the loan repayment program, there is also a list of sites, but it is significantly longer and applicants are able to visit and interview with sites before selecting them.
Pete Gordon of New York advocated greater emphasis on the loan forgiveness program, because it gives residents more choice in deciding where they want to serve. He asked if there was any potential to reallocate resources from scholarships to the loan repayment program.
Berry said he agreed with Gordon, but added that he had no control over how the money was allocated. He acknowledged that the consequences for defaulting on scholarship agreements were fairly onerous, requiring recipients to pay back three times the amount of their scholarships plus penalties and interest. As an example, Berry used a dental scholarship recipient whose schooling had cost $340,000. Were he to default, Berry explained, he would owe HRSA nearly $1 million. In consideration of these realities, the program has tried to target third- and fourth-year medical students, under the assumption that they have a better sense than first- and second-year medical students about their professional interests.
Keith Rawlings asked why the scholarship program was so small, given its success. Berry said that while scholarships help create a pipeline, they blunt the Bureau's ability to get more clinicians out into the field sooner. "The problem with scholarships," said Berry, "is that service can be deferred for up to 7 years while the recipient is finishing residency training." He said the Bureau has been focusing more on meeting the immediate needs of underserved communities.
Bruce Agins asked why there were only 10 J1 visas in 2008. Berry explained that there were two chief factors: 1) Limited resources available at the Bureau to implement the program; and 2) A 50 percent decline in the number of J1 visa holders over the past ten years. He added that the State-based Conrad program offers a total of 1530 waivers each year, while the number of J1 applicants seeking them is barely 1000. Berry is coordinating with States to ensure that applicants are referred to him when Conrad slots are filled.
Michelle Lopez of New York said her health center implemented HIV testing in 1990. Given that health centers do not employ sub-specialists, she asked Amanda Reyes whether BPHC had information on health center referral systems. Reyes said she is in discussions with colleagues about developing collaborations with sub-specialty providers, including HIV providers.
Janet Leigh from New Orleans expressed concern over the costs of medical and dental education as it affects the practice choices of clinicians. She asked whether the Bureau considers the cost of schools chosen by NHSC applicants in its award decisions. Berry said the choice of school is not specifically examined, however, BCRS does assess what services are most in demand in targeted communities. For example, if 20 percent of the vacancy list is in the area of family practice, then 20 percent of scholarships will go to medical students who plan to specialize in that area.
Another attendee asked about the status of the White paper developed by the National Advisory Council on the National Health Service Corps. The White paper will make recommendations for changes to NHSC authorization, which expired in September 2006. Berry explained that the document is still in clearance within the United States Department of Health and Human Services.
V. Panel 2: Pathways Challenges and Solutions
Targeting Pre-Professionals and Minority Students and Residents
Associate Vice President
Sade Kosoko-Lasaki is an ophthalmologist who sees clients with HIV/AIDS. She is also a Professor of Preventive Public Health and Associate Vice President of Creighton Univ. in Omaha, Nebraska.
Twenty percent of Omaha's population, she said, is comprised of Blacks, Hispanics, Native Americans, and Asian and Pacific Islanders. There is under-representation of these communities in the local physician workforce.
In response, Creighton, using a public health approach, developed several pipeline programs targeting students from economically, educationally and socially disadvantaged backgrounds. Middle school students participate in the Health Careers Club, where they learn about health and wellness issues in the context of math and science courses. They participate in a range of interactive educational activities and have opportunities to meet one-on-one with individuals who work in the health professions.
Creighton's Saturday Academy targets high school students, bringing them to campus every weekend to increase their proficiency in math, English, science and other subjects, with the intention of preparing them for undergraduate study in a pre-health field. Students receive a stipend equal to what they might earn if they worked for the day. They also receive assistance in preparing for their college entrance exams.
In the past 6 years, 1800 middle school, high school and college students have participated in the Univ.'s pipeline programs, which has helped raise their ACT and SAT scores. For the seven students participating in the Univ.'s post-baccalaureate program, Creighton has committed to awarding them $10,000 a year for health professions training. The institution also holds financial aid workshops for parents.
Arkansas Area Health Education Center
Associate Director of Education
The Arkansas Area Health Education Centers (AHEC) system has been in existence since the 1970s, and is administrated through seven regional locations throughout the State. The program covers every county in the State except the one that contains the Univ. of Arkansas Medical School.
The AHEC operates a number of pathway programs. Career awareness activities are designed to acquaint young students with opportunities in the health care field. These are held at grammar and middle schools, and include both students and parents. "A day in the life of a health professional" and other similar presentations are provided in a variety of formats.
Career fairs are also held in high schools to generate interest in educational opportunities leading to employment in health care. The AHEC develops online and print guides that outline educational requirements and responsibilities of different clinicians, and lists educational institutions in State that have certificate and degree programs in the health professions.
A number of pipeline programs are administered through the AHEC regional sites. The Community Health Applied to Medical Public Service (CHAMPS) program engages 9th and 10th graders in service and learning activities that introduce them to careers in the health professions. The Medical Applications of Science to Health (MASH) program enables 11th and 12th graders to shadow health care professionals and receive instruction in health and medical topics. Students are tracked over time and about 70 percent enroll in science majors or are already involved in health training programs.
AHEC also provides MCAT prep courses, mock interviews and assistance in preparing college applications.
Arkansas' Family Medicine Residency Training program operates in six locations around the State. Since its inception, the program has trained 571 physicians who are currently practicing in 67 of the State's 75 counties. AHEC-trained physicians comprise 49 percent of the total population of family physicians in the State.
"We feel if we train health professionals in a community, they will stay in those communities," said Arkansas AHEC's Patricia Vannatta, "and our experience has borne that out."
All training sites are affiliated with community hospitals, health centers, health Department clinics or nursing homes. The curriculum for each varies based on the emphasis of the residency program. Two programs concentrate on HIV management.
Professional isolation can be a challenge in rural areas, says Vannatta, so all programs are linked to the Univ. Medical Center through telemedicine technology, interactive video and other means. In addition, all programs use electronic records and other online resources to promote quality patient care.
Preceptorships are offered to medical students in their first 2 years and four-week community clerkships are required in the third year of medical school. Fourth-year medical students are able to do family medicine rotations throughout the AHEC system.
American Academy of HIV Medicine Workforce Initiative
American Academy of HIV Medicine (AAHIVM)
Jim Friedman AAHIVM's Executive Director, discussed the Academy's workforce initiative, launched in April 2008 and designed to generate interest in HIV medicine by "intervening at critical points in the [provider's] career path."
As part of the initiative, the Academy provides free membership to students in training, an effort that has attracted 170 new members since the program's inception. Students are paired with clinical mentors in their communities; the mentors are given access to AAHIVM-developed learning modules to help teach students about the fundamentals of HIV medicine.
A recently launched grant program provides $100,000 to residency programs to design, implement and assess innovative ways to encourage students to enter the HIV field. At least one grant will go to a Historically Black College and Univ. (HBCU). Best practices from this effort will be included in a guide and disseminated to medical schools and training programs around the country.
AAHIVM provides financial support to first-year HIV practitioners, their employers and their clinical mentors, as part of package aimed at increasing their competency for practicing HIV medicine. The package of support includes requirements for completing a certain number of HIV continuing medical education (CME) credits and becoming credentialed by the third year of practice. In conjunction with this effort, AAHIVM will be advocating for greater loan repayment through the NHSC to facilitate student entry into HIV medicine. In the area of retention, the program is working to secure enhanced reimbursements for HIV specialists.
Fellowship Training in New York State
New York State Dept. of Health/AIDS Institute
The New York State Clinical Scholars Program was established in 1990 through a legislative earmark of $1.5 million. The program targets nurses, physicians and physician assistants in a variety of health care settings. Grants for the program are awarded on a competitive basis every 5 years. Despite a cut of 6 percent to the program's budget for 2008-09, it was able to fund training for 12 scholars working at nine hospitals throughout the State.
The goal of the program is to expand the network of HIV providers practicing in the State. The program features three components: 1) A clinical track; 2) A core curriculum; and 3) An independent study project. Scholars start their clinical rotation at a funded institution and eventually build to a full panel of patients. The State Health Dept. provides instruction in a core curriculum. Scholars also spend one full day per week learning about broad policy and public health issues and complete an independent study by the end of the 2-year program. Once the program is completed, scholars must pass the AAHIVM exam to be certified.
Data shows that the program has been successful in keeping HIV providers working in the State. A recent survey of 73 graduates showed that 89 percent still work in HIV and 78 percent still practice in New York.
Bruce Agins of the New York State AIDS Institute described the program as a "Cadillac model" developed at a time when there was ample support for HIV services. Shifts in the economic climate, he added, coupled with changes in the epidemic have led the AIDS Institute to consider modifications. These may include condensing the program to 1 year to train more individuals, different/better targeting of shortage areas, adding an international rotation, linking to other certification or degree programs and requiring scholars to sign service commitments.
Among the policy implications for the program, said Agins, is whether it is still necessary given the growth in HIV clinical certification programs. Additionally, he posed these questions: 1) What role can an HIV scholar play in a model of care that integrates HIV into primary care?; 2) What can be learned from the President's Emergency Plan for AIDS Relief (PEPFAR) where a group of providers is trained in HIV care?; and 3) Should the program be combined with AETC and similar training programs?
HIVMA Minority Clinical Fellowship Program
Assistant Professor of Medicine
Emory Univ. Center for AIDS Research
Loida Bonney, a former HIVMA Minority Clinical Fellow, described the HIVMA minority clinical fellowship program as an "excellent" learning opportunity that enables post-residency physicians to gain HIV clinical experience and expertise. She said the goal is to expand the number of HIV clinicians from underrepresented minority communities.
During her fellowship, Bonney split her time between an academic position at Emory Univ. and a clinical practice at Grady Memorial Hospital, where she personally cared for 55 patients with HIV. The fellowship included weekly meetings with a mentor, attending several key medical conferences, and publication of an article on access to care.
"The beauty of this fellowship lies not so much in what I did last year," said Bonney, "but in what I will be doing in the future." Her plans include continuing to work at Grady to further build her panel of patients and build professional relationships with staff that will support her ongoing learning. She also will have the opportunity to share her enthusiasm for, and knowledge of, HIV medicine as she teaches students and residents in her attending role, and as she continues her research on HIV.
In concluding, Bonney suggested that 1 year of HIV training might not be adequate to orient a new provider to the field, but added that lifelong learning in HIV is important for every clinician.
The Role of Historically Black Colleges and Universities (HBCUs) and Hispanic Serving Institutions (HSIs)
Professor and Center Director
Center for Minority Health Services Research
Howard Univ. School of Pharmacy
Howard Univ.'s Anthony Wutoh explained that HBCUs and HSIs have, as part of their mission, a commitment to addressing a range of health issues that disproportionately affect communities of color, such as HIV/AIDS. As such, they are well positioned to help address workforce challenges by providing uniquely trained professionals with expertise in gaining access to underserved or hard-to-reach populations.
Wutoh explained that more than 80 percent of African Americans in the United States who hold medical or dental degrees received their education at either Howard or Meharry Medical College. Currently, nearly 20 percent of the medical and dental degrees awarded each year to African Americans are from HBCUs.
"So how can this potential workforce be accessed?," asked Wutoh. He suggested several approaches for reaching out to these students:
Wutoh, who is a pharmacist, says that Howard provides students in its health professions schools with instruction in HIV. In noting that there is a shortage of pharmacists nationwide and increasing opportunities for students to enter other fields, he emphasized the importance of reaching out to students early to foster an interest in HIV.
"HRSA will not be able to do these things alone" he said, "but it should consider targeting some of these individuals through its programs."
Nurse Retention in the Ryan White HIV/AIDS
Program Outpatient Setting
School of Nursing
Univ. of Maryland, Baltimore
With a workforce of 2.9 million, nurses represent the largest health profession in the country, said Zangaro. Nearly 60 percent of nurses work in acute care facilities and less than 10 percent work in outpatient settings.
Univ. of Maryland School of Nursing's George Zangaro pointed out several things that currently contribute to the severe and growing nursing shortage in the United States The nursing population is aging, there are insufficient faculty and learning opportunities and there is a growing demand for nursing services. In 2007, nursing programs turned away over 40,000 students due to lack of clinical spaces, faculty, and classroom capacity. As a result, it is projected that the nation may be short 500,000 registered nurses (RNs) by 2025.
The practice environment is the main driver in nurse retention, said Zangaro, and is influenced by factors such as job stress, inadequate staffing, high work volume, poor collaboration with other nurses and health professionals, and professional isolation, particularly in rural areas. "Nurses have described their practice environments as intellectually oppressive and cognitively restrictive," said Zangaro. As such, work settings that empower nurses lead to better retention.
"How do we retain nurses in the workforce?" Zangaro asked. He suggested that magnet hospitals provide models for promoting leadership opportunities, supporting professional development, supporting nurses' autonomy and role in decision making, and creating a "culture of retention" within practice settings. Other approaches could involve developing partnerships with nursing school deans to facilitate student introduction to HIV learning opportunities. Additional recommendations from Zangaro include encouraging rural clinics to let their staff present on HIV issues at academic centers, developing HIV specializations within nursing schools, and getting nursing school faculty to work in HIV clinics.
Zangaro explained that most current research on nurse retention is focused on acute care facilities, so a better understanding of how outpatient settings can be organized to promote nurse retention is needed.
"It's also important to figure out what young people [coming into the field] want in their work environment and professional experiences," he said.
Midwest AIDS Education and Training Center
Characteristics of Recruited IMGs or Foreign Born Clinicians
Barbara Schechtman of the Midwest AETC spoke about the potential for increasing the HIV workforce by tapping into the pool of internationally trained clinicians who live in the United States but are not working in the health care system. Because many of these clinicians come from nations with high HIV incidence, said Schechtman, they may be uniquely able to connect with patients from immigrant communities with high rates of HIV.
Studies conducted by Johns Hopkins researcher Lisa Cooper, M.D. indicate that racial and ethnic matches between providers and patients positively influence patient ratings of care, said Schechtman. That may mean that engaging foreign-born and foreign-trained providers in the HIV health care system could help expand access to culturally competent care for immigrant populations. Schechtman described African medical providers in Minnesota as motivated to give back to their communities, wanting to work in medicine, and interested in leading culturally specific training for other providers.
Schechtman outlined some opportunities to partner with groups that target these provider populations. The HRSA-funded Welcome Back Program provides intensive case management for foreign-trained clinicians to help facilitate their entry into the United States health care system. Florida International Univ. (FIU) in Miami operates a Foreign-Educated Physician-BSN Program, an accelerated nursing curriculum for foreign-trained physicians. The program, the first of its kind in the country, graduates roughly 40 nurses a year and was developed to address the nursing shortage in South Florida.
MATEC has reached out to foreign-born clinicians through HIV rotation and infectious disease fellowships at the Univ. of Minnesota, and through local partnership with organizations such as the African and American Friendship Association for Cooperation and Development, which focuses on licensure for foreign-trained professionals. The program is also using Minority AIDS Initiative (MAI) funds to provide shadowing experiences for clinicians in training. MATEC's Individualized Clinician Training Program also includes some foreign-trained clinicians from Africa. MATEC uses the Twin Cities Clinician's Group meetings to introduce foreign-trained clinicians to networking and partnership opportunities with HIV providers.
"MATEC has really put an emphasis on reaching out to these clinicians before they get certified," said Schechtman, "because we have found that increases their interest in entering the field of HIV."
Questions and Answers
Pete Gordon asked if the AHEC training programs were based at community health centers or academic health centers. Patricia Vannatta responded that the training programs are all located at community hospitals, as well as at freestanding clinics on their campuses. She added that most of the participating hospitals are the largest in their regions. The programs are long-standing and are centrally administered out of the Univ.-based office.
A participant asked Jim Friedman how AAHIVM intends to fund its workforce initiative. Friedman said the Academy is seeking funding from foundations and private sources. "We are making a point of not seeking funding from Ryan White, as we do not want to take from one program and give to another," he said.
Michelle Lopez mentioned that HBCUs could use high-school career days to generate early interest in HIV. Anthony Wutoh liked Lopez's idea and said he suspects some HBCUs shy away from the topic of HIV because they feel it will negatively impact recruitment. He echoed what others said about reaching out to students early in their studies, saying "I am an HIV researcher and I gave a presentation recently to over 30 students who have an interest in HIV."
Sade Kosoko-Lasaki said Creighton has had success in using peers to educate students, because students speak the same language, come from the same vantage point and belong to similar social groups. "So for example, we have high school students mentor kids in grade school and do this as we encourage students to look at the health professions," she said.
Inge Corless said the MGH Institute of Health Professions has an HIV specialization for nurse practitioners, a nine-credit certificate program funded by HRSA that now is available online.
VI. Breakout Sessions
Attendees were divided into three groups and asked to develop actions items to strengthen the pathway for individuals entering HIV clinical practice. Each group was asked to consider barriers to the pathway and in response develop potential short-, medium- and long-term solutions. Their discussions and actions items are reported below.
The group talked about factors that influence practice decisions among medical students and residents. One group member offered that decisions are often driven by what students think their quality of life will be in one field versus another. A member who previously taught in a health professions school said that her students, particularly those who came from disadvantaged backgrounds, are trying to move up the socioeconomic ladder and are inclined to choose specialties in which the remuneration is greater.
Another mentioned that recent legislation prohibits students from deferring loan repayment during residency, which she thinks will drive medical students to shorter residencies and more lucrative fields. She felt it would be valuable to look at more "innovative delivery systems" in which clinicians share responsibility for patient care.
A doctor in the group lamented the loss of a "commitment to doing something positive for the community" that once characterized medical practice. He believes a value of service should be re-instilled in the profession.
Members of the group also discussed the need to intervene early in the educational process. One participant referenced a Robert Wood Johnson pipeline project that targets minority college students for careers in dentistry, but her concern was that the program funded more "well-resourced" schools, rather than those having difficulty attracting minority students.
One group member offered, "I think what we need to do is put HIV in the primary care sphere rather than pull people into HIV." She added, "In primary care you get people who are more predisposed to the notion of serving and want to work with the underserved." It was suggested that HRSA could consider working with the National Association of Community Health Centers on a SPNS initiative to develop a model for delivering high quality HIV care within a community health center. This could, in turn, influence changes to legislation governing Ryan White HIV/AIDS Program Part C clinics.
One group member mentioned that all students who serve in her dental clinic say it is one of the most interesting rotations they perform. She wondered about the value of collecting data on whether this exposure makes dentists more inclined to serve HIV patients.
Finally, the group said that the absence of data is a big problem in trying to get political support for addressing the issue. They called for data on workforce shortages specifically as they affect HIV care were deemed necessary.
Group 2 examined barriers at both the pre-professional and professional levels. They believed recruitment efforts were hampered by a growing number of career options for clinicians both inside and outside of health care, coupled with a widespread belief that HIV was no longer a domestic challenge. Other barriers identified included the cost, and subsequent debt, associated with health professions training, concerns about work/life balance, and a diminished sense of HIV as a "cause" to pursue.
The group discussed a range of issues that inhibit health professionals from entering HIV practice: the desire to earn more given the cost of schooling; the minimal focus on HIV coursework in health professions programs; the inadequate supply of faculty who can teach students about HIV/AIDS; the multidisciplinary nature of treating HIV (specialty vs. general); the high number of patients with co-morbidities; the stigma still associated with the disease; and, the funding environment. Finally, the group felt that issues of race and class also influenced the desire, or lack thereof, of some professionals to work with affected patient populations.
Stigma, the frequency of co-morbidities among HIV patients, the diminished sense of "call" that once characterized the HIV workforce, concerns about living standards given low reimbursements for HIV care, and system pressures to serve more patients in less time were all cited as barriers to practice. Also discussed was provider discomfort with addressing patient drug use and sexual behavior, a critical component of assessing risk and identifying effective treatment plans. Safety concerns regarding occupational exposure to the disease, patient behaviors and location of care sites were also seen as barriers.
Recommendations in the Pre-professional Realm
Recommendations on Data
Group 3 touched on some of the same barriers at the pre-professional level identified by the other two groups, such as low reimbursements, high levels of educational debt, and lack of training opportunities in outpatient settings. They also noted lack of passion for HIV work as a significant obstacle. The group felt that students tend to be quite knowledgeable about HIV, but are unprepared to deal with co-morbidities, such as chemical dependency and drug use.
General apathy about HIV (e.g., lack of public response to recent data that infections are increasing), the group asserted, has translated into apathy toward involvement in HIV training. Few faculty are prepared to teach students about HIV and lack the requisite enthusiasm. Further, accrediting agencies do not require health professions schools to provide HIV instruction. Many clinicians are not well versed on the public health issues surrounding the epidemic. HIV is not a recognized specialty and associations and societies are not focused on it. Public health is such a broad topic that coverage of HIV within that context is often insufficient.
Meeting facilitator Lori DeLorenzo identified the following cross-cutting themes and strategies identified by all three groups:
Lori DeLorenzo provided a brief recap of the first day's discussions and noted that it had been successful in "generating some great ideas." She emphasized the importance of developing an action plan that builds on current approaches, taps into a variety of resources and captures the value of innovative approaches already at work in the field.
DeLorenzo said the perspective for the second day would shift to systems challenges and solutions.
VII. Panel III: System Challenges and Potential Solutions
Workforce Reduction in HIV Care:
The Impact on Consumers Living with HIV/AIDS
Community Health Care Network
New York, New York
Michelle Lopez of New York's Community Health Care Network spoke from her perspective as a consumer about the impact of workforce shortages on access to quality care. She raised concerns about the role of stigma as a disincentive for clinicians to seek work in the field of HIV, and pointed to data presented the first day of the meeting that indicated some providers are unwilling to treat patients with HIV, particularly in the south.
Lopez noted data from a 2005 national survey of HIV positive consumers in which 36 percent of respondents reported having experienced discrimination by a health care worker, and 8 percent indicated they had been refused medical treatment as a result of their HIV status. Data from a 2006 study cited by Lopez suggested that those who experience stigma are more likely to miss medical appointments and less likely to adhere to medication regimens.
She shared a personal story about her daughter, who had been perinatally infected, and became sexually active at 14, unbeknownst to Lopez. For 2 years, her daughter tried unsuccessfully to get an appointment with a gynecologist. Finally, the New York State AIDS Institute intervened and helped her secure an appointment with a gynecologist at a local clinic. Lopez's daughter loved her gynecologist, but when she went for a follow-up appointment, the doctor was not available and she was referred to another gynecologist, who gave her a "lecture" about her sexual behavior. This in turn made Lopez's daughter reluctant to seek treatment when she contracted an HIV-related yeast infection.
Lopez appealed to HRSA and other stakeholders to pay particular attention to the impact of provider prejudice in inhibiting access to HIV care, and to ensure the recruitment of compassionate, culturally competent professionals to treat people living with HIV/AIDS.
Fiscal: A System Challenged
Center for AIDS Research
Univ. of Alabama at Birmingham
Michael Saag, a physician and researcher at the Univ. of Alabama at Birmingham, highlighted the importance of early treatment. He said that 50 percent of patients with HIV/AIDS who begin treatment when their CD4 counts are lower than 50 die within 10 years. Of those who begin treatment when their CD4 counts are between 50 and 200, 25 percent die within ten years. Saag went on to explain that in clinics around the country, the median CD4 counts for those who enter initial treatment is 200, which indicates that many patients are starting treatment "too late."
Possibly due to opt-out universal testing, said Saag, those numbers have declined slightly in recent years. In 2008, nearly 30 percent of individuals with HIV had CD4 counts less than 200 when they first received treatment for HIV.
The average cost of care for a person with HIV, said Saag, is $18,300 per patient per year, a number that can increase dramatically as CD4 counts decline. Medications constitute 80 percent of the cost of care, with hospitalization representing 7 percent. In Alabama, the average reimbursement from Medicare for a patient with HIV is $359, a figure that does not change with a patient's level of disease.
"We don't pay primary care physicians to do what they do," said Saag. "That's where the problem is with workforce in my opinion."
He noted that the majority of increases in Ryan White funding in recent years have occurred in the AIDS Drug Assistance Program (ADAP). While acknowledging the critical role of pharmaceuticals in treating the disease, Saag suggested that the disproportionate focus on medications has belied the importance of quality primary care. Inadequate reimbursements to physicians, he said, will further imperil clinics that provide HIV care.
As an example, he presented data on his own clinic at the Univ. of Alabama. The operating budget for the clinic is $2.1 million per year. The clinic collects $500,000 a year in third-party payments and another $508,000 from the Ryan White HIV/AIDS Program Part C program. With a growth in patient population of 100 percent over the past 8 years, the clinic is now operating at an annual deficit of $1.1 million. Saag said his clinic is not unique; waiting lists for appointments are increasing at Part C clinics across the country.
Saag believes incentives may not be enough to attract clinicians to HIV. He thought loan repayments would entice people into the field, but felt they would likely leave after a few years if reimbursements continue to be low. Another issue, said Saag, is the time spent on prior authorizations. Data collected from his clinic over a 2-year period indicated that, on average, it took physicians 23 minutes to get a patient prescription with a prior authorization. Saag's clinic has a fully functional health record system, so for clinics without electronic systems, the time for prior authorizations would probably be doubled. "If as a provider you do three of these, that's the cost of reimbursement for an entire Medicare visit," he said.
In summation, Saag said that mortality is higher when patients enter care later. Therefore, diagnoses must be made earlier in the disease. Universal opt out testing is projected to increase patient volume by 20 percent-50 percent. On its face, said Saag, that is a good thing, but in an era of declining reimbursements to HIV providers who will be available to take care of these patients.
Saag advocated expanding the Ryan White HIV/AIDS Program Part C program and the provision of incentives for young physicians to enter the HIV field. "Without the drugs, providing care is difficult," he said, "but without qualified provider and clinics, HIV drugs mean nothing."
Fiscal: A Model That is Currently Working
New York Presbyterian System SelectHealth
Columbia Univ./New York Presbyterian
New York, New York
Pete Gordon of Columbia Univ. explained that HIV care in New York State is paid for primarily through Medicaid, Medicare and ADAP. The general apportionment of Medicaid dollars, however, has failed to support development of high quality ambulatory care, creating a problem as the disease has evolved into more of a chronic condition.
A robust economic situation, coupled with political will and effective AIDS activism coalesced into a public health program targeted at the epidemic. In response, the New York State AIDS Institute developed a center-of-excellence model that supported the establishment of a skilled, multi-professional workforce through a generous reimbursement for HIV ambulatory care. This, in essence, became a medical home for HIV/AIDS providers.
The advent of managed care in New York State, said Gordon, spurred development of HIV Special Needs Plans (SNPs). These provided the flexibility to address challenges and recruit new providers to expand the workforce. All of these plans can, and often do, reimburse physicians at an enhanced rate, resulting in engagement of more private-sector clinicians and eliminating provider shortages.
Fee-for-service Medicaid is often rendered through clinics with fixed reimbursement schedules and defined benefits packages, said Gordon, offering little flexibility to contract for new services. SNPs, instead, can choose to contract with providers at enhanced rates while bearing the risk of the additional costs.
The plans include hundreds of HIV primary care physicians and over 1000 sub-specialists who serve people living with HIV/AIDS. The approach has proven cost-effective and has garnered patient satisfaction scores at least equal to those experienced under fee-for-service Medicaid. In addition, the program has shortened waiting times for HIV specific and subspecialty physician appointments by months.
"It's been a sea change over what existed previously," said Gordon.
Gordon relayed that despite his initial ambivalence about managed care, it has proven effective in expanding the network of HIV providers and increasing timely access to quality HIV care in a cost-effective manner. "All too often," said Gordon, "I think we wind up reflexively supporting existing models of care rather than being open to what new models of care [can offer]."
"New York State's HIV Special Needs Plans are a model worth consideration at a time when we are experiencing shortages in the workforce," he said.
Chief of Service
El Rio Special Immunology Associates
Kevin Carmichael of El Rio Special Immunology Associates explained how the clinic developed its productivity standards. HIV care in general, he said, evolved accidentally as the epidemic came to the fore and has developed along divided "axes": outpatient versus inpatient, community-based versus academic centers, primary care versus specialty care, and integrated versus non-integrated programs.
At El Rio, both HIV specialty and primary care are provided as well as inpatient care. There was a push by the administration to apply the same productivity standards for general primary care to clinicians providing HIV primary care.
In researching productivity standards, Carmichael discovered that there was little guidance available. What little data there was, largely culled from a question on the AETCs Listserve, New York AIDS Institute and HIVMA survey mentioned earlier, suggested panel sizes of 250-350 patients for physicians working a 40-hour week, 60 minutes allocated for first appointments and a half hour for each subsequent appointment.
Armed with this information, Carmichael went to El Rio's medical director and persuaded him to give the HIV clinic physicians incentives based on panel size rather than patient encounters. The clinicians also started receiving additional compensation for hospital on call, something that other physicians at El Rio had always received but that had never been offered to Carmichael and his colleagues.
In light of his experiences, Carmichael suggests that work toward consensus guidelines for HIV productivity and credentialing may enhance provider satisfaction and thus assist recruitment and retention efforts.
Deputy Commissioner and Chief Medical Officer
New York State Dept. of Correctional Services
Albany, New York
"It's too easy to think about corrections as separate from the HIV epidemic," said Lester Wright of the New York State Dept. of Correctional Services. "But most people who are my patients will eventually return to community, and they are risk takers by nature, which is why they wound up in prison." Wright said a substantial number of individuals with HIV "cycle through the corrections system at one point or another."
In New York, said Wright, one quarter of the 16000 inmates in the correctional system have HIV. Given that prisons are often located in remote areas, the challenges to providing care are significant. Continuity of care is an issue, said Wright, because prisoners are often transferred between facilities. In addition, prisoners are highly suspicious of prison medical systems and often try to manipulate those systems to their own benefit. Further complications arise from the fact that many individuals in prison had no health insurance prior to their incarceration, had little access to care when they were not in prison, and have low health literacy levels. Delivering quality care despite these obstacles is the goal.
To reach that goal, the corrections Department collaborates with the New York State AIDS Institute to provide primary care providers working in prisons with HIV instruction via distance learning, and warm- and hotline consultations. Fellowships and HIV certification programs offer additional opportunities for developing expertise in treating patients.
Patient education is also a priority; the corrections system teaches inmates about HIV using peer and video presentations, as well as comic books. The system, in collaboration with the New York State AIDS Institute, trains 800 peer educators per year who, Wright says, are "far more effective than I will ever be in getting the message across to their fellow prisoners." Continuity of care is coordinated through community-based organizations.
New Models/Systems Development
Director, Infectious Disease Clinic
Denver Public Health
Denver Public Health, an integrated health care system, serves a mostly indigent patient population through the local health Department, hospital center, school-based clinics and a community health center program. The system operates the largest HIV diagnosis program in the State, which includes referrals to care. Testing is done at hospital emergency rooms, the Denver County jail, the STD clinic, and through outreach activities at gay bathhouses.
The system operates two HIV primary care sites. One is a Ryan White HIV/AIDS Program-funded Part C clinic and the other is an infectious disease clinic that receives Ryan White HIV/AIDS Program Part A funds. Patients in those clinics have access to a range of services, including pharmacy services, specialty care, social work services, psychiatric assessments, outreach and identification, and retention support. "We also have robust retention and prevention programs," said William Burman, Director of Denver Health's Infectious Disease Clinic.
The system is organized based on several premises.
Care coordination is the basis of primary care. Nurses are primary care providers and tend to bring a broad perspective to treatment given their focus on the patient's environment as it affects their health. Each clinic is co-located with a pharmacy, from which patients receive adherence monitoring and intervention, as well as prescription services. Weekly multi-disciplinary meetings assist providers in coordinating care for challenging cases, such as patients who are in the hospital or prison, or have co-occurring disorders.
Any transition is an accident waiting to happen. Effective, consistent care can be achieved in part by focusing on key transitions in a patient's disease, such as the moment of diagnosis, entry into or release from prison, or movement into and out of inpatient facilities.
There is no such thing as being too involved in patients' lives. Clinics should develop structured approaches to promoting retention in care. At Denver Public Health, an outreach nurse helps facilitate this aspect of the program.
Burman said that Denver Public Health is successful in recruiting and retaining clinicians because it:
Interdisciplinary Team/Task Shifting
Pacific AIDS Education and Training Center
Task shifting, said Kathleen Clanon of the Pacific AETC, is an idea that was developed by the World Health Organization as a way to expand access to HIV care in under-resourced countries. Task shifting is the rational delegation of health care tasks by more highly trained health professionals to those with less training. This approach has been used in United States systems of care designed to treat diseases such as diabetes, hyperlidemia and depression.
In the United States, said Clanon, the Kaiser Permanente health system uses task shifting to ensure cost-effective care. Within the Kaiser Permanente system, she explained, a patient with diabetes might see a doctor, and then throughout the year be contacted by nutritionists and pharmacists who help manage the care and stay apprised of the patient's health status. The pharmacist may order lab testing and adjust medications accordingly to maintain the patient's blood sugar levels. The patient would see the doctor once a year unless he or she had problems that required physician intervention.
In an HIV setting, said Clanon, a task-shifting arrangement might also call for a patient to see his or her physician once a year. In between, the patient may have appointments with a nurse clinician, who administers care using a standard protocol. Additionally, there may be interim adherence visits with a pharmacist, who also conducts side-effect screening by phone and/or email. In complex cases, the patient would see the physician more regularly.
In Clanon's program in Oakland, substance abuse and psychosocial case managers take on responsibility for assuring patients engage in routine health maintenance. Initially resistant to taking on these responsibilities, said Clanon, the case managers now enjoy working with patients in this manner.
The advantages of task-shifting arrangements, said Clanon, include:
Clanon also outlined some disadvantages to the use of the task-shifting model, which include:
For information on the World Health Organization guidelines on task-shifting, visit UNAIDS.org
Clanon described the changes needed to facilitate use of a task-shifting model in the field of domestic HIV care. The regulatory framework for providing care would need to be altered. Labor unions and professional organizations would have to be consulted; Clanon anticipated that these groups might exhibit initial resistance to the idea of task shifting. A well functioning referral system would be critical. Robust quality assurance mechanisms and functional referral systems would also be key, as would adequate pay and reimbursements systems to help prevent clinician turnover.
"In terms of my own experience, I think [task shifting] makes perfect sense and works well," said Clanon. "International experiences offer great [guidance] about how we can remake our system without necessarily having to increase the pipeline," she said. In the short-term, Clanon suggested increased outreach and training to primary care physicians, nurse practitioners, and physician assistants, to prepare them for delivering a greater proportion of care to people living with HIV/AIDS. HIV experts could consult at critical points in the patient's disease, but shift the more routine aspects of care to other clinicians.
Use of GeoMapping For Targeting Training: An AETC Experience
Kathleen Clanon for Michael Reyes
Pacific AIDS Education and Training Center
San Francisco, California
Within each AETC, local performance sites have responsibility for determining the care and educational needs in their regions. Because they have limited budgets for data collection, the PAETC has explored ways of supporting the sites in targeting their training programs.
One approach has involved the use of geographic information system technology to help determine if training activities correspond with local needs. The PAETC prepares individual maps for each local performance site using a variety of data. A map prepared for the North Coast AETC, for example, compares the number of clients by county to the location of pharmacies and physician practice sites. A San Francisco map shows which parts of the city generate the most participants for certain types of training activities.
Key informants in local performance sites have been surveyed to assess the value of the maps to their training efforts, and the extent to which the maps have informed their planning. Responses show sites use the maps in a variety of ways. Some have used them to initiate collaboration with other agencies, some to target underserved areas, and others to increase trainees' understanding of local epidemics. The sites have found it particularly helpful to have spatial data on clinician calls to the National Clinicians' Consultation Center.
Future efforts may include mapping TB cases, sexually transmitted disease cases and training partner data to assess if training is being directed to areas of need and addressing the most relevant topics. As with past efforts, sites will be involved in all phases of project development, and data will be presented in layers so that users can see trends and determine the relevance of spatial relationships.
MATEC's Individualized Clinician Training Program
Midwest AIDS Education and Training Center
The goal of the Individualized Clinician Training Program (ICTP) is to improve access to quality HIV care and reduce disparities in health outcomes by increasing the number of providers in underserved and minority communities. The goal is to ensure that each region of Illinois has a minimum of one HIV specialist, a challenge especially in rural parts of the State.
The program gives clinicians-physicians, pharmacists, nurses, physician assistants and nurse practitioners-an opportunity to expand their knowledge of HIV, hone their HIV care skills, and become experts in their local communities. Participants must complete 40 hours of instruction during their first year in the program. Components of the program include: guided reading and study; training; direct patient observation; and, attendance at infectious disease conferences, grand rounds and other professional development activities. The program also provides opportunities for participants to make presentations to community or professional groups and to be paired with mentors.
Barbara Schechtman of the Midwest AETC shared information about individual participant experiences. One, a pediatric nurse practitioner who works in a large HIV clinic in Chicago, had been working in HIV care for some time but did not feel confident about her skills. Following her ICTP training, some of which took place at AETC sites in California, she actually became a trainer for the program, and is now considered a leading pediatric HIV practitioner in the State.
A family nurse practitioner from Indiana enrolled in the program at a time when she had only seen three HIV positive patients at her community health center. Within a year of starting the program, she had a panel of 75 patients. She now runs a very busy Ryan White HIV/AIDS Program Part C clinic, where new physicians consult her regarding care and treatment issues. In addition, she has been instrumental in bringing a dentist on board to increase access to oral health care for those in the local community.
The program is trying to build its alumni networks to strengthen relationships between HIV providers. In addition, graduates are being used to help spread awareness of the program and its benefits to clinicians.
Questions and Answers
One participant expressed concern about the use of productivity incentives at El Rio, and asked Kevin Carmichael if the clinic had given any consideration to quality performance incentives. Carmichael said he has asked to be assessed based on patient evaluations, but there are no plans presently to change the incentive structure.
Keith Rawlings of Dallas asked Kathleen Clanon whether and how a task-shifting model would work outside of a managed care setting. She suggested that a pilot could be tested through the Ryan White program, which is not a capitated system. The results could be used to revise existing legislation and reallocate resources.
In response, Rawlings asked how the model could be "sold" beyond the Ryan White system to other health care payers. Clanon explained that she has seen the model operate in fully capitated systems, such as Kaiser, but that regulatory changes would be necessary for it to be used in fee-for-service systems or those with third-party payers.
Laura Cheever thought the approach would be effective in systems with interdisciplinary teams, where 15 minutes for a physician follow up would be appropriate because the patient would then see other clinicians. It would not work, she said, in a situation where a physician works alone and may be the only one able, or willing, to see a patient with HIV. She wondered about the quality of care provided when multiple clinicians are managing the same patient.
Michael Saag said changing the focus of reimbursement mechanisms from providers to systems of care would require health care reform.
Clanon said the task-shifting model calls for a rethinking of the way in which health care is currently organized around the physician's role in care. Signaling her agreement, one participant suggested renaming the "doctor's visit" to a "health care visit" in recognition of the roles of multiple providers in delivering health services.
Bruce Agins asked the panelists about models for rural communities. William Burman indicated that Denver Public Health uses telemedicine to see patients in the Dept. of Corrections and is working to build telemedicine capacity in its community health center. Lester Wright said that many of the physicians in New York prisons also provide HIV care in the community. It was also noted that the warmline at the Univ. of California, San Francisco provides HIV consultation to rural primary care providers across the country.
A final question was directed to Barbara Schechtman. She was asked about the role of nurses in MATEC's trainings. She replied that nurses perform a variety of functions and can do advanced practice without advanced degrees in some locations. Some become educators and others do adjunct services around HIV treatment.
VIII. Breakout Sessions
Consistent with the format used the first day, participants were asked to separate into three breakout groups and tasked with identifying system-level contributors to workforce shortages. Each group was also charged with developing potential
short-, medium-, and long-term solutions. Their discussions and action items are reported below.
Group 1 began their discussion by focusing on reimbursements for care. Some members of the group felt that as long as States were involved in health care regulation, maldistribution would always be an issue and there would be minimal opportunity to influence reimbursement rates. At the same time, some group members cautioned against a "nihilistic" perspective, noting that some States have implemented enhancements beyond Medicaid's threshold requirements.
One group member talked about medicine's growing interest in the concept of a medical home, adding that certain reimbursement mechanisms present barriers to implementation of the model because they reimburse for individual services. One group member said that nurse practitioners provide the majority of care in her system, but physician signatures are required to garner higher reimbursements. In this situation, the work of the nurse practitioner becomes invisible she said.
It was suggested that a HRSA SPNS initiative on integrated models of care could produce data in support of changes to reimbursement mechanisms. Another suggestion called for redistributing the unobligated balances of some Ryan White grantees to other grantees in need of additional funding.
The group wondered about the potential for instituting changes to the PEPFAR program that would require PEPFAR providers to apply what they have learned overseas in United States systems of HIV care. In addition, they thought there might be opportunities within the NHSC to connect service obligations to work with HIV communities.
The group highlighted some of the systems issues contributing to the clinician shortage. An absence of streamlining within the system was seen as hampering efforts to keep patients engaged in care, particularly those with complex needs who comprise a growing proportion of the HIV/AIDS population.
In terms of fiscal challenges, the group believed there was an imbalance of funding across various parts of the Ryan White program, resulting in a lack of emphasis on the growing rural epidemic. Further, the group Stated that the burden of regulations, fundraising and paperwork requirements proved demoralizing to many providers and made the field less attractive to potential newcomers.
Group members thought the task-shifting model offered an opportunity to reconsider reimbursement structures and link them to the quality of care provided. They suggested that Health Professions Title VII programs might offer a potential model of reimbursement that tied payment to services, rather than types of providers.
The group also thought it might be valuable to examine the impact of the community-based dental partnership program in increasing the number of dentists who serve patients with HIV/AIDS. Are dentists who train in this program staying in the field, and if not, why? It was suggested that HRSA might conduct a survey of dentists who participated in these programs to assess their experiences with, and attitudes about, serving HIV patient populations.
Finally, the group felt it was imperative for the Ryan White program to be actively involved in universal health care reform, under a new presidential administration.
Group 3 discussed how many of the ideas offered at the meeting point to interdisciplinary enhancements in systems of care. Yet, they noted, reimbursements are largely tied to medical visits. They felt HMOs could be structured for interdisciplinary reimbursement, but fee-for-service systems would prove more difficult.
In hospital systems, said one member, it is unclear how various sub-specialty staff contribute to patient outcomes. Other problems arise from different payment systems for inpatient versus outpatient services. Further, incentives for payment may be unaligned; for example, hospitals stand to lose revenue when inpatient visits decrease as a result of successful outpatient treatment.
Silos of care (e.g., HIV, obesity, TB) complicate delivery of care. Ryan White funding is perceived by other silos as being better funded and this can engender resentment and the perception that funding levels for HIV are not the norm. However, Ryan White has established a better, more integrated system of care as a result of the hard work of many pioneers. The HIV model of care should be advanced as the standard for all diseases.
Competing systems of care also exist within the Ryan White structure itself and collaboration across the individual Parts of the program does not always happen appropriately. Further, referrals out to other systems of care do not always work well, due to the stigma and discrimination experienced by patients with HIV/AIDS.
The group questioned whether the role of nursing in HIV is defined well enough. The definition/function of nursing varies based on the system of care leading to variations in how nursing is defined. State regulations, however, outline parameters for nursing practice.
Group members noted that by and large nurses, except for nurse practitioners, are not fully utilized in many outpatient settings. RNs are often too expensive relative to other positions. While teaching, symptom assessment, and other functions can be performed by RNs, tasks like taking blood pressure are more cost effective when performed by licensed practical nurses.
IX. Wrap Up and Closing
There were several final comments from participants. One suggested that discussion of workforce shortages should incorporate a focus on STDs as they are often co-occurring with HIV. Kathleen Clanon advocated greater articulation of HIV programs' focus on health disparities, adding that there might be opportunities to access available federal funding to address disparities. It was further recommended that the National Institutes of Health and other public agencies be involved in efforts to address HIV workforce shortages as a health disparities issue. Finally, Jim Friedman noted that many of the recommendations developed by participants were directed to HRSA, but argued "each of us have a role to play, and let's remember these are good recommendations for all of us."
DeLorenzo said attendees had really "answered the call" to address the workforce shortage issue. She commented on the level of passion and commitment to the issue exhibited by meeting participants.
Laura Cheever thanked attendees for their energy, ideas and contributions, and said HRSA would continue to seek their input and involvement as it considers what resources and capabilities it has for assessing and implementing their recommendations. She mentioned that a summary of the meeting would be disseminated to all participants.
She then briefly described the study the agency would be undertaking with Mathematica. HRSA will do 4-6 case studies to identify workforce shortage areas. These will involve interviews with administrators and clinicians to collect qualitative information on issues faced by grantees and how they impact care quality. The study will further identify promising strategies for potential replication.
"I want to assure you that this meeting is not an end in itself," said Cheever. "It's been an opportunity to start thinking about things differently and to lay the groundwork for moving forward with an agenda."