Goal 5: Strengthen the Nation’s Health and Human Service Infrastructure and Workforce
Currently, areas in the Nation face shortages of critical healthcare workers, including primary care physicians, nurses, behavioral health and long-term care workers, as well as public health and human service professionals. Moreover, this problem is anticipated to increase in the coming years. More than 64 million people currently live in a primary-care health professional shortage area, and others live in smaller areas with health professional shortages. More than half of the counties in the United States have no behavioral health worker at all. With the implementation of the Affordable Care Act and the resulting expansion of health insurance coverage, demand for services of primary care professionals will increase substantially.
These concerns come at a time when demand for services is increasing—particularly with an aging population with more frail seniors in need of care—and the healthcare system is grappling with quality of care concerns. Natural and manmade disasters can strain existing health care, public health, and human service workforce capacity, and require rapid identification and deployment of skilled professionals to affected areas. In addition, all health professions will need to be responsive to new challenges and realize the potential of new technologies. Innovative approaches, including improved preparation of primary care practitioners and the enhanced use of mid-level professionals, such as nurse practitioners and physician assistants, will be required to meet the increased demand. Moreover, new approaches using peer mentors, recovery coaches, and care managers will be needed for persons with long-term care needs.
HHS is addressing many of these workforce issues. Through implementation of the Affordable Care Act, HHS will fund scholarships and loan repayment programs to increase the number of primary care physicians, nurses, physician assistants, mental health providers, and dentists in the areas of the country that need them most. With a comprehensive approach focusing on retention and enhanced educational opportunities, HHS is addressing the continuing need for a highly skilled, diverse nursing workforce. HHS is working with state, local, and tribal governments to develop health workforce training, recruitment, and retention strategies and to expand critical, timely access to care by funding the expansion, construction, and operation of Health Centers throughout the United States.
Providers, policymakers, and consumers are likely to consider a broad range of strategies to address gaps in infrastructure and workforce: engaging students at younger ages, improving wages and benefits of direct care workers, tapping new worker pools, strengthening the skills that new workers bring at job entry, and providing more useful continuing education and training.
Findings from HHS’s analyses of health and human service workforce issues were the impetus for this goal. Reviews of nursing and nursing assistant studies; data on state, local, and tribal public health workforce shortages; and information on the impact of the health professions training programs informed the workforce development and infrastructure goal and objectives. HHS will continue to monitor national workforce issues and conduct evaluations on topics such as the HIV clinician workforce and access to specialty care for clients of HRSA’s Health Centers.
HHS is committed to helping recruit, train, develop, retain, and support a competent workforce. Among the operating and staff divisions contributing to these efforts are ACF, AoA, the Office of the Assistant Secretary for Administration (ASA), ASPE, CMS, HRSA, IHS, OD, OASH, and SAMHSA.
The United States has overcome challenges in our history because men and women of good will, keen minds, and strong hearts have always stepped forward to aid their Nation through service, both in civilian government and in our Uniformed Services. The Civil Service of today carries forward that proud American tradition. Whether it is defending our homeland, restoring confidence in our financial system and administering a historic economic recovery effort, ensuring adequate health care for our veterans and fellow citizens, or searching for cures to the most vexing diseases, we are fortunate to have our best and our brightest engaged in these efforts. People are our most important resource for facing any challenge.
HHS is engaging in a variety of activities to strengthen its human capital and to address challenges in recruitment and retention with a specific emphasis on workforce diversity and succession planning. HHS is focusing on human capital development to inspire innovative approaches to training, recruitment, retention, and ongoing development of Federal workers. Combined with a focus on opportunities to align multiple training programs supported by HHS, the Department will enhance its capacity to address current and emerging challenges. HHS also is developing a culture of wellness among its employees. HHS has launched an enhanced, comprehensive and integrated health and wellness program, modeled after best practices in private industry; this program seeks to reduce health risks and improve productivity among its employees.
As one of the seven Uniformed Services of the United States, the USPHS Commissioned Corps is a specialized career system designed to attract, develop, and retain health professionals who may be assigned to federal, state, local, tribal, and urban Indian organization agencies or international organizations. The mission of the Commissioned Corps is to protect, promote, and advance the health and safety of our Nation. The Commissioned Corps achieves its mission through rapid, effective response to public health needs, leadership and excellence in public health practices, and the advancement of public health science, including onsite support and services during natural and manmade disasters. HHS will continue to invest in the Commissioned Corps to improve healthcare services to medically underserved populations; prevent and control disease and identify and correct health hazards in the environment; promote healthy lifestyles for the Nation's citizens; improve the Nation's mental health; ensure that drugs and medical devices are safe and effective; conduct biomedical, behavioral, and health services research; and work with other nations on global health problems and their solutions.
Other health and human service agencies, including IHS, are also working diligently to improve capacity to meet America’s health and human services needs now and in the future. All HHS agencies and offices are committed to investing in its workforce through the following key strategies.
- Recruit, hire, and retain a talented and diverse HHS workforce that is representative of the American people HHS serves, by promoting innovative and coordinated approaches to recruiting, hiring, training, and retaining students, mid-career professionals, and retirees to meet agency talent needs, and helping veterans and individuals with targeted disabilities identify skills that match Federal opportunities;
- Create a climate of innovation, opportunity, and success within HHS that capitalizes on the cultural, professional, ethnic, and personal diversity of our workforce and strengthen all segments of the multigenerational workforce;
- Create a culture of wellness across HHS by assessing existing onsite health and wellness programs, and develop plans to expand and enhance programs across HHS that meet established Healthy People 2020 objectives for comprehensive worksite wellness programs and best practices in the industry;
- Ensure the HHS workforce and its leaders are fully accountable, fairly appraised, and have the tools, systems, and resources to perform at the highest levels to achieve superior results; and
- Recruit and retain Commissioned Corps officers and other emergency response personnel to provide ongoing health care, and train and equip them to respond to emerging public health threats so that they can improve response operations to medical emergencies and urgent public health needs.
The factors placing demands on our healthcare workforce include the aging of the Nation’s population, accompanied by a greater burden of chronic disease; an increasingly diverse population; the need to incorporate scientific advances into standard medical practice; and the challenge of translating healthcare reform into effective access to care, particularly for the newly insured. In addition, while the movement toward electronic health records holds the promise of improving both the quality and the efficiency of care over the long term, transitions will require support for successful implementation.
These challenges play out against a backdrop of persisting problems. Our health professions workforce is not well-distributed geographically. Too many areas find themselves without needed physician, dentists, and behavioral health and other healthcare professionals. Rural and remote areas face the difficulties of low population density and long distances to care, which are especially problematic in Indian Country. Despite the need for greater primary care capacity, physicians are apt to choose other specialties—in part, because educational debt levels have grown and primary care and behavioral health practitioners have lower incomes compared with most specialists. The composition of our health professions workforce does not reflect that of the Nation racially or ethnically. There are chronic shortages in some health professions and intermittent shortages in others. Direct care and personal care workers are in short supply, and have demanding jobs, low wages, and limited opportunities for professional growth. Finally, data on the health professions workforce are limited and scattered as are analytic tools for workforce modeling, planning, and policy development.
HHS supports health workforce training efforts across the educational spectrum. CMS now makes the largest financial investment in the health professions workforce through supporting the graduate medical education of physicians. CMS also uses various payment incentives to help encourage providers to practice in underserved areas. HRSA and IHS offer programs that provide scholarships and loan repayment in exchange for employment in underserved areas. HRSA also provides support to medical, nursing, and other health professional schools to improve specialty and geographic distribution and to encourage innovation in the education and training of the health professions workforce. IHS also supports programs to increase the numbers of AI/AN health professionals through its scholarship program and grants to educational institutions for the Indians into Medicine, Indians into Nursing, and Indians into Psychology programs and through the operation of extern programs to allow IHS scholarship recipients and other AI/AN health professional students to obtain real-world clinical experience with IHS and tribal health professionals in their chosen disciplines.
The Affordable Care Act authorizes many new activities and modifications to existing activities related to the Nation’s current workforce challenges. Its provisions affect agencies and offices across the Department. The Affordable Care Act authorized the creation of the independent Health Care Workforce Commission, to guide the identification and resolution of workforce issues across the Federal Government. Through its interactions with the Commission, the Department’s workforce programs and issues have new public prominence. Another requirement of the Affordable Care Act is the opportunity to develop demonstration projects to address the needs of the healthcare profession. ACF is funding projects that provide TANF recipients and other low-income individuals with training that will prepare them to enter and advance in the healthcare sector. These training programs will prepare participants for employment within the healthcare sector in positions that pay well, and will provide employment in areas that are expected either to experience labor shortages or to be in high demand or in remote or isolated rural communities.
Within HHS, ACF, CMS, HRSA, IHS, SAMHSA, and others are working on this objective. The following key strategies will be implemented to ensure that the Nation’s healthcare workforce can meet increased demands.
- Improve HHS’s ability to monitor and assess the adequacy of the Nation’s health professions workforce in shortage areas and in those smaller communities likely to experience health professional shortages;
- Implement strategies to address the Nation’s workforce needs following health reform and the reauthorization of the Indian Health Care Improvement Act and to evaluate their effectiveness;
- Explore ways to meet expanding health and human service needs in underserved communities by training and making full use of all health professionals and telelink technologies, expanding the primary care teams, and promoting models that incorporate new providers and interagency collaborations;
- Expand the primary oral healthcare team and promote models that incorporate new providers, expanded scope of existing providers, and utilization of medical providers to provide evidence-based oral health preventive services, where appropriate;
- Promote interprofessional training and team-based practice to assure quality care;
- Address persisting problems of workforce shortages, lack of diversity, maldistribution, and lack of access to care that meets cultural and linguistic needs; and
- Build primary care and behavioral health capacity, especially in underserved areas, remote and isolated rural areas, and among groups underrepresented in the health professions, through the focused use of scholarship and loan repayment programs as well as extern, intern, fellow, and other training and experiential opportunities.
- Expand community-based, interprofessional/interdisciplinary training opportunities; and increase collaboration of health career pipeline outreach activities, with special emphasis to reach underrepresented minority students and economically or educationally disadvantaged students; and
- Ensure that all health professions students, faculty, and practitioners, direct services workers, and lay and family caregivers receive high quality interprofessional education and training in geriatrics to meet the needs of an aging population and promote access to quality geriatric health care and services.
For at least a decade, the United States has experienced worsening workforce shortages in the public health professions. Predicted personnel shortages in research, information sciences, health promotion, preparedness, epidemiology, and the laboratory sciences will affect critical core public health capacities. The current public health workforce is inadequate to meet the needs of the U.S. population and shortages are predicted to reach 250,000 by 2020.
Differences in the training requirements, goals, and objectives of varied public health programs reduce the flexibility of the public health workforce and its ability to serve in different settings. As a result, a need exists for greater standardization in curricula and more clearly defined objectives.
Workforce issues also are critical to improve global public health capacity and to minimize global health threats that may affect Americans here at home. With the global nature of disease and illness, greater public health capacity is needed to support health diplomacy activities, detect and contain emerging health threats, and respond rapidly to outbreaks and other health incidents. The emergence of new and more virulent virus strains, inadequate sanitation, and global migration are among the factors stretching our public health workforce. Within HHS, ASPR is working to support the PAHPA mandate to examine gaps in an effective and prepared public health workforce, identify ways to develop a sustainable workforce, and keep them protected during emergencies.
The Affordable Care Act establishes new programs to support training of entry-level and mid-career public health professionals in Government service at the federal, state, local, and tribal levels. The Affordable Care Act also authorizes expansion of existing CDC workforce programs that contribute to the public health ranks in the areas of epidemiology, laboratory science, and informatics. And the Affordable Care Act provides substantial new funding for the National Health Service Corps.
ASPR, CDC, HRSA, IHS, NIH, OASH, and SAMHSA are working to achieve this objective through the following key strategies.
- Build public health capacity to detect threats and improve health through improved public health surveillance and laboratory capacity;
- Support public health at the state, tribal, urban Indian, local, and territorial levels to increase the public health workforce;
- Promote efforts to ensure the health workforce is ready to respond to major health incidents; and
- Act in concert with other U.S. Government agencies and global partners to address common public health threats throughout the world, enhance capacities to detect and respond to these threats, and learn from each other’s experiences.
The Nation’s human service workforce serves some of the most vulnerable populations in the United States. These workers can be found in early childhood and after school programs; domestic violence and child protection services; programs for individuals, youth, and families experiencing homelessness; teen pregnancy prevention programs; care for older adults; programs addressing behavioral health issues, including mental illness and substance abuse; and a range of other community-based services. Human service workers promote economic and social self-sufficiency and the healthy development of children and youth.
In addition to the difficulty of addressing the complex issues of individuals, families, and communities, the human service workforce faces a number of challenges: high staff turnover rates, poorly developed or undefined core competencies and professional development guidelines, and unclear compensation expectations and career trajectories. Both demographic changes and the recent economic recession are impacting efforts to improve the well-being of Americans. As our population ages, the percentage of people ages 18 to 64 is expected to decline, shrinking the potential supply of human service workers. The population is growing more racially and ethnically diverse, reinforcing the need to equip the human service workforce with the necessary cultural and linguistic skills to be responsive to all Americans’ needs. And finally, as the Nation recovers from the economic recession, we face challenges of securing economic and housing stability for large numbers of families while also strengthening the capacity of the human service safety net.
HHS is working to strengthen the human service workforce and improve the quality of human services through training and technical assistance; strategic use of data, monitoring, and evaluation efforts; collaboration with other agencies; and the promotion of evidence-based practices. For example, child care administrators are using expanded Child Care and Development Fund (CCDF) resources to provide professional development opportunities for child care teachers to enhance the quality of child care.
ACF and HRSA are dedicated to strengthening the Nation’s human service workforce through the following key strategies.
- Promote recruitment and retention strategies that attract qualified, competent, and diverse professionals to the human service workforce;
- Work with states to develop systems for the training and ongoing professional development of early childhood educators through the Race to the Top—Early Learning Challenge and through enhanced professional development opportunities for child care professionals in states;
- Build the capacity of staff in local Head Start/ Early Head Start programs to deliver high-quality, evidence-based services to children and families through the redesigned Training and Technical Assistance system;
- Promote training, cross-system training, continuing education, and technical assistance for human service personnel to help them develop core competencies;
- Improve the cultural competence of the Nation’s human service workforce;
- Foster the use of evidence-based practices in human services to professionalize the field; and
- Use data and evaluation in human service programming to inform professional development and future practice.
Three critical elements underpin public health practice: surveillance, epidemiology, and laboratory services. Carrying out these activities requires quality data and specimen collection, evidence-based epidemiology, and adequate laboratory services across the national, state, local, and tribal departments and organizations that make up the Nation’s public health infrastructure. These services enable the public health field to detect emerging threats, monitor ongoing health issues and their risk factors, and identify and evaluate the impact of strategies to prevent disease and promote health.
To achieve this objective, HHS is working to strengthen surveillance systems at the national, state, local, and tribal levels, including the monitoring of healthcare quality to ensure that best practices are used to prevent and treat the leading causes of death and disability.
HHS is working toward a robust data system that provides data, feedback, and tools directly to national, state, local, and tribal health agencies, urban Indian organizations, and healthcare facilities to improve practices— and thus, health. A data system for public reporting and using electronic data sources for data collection and prevention will enhance the ability of the United States to monitor trends in critical health measures among priority populations; monitor health status, health care, and health policy concerns at the national, state, local, and tribal levels; and conduct in-depth studies of population health at the community level and for specific subpopulations.
Responsibility for these activities rests with several HHS agencies. CDC is the lead agency for HHS that provides funding and technical assistance to states and localities, and provides capacity at the national level to ensure that links across entities work effectively together. Other HHS agencies and offices, including ASPR, FDA, IHS, NIH, and SAMHSA, are working to realize this objective through the following key strategies.
- Improve surveillance in outpatient clinical settings to identify sources and control of healthcare-associated infections;
- Implement cutting-edge information technology solutions that support rapid, secure, and accurate information exchange; diverse types of information; and linking of information among local, state, tribal and urban Indian, and federal public health agencies, healthcare facilities, and laboratories;
- Enhance and sustain nationwide and international laboratory capacity to gather, ship, screen, and test specimen samples for public health threats and to conduct research and development that lead to interventions for such threats;
- Work with public health laboratories in states, territories, tribal and urban Indian organizations, cities, and counties to assist them in expanding their chemical laboratory capacity to prepare and respond to chemical terrorism incidents or other emergencies involving chemicals;
- Build and enhance state and local laboratory capacity by providing funding to purchase and maintain state-of-the-art laboratory technology;
- Increase access to and sharing of data, and support for epidemiology programs at the state, local, and tribal government levels and by urban Indian organizations and other partners; and
- Build epidemiology, surveillance, and laboratory capacity, and support monitoring and evaluation systems that measure HIV prevalence and incidence, behavior change, and population health status.
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