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Understanding the population health workforce is important to ensuring population health needs are met. In their contribution to The Milbank Quarterly centennial anniversary issue, Bianca Frogner, Davis G. Patterson, and Susan M. Skillman of the University of Washington School of Medicine discuss how the population health workforce, which spans clinical care, public health, and social services, has been defined. The authors call for a broad definition of the population health workforce and offer policy recommendations to retain and recruit a diverse workforce—and one that can address social drivers of health like inadequate childcare or education. This piece is the second in a series of Q&As with authors from the special issue, The Future of Population Health: Challenges and Opportunities.
Frogner: We’re moving forward with addressing population health without a clear sense of who’s doing the work. We need to recognize that there are many people all working toward the same goal of helping our population get better.
Patterson: The public health workforce is a group of workers that has been identified as most clearly addressing population health issues. It’s people who work for local or state health departments, for example, people with epidemiology or statistics backgrounds, or a master’s or a bachelor’s in public health. Another group is community health workers. These workers are not always certified or licensed, but some states require certification. A lot of times they’re self-identified because they’re volunteering in the community, or they may be paid by an employer.
Skillman: There are, of course, clinicians, like public health nurses and physicians, who do direct service within the public health departments or the community.
Frogner: The population health workforce includes people who provide health care services, who have increasingly been pressed to address the social determinants of health. It’s an expanding role for people who traditionally were mostly in the business of delivering fee-for-service health care.
There are also folks that affect health that are not squarely in the health space. That’s one reason why we mentioned law enforcement as an example in our article.
Patterson: It gets to the health-in-all policies points that we make, which is about making sure that people who are interacting with the public are doing so in a way that connects the public to the right resources. It really is a wide gamut of people, across the skill spectrum, both in the health care as well as the social care space.
Frogner: One of the challenges is trying to figure out where people’s roles begin and end, especially if they’re not squarely identifiable as a health care worker. Population health and addressing the social determinants of health is oftentimes a role within an occupation. We don’t have a formal job title called population health worker. Given that population health and the social determinants of health really are about everything in people’s lives, trying to define when somebody’s role or activity is affecting health can be a challenge. I’m thinking about urban planners, people who think about social determinants of health like affordable housing and public transportation. In our paper we say they are part of our population health workforce, but then are we counting just about every worker in our society as part of a population health workforce?
Because the population health workforce is broadly defined and there isn’t a specific population health worker, we struggle to leverage our usual data sources, like the American Community Survey or the Bureau of Labor Statistics, to help us count and track whether the population health workforce is growing, shrinking, whether it’s distributed appropriately or whether it’s paid appropriately.
Skillman: Some of the factors involved in retaining people are about having work environments that are supportive, where workers feel their contributions are valued and useful. When we look at population health, having a workforce that understands, empathizes, and is often of the communities is extremely important. There is lots of evidence that people who understand where people are coming from are the most empathetic and effective.
Frogner: We know that population health challenges tend to skew toward certain population groups. An increasing number of papers document health disparities by race and ethnicity and rural and urban health disparities. We need workers who can understand the lived experience of the individuals that they’re caring for. One way to get a workforce that understands that lived experience is to get a workforce that looks like the people or is from the communities that they’re addressing.
The health care industry has noted diversity challenges, with a lot more racial and ethnic diversity among lower-paid workers with lower levels of education, like community health workers. Moving up the educational spectrum to physicians or other higher skilled workers, we lose a lot of racial and ethnic diversity. It can take a long time to get someone through the educational pipeline and there are many barriers, especially to becoming a physician. As a result, we have to think about cultural competency and training health care workers to understand the experiences of the populations that they’re caring for.
Patterson: It’s also a matter of equity. Some of these health careers are among the highest paid professions in society. We need to have opportunities for folks that are at an educational disadvantage overall in society, which contributes to their being underrepresented.
Frogner: We want to give people opportunities to move to the best job that matches their interests, skillsets, and opportunities, but as a field we are struggling to identify the best career pathways. People talk about medical assistants becoming registered nurses, and registered nurses becoming nurse practitioners or physicians, but that doesn’t happen often. Part of a retention issue is how to make sure people are progressing in their careers, even if it is within the same job title. There are ways to advance them over time, whether it’s recognition of experience, creating different levels with more responsibility, additional on-the-job training, or additional pay. You can create career ladders by expanding those kinds of opportunities within an occupation.
Skillman: It has become very apparent that the cost of education and training, and sometimes the perceived costs, are contributing to racial and ethnic disparities in this workforce and other workforces.
Frogner: And it’s not just the cost of the education itself, but it’s also the time away from work. To step out of the workforce and go back to school is not financially feasible. Not working and finding childcare while you’re taking your classes are significant barriers that have to be addressed if we are encouraging people to go back to school.
Frogner: Federally recognized Department of Labor apprenticeship programs that have structure to help people stay on the job, get paid on the job, and also get credit that could apply toward an educational degree.
Patterson: We should also consider cross-disciplinary support for programs that bring health into other policy arenas like urban planning or law enforcement. You’re not going to achieve population health goals without integrating health goals and objectives.
We’re horribly underfunding public health. If we’re going to expand public health roles, we have to support their core functions, and we also have to fund them to do this additional work.
Frogner: Hospitals are increasingly recognizing the importance of population health and social determinants of health and are creating new titles, investments, and initiatives to address population health. They have resources to be able to do that, but it should not be a substitution for partnerships with public health departments. We need better coordination of services across settings, so that we’re not in conflict with each other in what we’re trying to accomplish.
Frogner: In this economy, where companies are shedding jobs and people are looking for work, there’s an opportunity to recruit people into health care jobs and population health jobs.
Skillman: There is evidence that people are looking for greater meaning in their work. If organizations can reconceptualize jobs so that people have opportunities to feel like they’re making a difference, that could be a good recruitment and retention strategy.
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