This interview with Janet Heinrich is the seventh in a series of brief chats between CFAH president and founder, Jessie Gruman, and health care experts - among them our CFAH Board of Trustees - who have devoted their careers to helping people find good health care and make the most of it.
Expanding the Primary Care Workforce
Gruman: Your career has been very diverse but has always focused in some way on enabling people to benefit from the health care services available to them. Describe how your current position helps individuals participate positively in their health care.
Janet Heinrich: As the Associate Administrator of the Bureau of Health Professions, my focus is on expanding the primary care workforce. Primary care is the entry point into health care for most people. It provides the continuity of care over the lifespan. From that standpoint, it is the most familiar, trusted experience people have with health care.
These days, people talk about primary care and medical homes and in the next breath they talk about patient centeredness. I am concerned that people adopt these phrases and then forget what they mean.
I think that HRSA funding can do a lot to help professionals stay focused on the practical and clinical and organizational details of patient-centeredness and incorporate them into professional training ' and retraining ' so that care in this country is truly effective in involving individuals in caring for themselves.
Gruman: What's your sense of how that's going?
Janet Heinrich: Our focus is on encouraging institutions applying to receive Federal funds to support the development of the primary care work force and address patient-centeredness.' I've been intrigued to see that in pediatrics, internal medicine and family medicine, many of the institutions really do understand what it means to be patient-focused.' Those organizations know that they have to provide patients and caregivers with information and that health care professionals need to have the time to listen, to explain and to explore patient preferences. They try to organize care so that primary care providers are in a position to know the individual and the family.' They train professionals to guide their patients through health promotion but also to assist them in other diseases and conditions - sorting through the best mode of treatment for example.
Gruman: So where do you see these efforts falling short?
Janet Heinrich: People working in primary care are working hard to keep their patients healthy and sometimes don't have the time to realize the incentives for focusing on care coordination right now.' But we know this is incredibly important so we are seeking the best ways to incentivize them.
Gruman: With such a broad mandate to improve the size and skills of all of the primary care workforce you probably have many different entry points to get professional schools and researchers to figure this out. Tell me about some of them.
Janet Heinrich: We support nursing programs that focus on advanced education primarily nurse practitioner programs. Our nursing programs target nurse practitioners in primary care with support to build their skills. We also provide educational support for minority and disadvantaged nurses.
We have a major investment in continuing education for the existing workforce in official public health agencies. Very often, those professionals should be out in the community, in homes and workplaces. But as we know, many state health department budgets have been cut and so it's been critical to provide educational support to those who remain and who are likely to have expanded responsibilities. For instance, we want to make sure that we reach administrative assistants who keep records and nurses with associate degrees who may be taking on the responsibilities previously assigned to trained epidemiologists, doctors or laboratory people.
Gruman: What other kinds of efforts are you making that focus particularly on building the patient-centeredness of primary care?
Janet Heinrich: We need more people prepared to provide behavioral health services to provide services for people with mental illnesses like depression, bi-polar disorder and schizophrenia. We are working through the National Center for Health Workforce Analysis, looking at how many psychiatric nurses, psychiatrists, psychologists, clinical social workers and counselors are currently practicing. We're doing some work with the Department of Labor and also with the Department of Education, which tracks accreditation.
This year HRSA will fund a new program to build the behavioral health workforce. We have about $10 million that will be used to fund psychologists and clinical social workers to work with individuals who are currently underserved and at high risk, and in particular, will provide services to returning veterans.
Gruman: You also have a number of programs directed specifically at training primary care physicians, correct?
Janet Heinrich: We are always looking for innovative approaches for patient-centered care that can be replicated. In Vermont, for example, the state has a program that uses care coordination teams to link individuals to clinicians in medical homes. Care coordination is done by teams of people from different backgrounds and expertise and is lead by a public health nurse working with primary care providers to make sure that individuals and families obtain the care they need.
There is encouragement within HRSA's community health centers program to encourage Federally Qualified Health Centers (FQHC) and various community health programs to meet the standards and criteria of medical homes. Legislation was recently passed that allows HRSA to reverse its usual focus on teaching hospitals.' This new legislation allows us to support residents in community-based settings that hold accreditation for the residence program. This could be an FQHC or another type of community-based program. Those residents have to do hospital rotations, but the new concept is more of a community focus, more of an ambulatory care focus. These residents don't spend their whole time doing hospital rotations. We now have 22 settings (some with academic affiliations, although not all); all of which are accredited programs with the purpose of training medical residents in community settings.
So, for example, we are supporting Teaching Health Centers at Northwestern University, which is academic but based in FHQCs; the Lone Star Community Health Center in TX; the Institute for Family Health in New York City; the Greater Lawrence Health Center in Lawrence, MA. And we have a free-standing program in Boise, Idaho; their academic link is with the University of Washington.
We are doing a thorough evaluation of Teaching Health Centers and this new approach to residency training. Does it cost more?' Less? ' We set this up so we really can learn about how effective this program is. We are trying to develop the gold standard, so we want to know about the quality of the programs. We want to understand more about what kind of mentoring goes on, to understand the focus of the curriculum of these programs and we plan to track where the graduates go to practice.' Do they stay in rural areas?' Do they remain in FQHCs? The evidence we have to date says that they do.
Gruman: Do you have any content-specific training programs that are relevant to patient engagement?
Janet Heinrich: I would put our integrative medicine initiative in that category.' So many people use alternative and complementary medicine like herbs, mindfulness, colonics in the U.S.' They are willing to pay their own money for it without scientific evidence of its effectiveness.' We believe that primary care clinicians, particularly, need to understand its use, the evidence for its effectiveness and the potential for harmful ' or beneficial ' drug interactions.' This initiative is in the appropriation for 2012. There is language in the bill that directs us to put out grants to medical residency programs to encourage the inclusion of integrative medicine.' We sought help from the National Centers for Complementary and Alternative Medicine at NIH to define the universe of what counts as integrative medicine.
We truly believe that building the size and robustness of the primary care workforce with a clear eye trained on training clinicians to be responsive to the needs of individuals and encouraging of their role in their own care will have a significant impact on the health of the nation for decades to come.