In several of the communities included in this study, health care providers and other stakeholders have been thinking about the workforce implications of the expansion of eligibility for Medicaid, coupled with potential changes in payment mechanisms as states increasingly move toward managed care arrangements for financing health care. Many communities will likely experience a shortage of primary care providers, as well as providers of specialty medical services. People obtaining coverage through Medicaid and subsidized insurance in 2014 under the provisions of the Affordable Care Act may find it difficult to locate a provider or get care in a timely manner. To translate coverage into meaningful access to care will require not only more medical providers in some communities, but also changes in the ways that health care is delivered to improve efficiency and the quality of care.
Team models using personnel such as nurses and community health workers as "care extenders" are likely to be important strategies. Some of the innovative providers of health care who met with us as part of this study talked about encouraging all of their staff members and partners to "work at the top of" their credentials, and to help other team members increase their skills and take on greater responsibility for providing some services to consumers, within appropriate limits related to "scope of practice." This can be challenging, however, because Medicaid reimbursement rules can create incentives to use physicians or mid-level practitioners to deliver some services that might otherwise be provided by a nurse or other health worker, but reimbursement may not be available if services are delivered by staff members who have different types of credentials.
For organizations delivering services in PSH and those serving people experiencing chronic homelessness, this creates both challenges and potential opportunities. By reducing resources spent on avoidable hospitalizations, re-admissions, and emergency room visits, PSH frees up those resources to be used to provide access to health care for those who need it. Multidisciplinary teams can extend the reach of clinicians, and help them serve the most challenging and complex clients more effectively.
But as some communities increasingly prioritize the most vulnerable people for access to PSH, some service providers have reasonable concerns that their current staff lack the skills and credentials required to safely respond to some tenants' complex medical and behavioral health conditions without additional clinical consultation or supervision. Some service providers are adding nurses to their teams, and others are training case managers or other paraprofessional staff to be more involved in helping PSH tenants and other clients monitor their blood pressure or follow-through on other tasks related to monitoring and managing chronic illnesses such as diabetes.
Other workforce challenges arise because even highly trained clinicians are often not trained to work across disciplines or as members of teams. Primary care providers may have little training about substance use disorders or mental health, while most workers in mental health or substance use treatment programs do not speak the language of health care. Providers of services in PSH report that cross-training is important, and training on specific skills and approaches such as motivational interviewing can help to create a common language and shared approach for serving shared clients.