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Health & Science

Thinking Creatively To Fill Gaps In The Health Care Work Force

Like many states, Texas faces shortages of doctors and other health workers. A conference at the Texas Medical Center explored the research behind several possible solutions, such as “grand-aides” and dental therapists.



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Texas is suffering from a doctor shortage and a nurse shortage, and both are expected to get worse as the state's population grows. It's an issue across the country, as the medical workforce braces for the aging of the Baby Boomer population.

Research shows the medical talent in Texas has clustered in and around the big cities. In between, there are wide swaths of rural Texas where there are few or even no doctors of any sort.

"About 25 percent of Texas counties have less than five docs,” said Dr. Tim Garson, the director of health policy for the Texas Medical Center. “Over 50 percent have no psychiatrist and no obstetrician.”

Garson recently organized a conference on the issue at the medical center.

But the solution isn't necessarily to train more doctors, Garson said. First of all, you can't tell doctors where they have to live. And secondly, doctors are expensive. In an era when healthcare costs are soaring, it's better to see who else might be able to fill in those gaps.

"There are a bunch of things a doctor doesn't have to do, (that) a nurse could do, such as a physical for camp," he explained.

Twenty-one states allow nurse practitioners to work autonomously, diagnosing many illnesses and prescribing medications.

But Texas is more restrictive when it comes to nurse practitioners. Texas law does allow nurse practitioners to provide many primary care services, but only under the supervision of a physician. Removing that requirement, as other states have done, would help ease the shortage of primary care providers in Texas, Garson said.

Some experts say pharmacists could help treat minor problems, like cuts or pink eye, right in the pharmacy. That idea is being tried out in Washington state.

Other states have created new categories of health workers, such as the dental therapist. A dental therapist isn't a dentist, but can fill simple cavities. They've been working successfully in places with acute dentist shortages, like Alaska and Minnesota.

Medical licensing is handled state by state. State regulators decide who gets licensed and what they can do with that license. That can be both good and bad, according to Edward Salsberg, an expert in health care workforce issues at George Washington University.

"It provides us with this great opportunity to say ‘If it worked there, then maybe we can try it elsewhere,'” said Salsberg. “The challenge, of course, is just because it works in two or three states, it doesn't mean it's automatically going to be adopted by all the other states."

Another potential solution is to start by hiring an already-licensed worker, like a nurse's aide, and then deploy him or her in a different way.

That’s the idea behind grand-aides. Just like it sounds, a "grand-aide" is a meant to be a cross between a wise grandparent — who has seen a lot of sick people over a lifetime — and a nurse's aide, according to Craig Thomas. He supervises grand-aides for the University of Virginia Health System.

"So the original idea was that a grandparent knows a lot about what health can be,” Thomas said. “When sick is sick enough to go to the hospital, and when sick is sick enough to stay home and take a Tylenol and you'll be OK."

Thomas came to Houston this week to attend the conference about the health worker shortage. He explained how grand-aides helped patients with heart failure in Charlottesville, Virginia.

After a patient checks out of the hospital, a grand-aide visits every day for a few days. They gradually cut back on the visits as the patient recovers. During the home visits, grand-aides can check vital signs, see if the patient is eating well, and look for hazards that could lead to accidents or falls.

"Having the grand-aide being the eyes and ears at the home gives us that insight into how they live daily," Thomas said.

"Do they really have all their medicines? You know, they say when they come to the clinic ‘Yes, I have them all.' But when we get there and we do the home visit we see that they're missing half of them. So we get a true story."

Thomas shared studies showing the heart-failure patients who were visited by a grand-aide were almost half as likely as comparable patients to be re-admitted to the hospital within 30 days.

Not only does that help the patient, but it helps the hospital avoid federal penalties.

Garson wants Texas regulators to consider more of these solutions. At the very least, he'd like the legislature, when it meets next year, to appoint a task force to study the health worker shortage in Texas and make recommendations to fix it.

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