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Charting a plan to stave off looming health care workforce shortages

Fernando Zhiminaicela

When Jessica Aguilar had an acute gallbladder attack last year, she had no choice but to bring her 12-year-old twins with her to the emergency room at 3 a.m.

The boys, who are both on the autism spectrum, are somewhat familiar with trailing their mother to adult spaces. Aguilar, a single parent, has approval for some Medicaid caregiving services for her sons, but more often than not over the past three years she has been unable to find a caregiver.

For starters, her support workers only make $11 or $12 an hour.

“The other thing is that they are scared. When my son has a crisis, he starts screaming and rolling on the floor and kicking. If it’s so bad that he starts throwing things, the people are scared, and they’re not prepared for that,” Aguilar said. “And then they’re scared and say, ‘This is not for me.’”

Aside from the issues of low pay and lack of training, she said that lack of benefits for the workers and lack of career advancement makes it hard to find — and keep — workers to care for her sons.

“I had one person for a long time — one I had for three years, and the other I had for four years,” Aguilar said. The twins were 8 or 9 years old when she started having to deal with very intermittent services.

“I have [someone] for two months, three months, and then won’t have for a long time, and then again for one month,” she said.

Aguilar is not alone in struggling to find caregiving help for her children. If health care workforce projections are close to correct, the lack of caregivers is likely to become an even bigger problem in the coming decade.

North Carolina, like many other states, is staring at a growing gap between the number of people who will need some form of health care over the next 10 years and the number of people who will be trained and available to provide it.

Before the pandemic, workforce researchers were predicting North Carolina would have a shortage of about 12,500 nurses by 2033. Those predictions have changed in the wake of staffing shortages, increased caseloads, increasing violence and other stressors that COVID-19 put on health care institutions. Now prognosticators are saying that within a decade, there could be a need for 21,000 more nurses.

That’s in addition to the need for more than 186,000 personal caregivers for older adults and for people with disabilities like Aguilar’s kids. That number only stands to grow as many health care workers head for the exits, burned out by the pandemic and the multiplying demands at their workplaces.

Such realities drove the formation of a Caregiving Workforce Strategic Leadership Council in March 2023 to delve deeply into reasons for the shortages and strategize a path forward. This past week, the council delivered its recommendations for educating new generations of health care workers in North Carolina and retaining them in the industry.

The recommendations focus on three areas of need: nursing, behavioral health and direct care workers, and they suggest ways to improve recruitment, training and retention.

“The key aspects of our health care workforce are really fragile,” state Health and Human Services Secretary Kody Kinsley told NC Health News in an interview this week.

North Carolina’s population over the age of 65 is on the rise. In 2020, one in six people were 65 and older. By 2028, one in five people will be 65 and older. By 2031, there will be more people 65+ than children under 18. Data: NC Office of State Budget and Management, Standard Population Estimates, Vintage 2020; Population Projections, Vintage 2040.
NC Dept of Aging and Adult Services
North Carolina’s population over the age of 65 is on the rise. In 2020, one in six people were 65 and older. By 2028, one in five people will be 65 and older. By 2031, there will be more people 65+ than children under 18. Data: NC Office of State Budget and Management, Standard Population Estimates, Vintage 2020; Population Projections, Vintage 2040.

Crafting a long-term strategy

Last year, the General Assembly appropriated hundreds of millions of dollars toward improving the health care workforce, but Kinsley said much of it was “without rhyme or reason.” He said there was not a lot of direction or coordination among state agencies on how those funds would be best used.

What’s really needed, Kinsley added, is a strategy that brings different workforce representatives together to figure that out in an informed way.

“I just wanted to try to get everybody into the same river rowing generally in the same direction, pushed by data,” Kinsley said. “I was just trying to get everybody on the same page.”

North Carolina Secretary of Health and Human Services Kody Kinsley will donate blood in Raleigh on Aug. 7, 2023.
North Carolina Secretary of Health and Human Services Kody Kinsley.

In creating the council, Kinsley and state Secretary of Commerce Machelle Sanders worked outside the political system, pulling together the group from the UNC and community college systems, from the state Department of Public Instruction and the state Board of Education. They also pulled in people with workforce expertise from the North Carolina Institute of Medicine and the Sheps Center for Health Services Research at UNC Chapel Hill.

One key organization represented on the council was the Area Health Education Center, or AHEC, which provides a lot of the health care training and continuing education services around the state.

“The information that's currently available shows that if we don't do anything different, North Carolina is projected to fall short by 80,000 people by the year 2030 that have the necessary degrees and credentials,” Cecilia Holden, the CEO of myFutureNC, said during a webinar Wednesday. The head of the nonprofit organization that works to improve education outcomes in the state was quoting a number that includes physicians, therapists, nurses, medical assistants and other workers who receive a credential or are licensed.

State data show that only about 30 percent of ninth graders will earn a degree or professional certificate within six years of their high school graduation, Holden said. That’s in all fields, not just those related to health care.

“Two-thirds of our jobs require higher levels of education. But less than a third of our high schoolers are actually getting the level of education necessary,” Holden added. “So we've got a lot of work to do.”

Council recommendations

For nursing, proposed initiatives include:

  • Establishing academic coaches for community college students to help them get through school. 
  • Increased funding for nursing instructors, who can often make more working in a hospital than teaching the next generation.
  • Increasing pay for public sector nurses to draw them into those jobs and keep them working. 

For behavioral health workers, recommendations include:

  • Creating a stronger data system to track how many workers there are and where they are.
  • Clearer definitions of job and training requirements for unlicensed workers, and creation of career pathways for those workers. 
  • Better training and credentialing for peer support workers. 

For direct support workers, recommendations include:

  • Creating clearer definitions and standards of what’s needed by direct care workers.
  • Training workers better for those jobs. 
  • Paying a living wage.

Political priorities can take precedence

One of the obstacles that Kinsley and any policymaker faces is the limitation created by lawmakers’ two-year terms. It can be challenging to get lawmakers to agree to allocate state resources when they want to tell constituents that they’ve trimmed costs.

On top of that, legislative priorities can change depending on the politics of the moment.

Having leaders from state agencies, universities and schools as well as movers and shakers from the private sector driving the initiative, Kinsley said, could help keep it on track, no matter who is in office.

“We reached out to predominantly institutions that the General Assembly invests resources into that either already have a responsibility for workforce development or getting resources to do more workforce development, and try to coordinate around that,” Kinsley added.

Some of that includes the NC Center of Workforce Development, which was born from a concept created three years ago by AHEC, the N.C. Institute of Medicine and the Sheps Center Program on Health Workforce Research and Policy. The center convenes nearly 400 groups to tackle some of the thornier health care workforce development issues across the state.

“Local boards of commerce and chamber boards, local employers, local hospital systems,” Kinsley said. “This was the group of people that had some skin in the game already. And we're going to get more money and resources to do it, and that’s a good place to start.”

Council members also tapped into the expertise of professional organizations, but they were not involved in crafting the final report.

“We appreciate the state’s commitment to addressing the workforce crisis facing nursing homes and other healthcare providers,” Adam Sholar, head of the NC Health Care Facilities Association, the trade group for nursing homes, said in an emailed statement. “We desperately need to attract more caregivers. The situation will only get worse as our population ages, so it’s imperative that we collectively focus our attention and resources on this issue.”

Correction: We originally misspelled Commerce Sec. Machelle Sanders as Michelle.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.

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