Expanding the Care Team: Leveraging a Broad Workforce to Improve Health Care in Kansas

Current Health Care Challenges and Gaps in Kansas

Shortage of Health Care Professionals

Kansas, like many other states, grapples with a shortage of health care professionals, including physicians, nurses and allied health workers. All but two counties in Kansas (Johnson and Miami), have at least one current health professional shortage area. These areas have a shortage of primary, dental or mental health care providers. The shortage is more pronounced in rural areas, leading to disparities in access to health care services. Furthermore, several hospital-based, expanded care team positions, as shown in Figure 2, have double digit vacancy rates in Kansas.

Lack of Health Insurance

In 2021, for the first time, the uninsured rate in Kansas (9.2 percent) surpassed the overall U.S. uninsured rate (8.6 percent). That year, Hispanic Kansans of all race groups were three times as likely to be uninsured as non-Hispanic White Kansans (20.4 percent compared to 6.7 percent) and non-Hispanic Black Kansans were twice as likely to be uninsured as non-Hispanic White Kansans (15.1 percent compared to 6.7 percent). Kansans with family income below the poverty line were nearly 5.7 times as likely to be uninsured as those with income above 400 percent of the federal poverty level (20.5 percent compared to 3.6 percent). Finally, some regions and counties — southwest Kansas and the most-rural counties — also face higher rates of uninsurance.

Hospital Closures

Hospital closures present another challenge for access to care in Kansas, particularly in rural communities. Since 2005, six rural hospitals in Kansas have completely closed. An additional four hospitals have converted and no longer provide inpatient services. Combined, 266 inpatient hospital beds in Kansas were lost through these closures and conversions.

Among the remaining 102 rural hospitals in Kansas, 59 (57.8 percent) are at risk of closing — the second most in the nation behind Texas, where 76 rural hospitals are at risk of closure. Among those 59 rural Kansas hospitals, 28 are at immediate risk of closure due to inadequate revenues to cover expenses and very low financial reserves. In addition, most Kansas hospitals experience challenges recruiting and retaining health care professionals, which may contribute to inadequate access to timely and comprehensive care.

Aging Population

Kansas, like the nation as a whole, has a growing aging population. In 2012, 13.7 percent of Kansans were over age 65. A decade later, that population had grown to 17.2 percent of Kansans (Figure 3). By 2039, forecasts predict 22.5 percent of Kansans will be over age 65. An aging demographic places additional strain on the health care system as demand increases for health care services, specialized care for age-related conditions, and family and professional caregivers.

Community Trust and Cultural Competence

A critical aspect influencing the health of a community is trust in the health care system. Those without trust are less likely to see a doctor, less likely to comply with medications and medical advice, and may be less honest in disclosing medical concerns. Many professionals in the expanded health care team may be particularly well suited to support and build trusting relationships. Community health workers, for example, are often defined as “trusted members” of the communities they serve. Culturally appropriate services and patient advocacy are common services CHWs may provide. Similarly, being “relationship-focused” is a foundational principle for peer workers providing peer recovery support or services. By emphasizing relationship building in their work and building cultural competence over time, these professionals may foster more trust with the health care system overall.

In addition, many patients prefer to receive services in their homes, and many services provided by health care workers such as home health aides, emergency medical services, community paramedics and CHWs are often provided in a patient’s home. In some contexts, this may allow workers to establish patient connections in ways that other providers cannot. For example, public perception of paramedics and other emergency services professionals is often high — these professionals are seen as reliable community members and a critical source of stabilization when individuals may be at their most vulnerable. Said another way, these professionals often show up on people’s worst days and make the situation better. Those experiences can help build trust for care provision outside of emergency situations as well.

Education and Training Requirements

The education and training pathways for health care workers are designed to equip individuals with the skills and knowledge necessary to perform specific roles within the health care system. Typically, these professionals undergo training programs that focus on profession-specific competencies and the practical aspects of their responsibilities. When hiring medical assistants, for example, most employers prefer to hire graduates of educational programs that cover a range of clinical and administrative tasks, often culminating in a diploma, certificate or associate degree. Community paramedics in Kansas do not have a specific, state-required education path, but programs may require that a community paramedic be trained at the paramedic level before becoming one. Meanwhile, CHWs must complete a training program approved by the Kansas Department of Health and Environment (KDHE) or have 800 hours of documented experience along with three letters of recommendation to apply for certification. Ultimately, though the specific education and training requirements may differ among the expanded set of health care professionals, requirements and expectations are designed to ensure competence and proficiency within their defined scope of practice.

Role and Scope of Practice

Understanding the role and scope of practice of members of the expanded health care team is essential for maximizing their potential contributions to the health care system in Kansas. Medical assistants, for instance, contribute to patient care by performing clinical and administrative tasks under the supervision of a licensed provider, aiding in the efficient functioning of health care facilities. Community paramedics, which currently have no defined scope of practice in Kansas statute, can support a wide range of services under the direction of a medical director. These services include primary care, public health, disease management, preventative services and direct care for Kansans in their homes or other non-urgent settings outside of the hospital. As another example, CHWs have a formal certification process in Kansas. As trusted members of a community, CHWs serve as a link to health and social services, improving the quality and cultural competence of service delivery and access to services.

Efforts to establish clear, standardized education, training and certification requirements for expanded health care team professions may help create well-defined scopes of practice. While not always necessary for individual programs or professionals to be successful, clearly defined and recognized training and scopes of practice may enable sustainable funding and reimbursement mechanisms, such as through Medicaid or private insurance payers, which may otherwise not be possible.

Addressing Workforce Shortages

The expanded health care workforce can act as a bridge to address the immediate shortage of health care professionals. By utilizing their expertise, especially in underserved areas, Kansas could enhance health care delivery and improve access to essential services. For example, in areas where a hospital has recently closed, a community paramedic who has already provided emergency services in the community may be able to provide non-urgent, non-transport services in a patient’s home, such as response to minor falls, routine diabetes care and follow-up services — situations where patients may otherwise utilize 911 and hospital resources.

Certified nurse aides (CNAs) also could enhance delivery and improve access to care. Several states have successfully implemented programs to leverage the expanded health care workforce by using strategies such as altering training requirements, expanding scopes of practice and leveraging state and federal funding. For instance, Iowa established two pathway programs for Certified Nursing Assistants: One to train high school students to become CNAs prior to graduation and the other with a community college to allow CNAs to easily progress to licensed practical nurse (LPN) positions. Missouri and Minnesota implemented apprenticeship programs that allow CNAs and other direct care workers to receive compensation while obtaining additional training and work experience. Several CNA programs in Kansas allow individuals to begin training programs at age 16.

Grow-your-own programs, which focus on supporting individuals in choosing health care careers and helping them develop skills and competencies they can deploy in their home communities, are well suited for many of the expanded health care professions. Overall, Kansas is becoming more racially and ethnically diverse. By leveraging the entry point into health care that many of these health professions provide, and intentionally supporting career progression pathways within health care, Kansas can grow the health care workforce to meet the health care needs of its changing population, developing a more diverse workforce for a more diverse state.

Cost-Effectiveness

Leveraging an expanded health care team can be a cost-effective strategy as reimbursement shifts to a value-based model. Value-based care is a form of reimbursement that ties payment for care to the quality of care delivered, rather than the quantity of services provided. Organizations may be incentivized to use an expanded health care team to provide quality community-based care, such as a community paramedicine program, that could prevent more costly service needs or the need for facility-based care. Several studies have shown the potential financial implications that using an expanded health care team may provide. In a rural Federally Qualified Health Center (FQHC) in Colorado, medical assistants were cross-trained in opportunities related to health coaching, patient navigation and community health. This cross-training increased productivity, allowing more patients to be seen by the FQHC, resulting in an estimated $500,000 increase in revenue.

Cost savings also have been shown in community paramedicine programs. Under the Affordable Care Act, hospitals can be penalized for high readmission rates — as much as 3 percent for each patient. The highest Kansas hospital penalty was 2.7 percent for one hospital in 2022, with some hospitals being penalized every year since 2016. WYCO Care Connection in Kansas City, Kansas, saw a 57-percent decrease in emergency department transports for patients in their community paramedicine program, ultimately leading to a decrease in hospital readmissions for high-need, high-utilization patients.

There also may be a cost benefit to the health care professional. Members of an expanded health care team have received specialized training, allowing them to contribute to health care needs without the prolonged educational timelines and associated costs of obtaining a full license. Understanding the financial incentives and impacts for the use of this workforce requires further examination as the use of the expanded workforce grows.

Payment Policy, Reimbursement & Funding

Programs and organizations leveraging the many professions in an expanded health care team may be able to use a variety of funding sources. Grant funding often serves as a valuable source for establishing and exploring new opportunities with these professionals. In some cases, organizations may opt to financially support a program using their own resources — such as an ambulance service funding its own community paramedicine program. In other cases, individual health care organizations may establish reimbursement contracts directly with insurance companies. These financing and funding options — grants, self-funding and private contracts — often have limited scale and long-term sustainability. Leveraging and growing the use of an expanded health care workforce to meet existing health care gaps and needs without additional funding opportunities may be challenging.

State policymakers have several opportunities to explore in order to enable more sustainable funding mechanisms for these professions. However, establishing reimbursement opportunities, through Medicaid state plan amendments, program changes or legislation, may require identifying and establishing clear training and/or licensing requirements. While standardizing requirements could enable new payment and financing opportunities, if required training or educational options are not available, new requirements could create barriers to entering the professions.

Increased adoption of alternative payment models, including value-based payment, may create additional financing opportunities for a broader set of health care professionals as part of interdisciplinary care teams. Additional policy changes and approaches, such as state plan amendments or Section 1115 demonstration waivers for the Medicaid program, may allow states to explore new reimbursement approaches for an expanded set of health care professionals. Several state Medicaid programs, for example, have utilized state plan amendments to support doulas and increase access to prenatal and postpartum services.

Other policy changes, such as waiving elements of existing scope of practice rules, may also allow states to test innovative models and programs utilizing the expanded health care team professionals. In 2014, California waived portions of the health and safety code and approved a community pilot study in 13 communities.

While many programs and efforts currently leverage the expanded health care workforce — including here in Kansas — the long-term sustainability of these programs and their growth into new and additional communities is likely limited without sustainable funding and reimbursement mechanisms.