NOVEMBER 2021 INNOVATION LANDSCAPE SERIES Solving Shortages: How Technology Can Help Meet California's Immediate Health Workforce Needs T he health care safety-net system, a patchwork of Valley, five in Southern California, and two in Northern programs and providers that serve Californians California. While this sample size is small, the organiza- with low incomes, faces unique challenges in tions represent a range of size and location (geographic, recruiting and maintaining its clinical staff due to work- and rural vs. urban), as well as varying degrees of tem- force shortages and inequitable distribution of health porary workforce needs, and thus provide information care providers across California. To address these short- likely applicable to the workforce recruitment practices ages, many health care systems serving patients living on and experiences of similar organizations throughout low incomes turn to the temporary workforce to fill their California. needs. Staffing agencies play an important role in sup- porting these health care organizations with recruitment, The data for this paper were collected before the given that many have few resources to maintain a tem- COVID-19 pandemic. The impact of the pandemic porary provider pool or a sizeable human resources (HR) appears to have increased the need for temporary work- department. In recent years, technology-enabled staffing ers. Although there are limited data, initial reports and services have emerged and addressed some limitations interviews conducted for this paper indicate that the use of traditional staffing agencies, including limited trans- of temporary workers has increased. One recent study parency and high cost. of traveling nurses found that at the height of the pan- demic, job postings for temporary nurse positions had This paper reviews the barriers to hiring providers in this tripled and increased faster in places facing extreme specific sector of the health care system, the role of the pandemic conditions.1 While it is still early to predict last- temporary workforce, and the emergence of technology- ing changes, the COVID-19 pandemic highlighted the enabled staffing companies as a potential alternative to continued importance of the temporary workforce in the traditional staffing agencies. This landscape analysis is delivery of health care. intended to inform investors and entrepreneurs invested in or working on these issues to help them understand the unmet needs and opportunities ripe for tech-enabled About the Authors innovation. It is also intended to help provider organiza- Joanne Spetz, PhD, is director of the Philip R. Lee Insti- tions encountering these challenges to understand the tute for Health Policy Studies and is a health economist emerging class of technology solutions that may meet whose fields of specialty are the health care workforce, their needs. organization and quality of health care services, and the evaluation of health care policy and programs. She To understand the recruiting and HR needs of safety- has conducted studies of the registered nurse, nurse practitioner, and long-term care workforces for nearly net organizations, the authors conducted a literature 30 years. review, interviewed five leaders of technology-enabled staffing companies, and talked with HR executives from Amy Quan is a research analyst at Healthforce Center at UCSF and works on a variety of projects related to 13 safety-net organizations. Among the HR executives, the health workforce, researching professions such as seven were hospital leaders (either county hospitals or registered nurses, physicians, nurse practitioners, and private nonprofits) and six were executives at multisite community health workers. She is a master of public clinics. Six of the organizations are located in the Central health candidate at UC Berkeley. Background: Workforce Leveraging the Temporary Shortages in the Safety Net Workforce Workforce trends nationwide point to a growing shortage Leveraging contract or temporary providers can serve and inequitable distribution of providers. In California, as a stopgap measure that enables health care facilities the shortage of primary care providers (physicians, nurse to maintain consistent levels of staffing when care teams practitioners, and physician assistants) is expected to are lean, such as when there are unfilled vacancies, staff become worse over time, with some regions expected to absences, turnover, or during high-census periods when face greater shortfalls than others.2 While the supply of patients outnumber staff available to provide services. registered nurses (RNs) is actually projected to be slightly Doing so can reduce the risk of staff burnout and ensure higher than demand through 2035, some RN job catego- consistent quality of care.4 The temporary workforce also ries are projected to experience shortages, especially for allows health care facilities to maintain their patient vol- experienced nurses who work in clinical specialties such umes, which can reduce revenue losses when faced with as critical care, emergency, and perioperative nursing.3 a shortage of providers. These shortages and the inequitable distribution of the There are models for leveraging temporary RNs and tem- clinical workforce are most acute in rural areas and in porary physicians and advanced practice providers. The the safety net. A number of factors make it particularly three main models for temporary RNs are (1) an internal challenging to recruit providers; these factors fall into per diem pool maintained by the health care organiza- four main categories as detailed in Table 1: professional, tion, consisting of employees who do not work a regular sociocultural, structural, and workplace. schedule and who are called to work directly by the employer; (2) agency-employed temporary nurses, who Over the long run, there are many strategies that gov- are assigned to single shifts or short-term assignments for ernment organizations, training institutions, and even multiple shifts; and (3) traveling nurses, who are agency- safety-net organizations can take to address workforce employed and assigned for longer periods of time shortages. (For more information on recommended work- (typically a minimum of 6 weeks, and often 13 weeks). force strategies, see the 2019 California Future Health Physicians, nurse practitioners, and physician assistants in Workforce Commission report). However, the need to the temporary workforce are usually employed through address the challenge is immediate, and utilizing the agencies as "locum tenens:" temporarily for a few shifts temporary workforce is a common short-term solution. or for an extended period. Table 1. Characteristics of Rural Practices and the Safety Net That Contribute to Provider Shortages PROFESSIONAL SOCIOCULTURAL STRUCTURAL WORKPLACE $ Greater breadth and depth $ Fewer career opportunities $ Limited financial resources $ Lack of clinical infrastructure of medical knowledge for spouses/partners for recruitment due to (e.g., lack of administrative required due to scarcity dependence on patients and clinical support, $ Challenges with work-life of in-house subspecialists who are more often resources, and equipment) balance uninsured $ Professional isolation $ Heavier workloads $ Community expectations $ High demand for care due $ Lack of role models and that extend beyond $ Greater bureaucratic demand to demographics of safety- mentors clinical role (e.g., higher Medicare and net and rural populations Medicaid populations and $ Fewer clinical education and $ Cultural barriers and and retirements in the associated required paper- professional development language differences current aging workforce work) opportunities $ Fewer social and cultural $ Transportation and $ Lower pay than urban, opportunities in the accessibility challenges private hospitals community Sources: Ines Weinhold and Sebastian Gurtner, "Understanding Shortages of Sufficient Health Care in Rural Areas," Health Policy 118, no. 2 (Nov. 2014): 201-214; and Xiaoming Zhang et al., "Physician Workforce in the United States of America: Forecasting Nationwide Shortages," Human Resources for Health 18, no. 1 (Feb. 6, 2020). California Health Care Foundation www.chcf.org 2 The use of a temporary workforce is increasing overall, health care organization receives a list of prescreened and in the health care sector in particular, it is used to candidates from a professional recruiter responsible for meet the needs of people who are underinsured and/ the early stages of the recruiting process, which may or living with low incomes. A complementary publica- include identifying candidates, verifying credentials, con- tion to this brief (Solving Shortages: A Snapshot of the ducting initial interviews, and checking references. This Temporary Workforce in California's Safety-Net Hospitals enables the health care organization to maintain a leaner and Clinics [PDF]) presents statistical information on the and more focused human resources team. use of temporary workers in hospitals and clinics in Cali- fornia. The analysis indicates that safety-net hospitals From the employer's perspective, the main disadvan- are more likely to utilize temporary RNs, and of those tages of staffing agencies are costs, trust in the agency's safety-net hospitals that use temporary RNs, most are in credentialing process, the challenge of managing multi- rural areas or are critical access hospitals.5 Safety-net ple staffing agencies to ensure that recruited staff possess clinics are more likely to utilize contract or temporary the appropriate experience and skills, and the lack of advanced clinical providers, like physicians, than other transparency in pricing and candidates referred.9 types of contract providers, including RNs. Further, the top quartile of safety-net clinics that use contract Because agencies are not intimately familiar with a health provider full-time equivalents utilize the vast majority system's needs, agency nurses can be assigned to units (96.3%). These findings are generally supported by pub- that do not match their experience or skill level - either lished literature. One study found that on average, one- to units that demand more complex skills than their com- third of Federally Qualified Health Centers (FQHCs) in petence, where nurses may not know how to operate the US utilized temporary providers between 2013 and equipment and/or lack the confidence to deliver effec- 2017; 59% of these health centers were large FQHCs tive patient care or to less-complex units, where their and 39% were located in rural areas.6 It was estimated skills are underutilized.10 This mismatch can contribute that 45,155 RNs worked in temporary positions in 2019 to a negative working environment for both temporary and that this number would grow 10% to reach 49,637 nurses and their permanent counterparts. Moreover, by 2025 across the US.7 In 2018, 2.7% of RNs living in staffing misplacements can negatively impact the quality California reported that they worked with a temporary of patient care and perpetuate workplace inefficiencies. or traveling agency for their primary job.8 Additionally, safety-net organizations sometimes find that staffing agencies do not understand their unique The Role of Staffing Agencies challenges and the importance of a cultural fit within the in Recruiting Temporary organization. Faced with these challenges, some of these organizations report feeling that staffing agencies do not Workers always provide a strong match. Therefore, even with lim- Data and interviews suggest that many safety-net and ited HR staff, they continue to recruit directly. rural facilities rely on staffing agencies and recruiters to assist with the hiring of temporary providers due to those facilities' limited scale, resources, and administra- Emergence and Potential of tive personnel. Staffing agencies are search-and-recruit firms that help to match candidates and open positions. Technology-Enabled Staffing Health care organizations less able to maintain an inter- Technology platforms for recruiting and placing provid- nal pool of nurses, physicians, and other providers may ers have emerged to address some of the disadvantages call on a staffing agency to coordinate the recruitment of of working with a traditional staffing agency. A variety temporary providers. of companies leverage information technology, such as complex relational databases, machine learning algo- Staffing agencies enable health care employers to access rithms, and automated query systems, to improve the a large network of passive and active candidates. The Solving Shortages: How Technology Can Help Meet California's Immediate Health Workforce Needs www.chcf.org 3 staffing process. These emerging companies offer a and overhead expenses compared to traditional staff- range of services, including these: ing agencies. Their intent is to drive efficiencies for their customers so that every dollar spent on recruit- A Algorithm-based "smart" matching between ing can go further and be more effective. Using these candidates and clients. Several companies aim to platforms may help organizations either reduce costs streamline and improve the match between candi- or hire more providers for the same spend. dates and health care facilities by using algorithms. Typically, candidates create a profile, input their per- A Faster placements. They aim to offer a one-stop sonal information (experience, education, hard and model where employers can complete multiple tasks soft skills, personal and professional interests), and on one platform. Thus, these platforms have the preferences (location, specialty, availability), and the potential to speed up the placement process. algorithm analyzes their profile to match them with A Streamlined verification. Some companies automati- open positions posted by health care facilities. The cally verify licenses and credentials, which can be an matching algorithms are improved as users spend important benefit for employers, allowing them to more time using the platform by incorporating infor- focus on interviewing candidates. The early verifi- mation about the searches made by candidates and cation of licenses may reduce the amount of time the positions that candidates click on. These platforms between interviewing, hiring, and onboarding. have different approaches in how they deliver candi- dates to employers. $ Increased transparency. In some systems, employ- ers can see how many and which candidates fulfill the A Automated workflow support for clients. Companies positions' requirements rather than seeing only the have developed tools to increase the efficiency of candidates selected by the recruiter. recruiting by automating portions of the process. These tools may include license verification, auto- The authors identified three categories of companies that mated interview scheduling, in-app chat functions, offer technology-enabled staffing platforms in the pro- and systems that track candidates from the initial vider recruitment space and interviewed five companies screening all the way through to hiring. to learn more about their offerings. While not intended A Services that attract job seekers and increase the to be a comprehensive list, these companies represent a pool of candidates. Some companies offer candidates range of solutions in the market and the potential value services to attract them to their platform. Services can for health care organizations facing challenging recruit- include free continuing education courses, online com- ment environments and limited internal HR resources. munity groups, newsletters and blogs, and podcasts. Each company has a unique approach to leveraging technology in the temporary and/or permanent place- $ Internet and social network marketing. Recruitment ment process. Some focus on a single professional group advertising on internet search platforms such as and others focus on multiple professions. Some focus on Google and within social media sites such as Facebook temporary placement and others on permanent staffing. is an essential piece of the search and placement pro- The categories and companies interviewed include: cess. Some companies specialize in these marketing techniques while others simply integrate them into $ Managed service providers (MSPs). In general, a their overall platform. staffing managed service provider (also called a man- aged services program) is a company that manages Companies that leverage these technological approaches specific human resources services such as staffing and for recruitment claim to offer health care organizations a recruitment for its customers. MSPs have been estab- number of benefits: lished for a long time and typically take responsibility A Lower costs. These technology platforms aim to for specific HR functions such as recruitment and hir- reduce or eliminate the need to employ recruiters and ing, which can benefit organizations by outsourcing marketing specialists, which can lower operational this expertise that may be hard to maintain in-house, California Health Care Foundation www.chcf.org 4 or provide more efficiency by taking advantage of these companies are open marketplaces where candi- economies of scale. MSPs are increasingly evolving dates can directly engage with job postings. They aim to integrate more technology into their product and to reduce the need for human recruiters by using better service offerings. A number of companies specialize data and matching algorithms. Many of these com- in health care facility recruiting, and some are subsid- panies also offer workforce tools, candidate-focused iaries of larger temporary placement agencies. Some services to draw candidates to their platforms, and MSPs also offer a vendor management system (VMS), internet and social network–focused marketing. The which provides web-based software systems to man- authors interviewed three companies in this category. age staffing and recruitment, including storing and Incredible Health focuses on permanent placements, tracking information, and to support the recruitment matching nurses to positions for which they are quali- and matching process. Most MSPs tap into multiple fied and allowing nurses to decide which jobs they temporary staffing agencies and aggregate candi- want to interview for. Nomad Health has developed dates into a single platform. MSPs usually operate in algorithms for matching nurses with temporary job one of three ways: (1) some are also staffing agencies opportunities, with each algorithm focused on a par- and recruit candidates from their own roster before ticular aspect of the matching process. Trusted Health offering candidates from other agencies; (2) some are has its own staffing needs system focused on tempo- staffing agencies but are vendor-neutral, meaning they rary and traveling nurses, which health care facilities source candidates from any agency, and (3) some are can use independently to recruit providers or can not staffing agencies and work with various agencies integrate into the human resources system they are to fill positions. Many of these companies also offer already using. workflow tools for their clients in addition to VMS soft- ware. There is a growing number of MSPs; prominent companies include Aya Healthcare, Medefis, Medical Limitations of Technology- Solutions, MedicusOne. More than half of travel nurse revenue was billed through a MSP program in 2017.11 Enabled Staffing The authors interviewed leadership at Medefis, which While these emerging companies and technology ser- offers a vendor-neutral MSP and is a subsidiary of vices are promising, most are new and still encounter AMN Healthcare, one of the nation's largest health challenges to widespread use in this particular health care staffing companies. care sector. Interviews conducted for this report surfaced a number of important limitations for the use of technol- $ Placement agencies that leverage internet and ogy-enabled staffing for hiring temporary providers by social network marketing. Some traditional staffing safety-net organizations. agencies have developed sophisticated marketing strategies as a pillar of their approach. The authors Perhaps the biggest issue is that few providers in this interviewed leadership at Inline Group, whose services health care sector are aware of these platforms or use include the development of dedicated recruiting web them to date, and none of the technology-enabled staff- pages for each of their clients and advanced internet ing companies identified for this report are currently advertising techniques to identify and target candi- focusing on safety-net organizations as a key customer dates for job openings. segment. These companies are very early in proving their value to customers in general, and potential users $ Algorithm-focused staffing agencies. While the two express concerns about timeliness, quality of matches, previous categories of companies grew from tradi- comprehensiveness of services, and cost. Even as these tional organizations, a new category of technology platforms demonstrate value over time, many employ- staffing company has been established within the past ers will continue to work with multiple staffing solutions several years that leverages advanced computing to fulfill their staffing needs. The market for recruiting algorithms to streamline temporary and permanent services in California is fragmented; even traditional clinical placements in health care organizations. Often agencies do not hold more than 10% of the market. Health Workforce Recruitment Platforms www.chcf.org 5 HR executives interviewed for this report said that Health and Trusted Health) started with a focus on plac- working with a recruiting partner that can establish a rela- ing temporary providers but may find opportunities tionship to understand the organization's needs is critical for growth in permanent placements while, conversely, to help make the appropriate match. Safety-net organi- Incredible Health, which started with a focus on perma- zations serve a diverse population of patients. Therefore, nent placements, may find opportunities for growth in the quality of candidates is paramount, particularly the temporary placement market. because the patient population served often has com- plex health and social needs. Safety-net organizations Safety-net clinics and hospitals, both urban and rural, that have used staffing agencies to fill temporary posi- struggle with staffing shortages. They may have more tions expressed the value of an established relationship opportunities to work with emerging technology partners, with their assigned recruiter(s). given that they may be more susceptible to workforce gaps because of the professional, sociocultural, struc- Furthermore, while a technology-enabled solution has tural, and workplace factors that influence providers' the potential to cut the cost of recruitment by using more decisions on where to practice. While some safety-net data and automation, these platforms still need to meet organizations may utilize a rotation of temporary provid- a wide variety of recruitment needs among their custom- ers as a part of a long-term staffing strategy, most turn to ers. For example, organizations that have worked with them to fill gaps when there are unfilled vacancies, staff MSPs value the comprehensive list of services they offer. absences, or significant unanticipated turnover, as well For these organizations, MSPs are essentially an external as during high-census periods such as flu season. These HR team that can assist with managing most if not all tasks organizations currently turn to traditional staffing agen- associated with hiring temporary providers. This compre- cies or MSP companies that provide a full set of services hensive approach usually involves working with one MSP to meet their recruiting needs. company instead of several staffing agencies and may be particularly valuable to safety-net organizations with The challenges of recruitment in the health care safety small HR teams but sizeable temporary workforce needs. net create a unique opportunity to consider how emerg- ing technology-enabled recruiting solutions can bring Last, while these technology-enabled platforms auto- more efficiency, transparency, and lower costs to the mate some parts of the recruitment process, employers market. Emerging technology vendors with data-driven must still conduct their own interviews to assess whether approaches have an opportunity to accurately match a candidate is truly a good fit for the organization and the unique needs of a safety-net organization with the position. Employers are also still responsible for onboard- unique qualifications of a provider applicant. Over time, ing temporary staff and need to develop and deploy an these vendors may also provide valuable support in hir- orientation process for them. ing temporary and permanent providers, or even serve as viable alternatives to traditional agencies. Looking to the Future However, these companies have significant work to do to The landscape of technology-based staffing solutions meet the unique needs and concerns of safety-net health continues to grow and evolve. Companies are constantly care organizations and to tailor their services accordingly. working to craft solutions that meet the needs of their This could include highlighting bilingual candidates or potential customers. As new companies enter the mar- candidates with experience working with vulnerable and ketplace, bringing new approaches and technologies, rural populations, and tailoring price points to meet the older companies adjust their services and offerings to budget needs of safety-net organizations. Eventually, address the competition. For example, Nomad Health while technology-enabled platforms may not solve all began by placing both locum tenens physicians and safety-net provider staffing problems, they could poten- temporary nurses but has since narrowed its focus to tially serve as valuable partners. registered nurses. Two of the newer entrants (Nomad California Health Care Foundation www.chcf.org 6 Nurse, Physician, and Other Rather, the goal was to give a sense of how this market is shaping up and the types of organizations addressing Provider Recruitment this unmet need. For more information, please contact Technology Vendors each organization directly. The organizations presented in Table 2 were identified as providing a technology platform for provider recruit- ment. This is not intended to be a comprehensive list of organizations nor an endorsement of these companies. Table 2. Examples of Technology-Enabled Platforms Focused on Nurse, Physician, and Other Provider Recruitment OTHER TARGETED YEAR SERVICES LICENSE COMPANY TYPE PROFESSIONS KEY CUSTOMERS FOUNDED OFFERED VERIFICATION Algorithm- Permanent nurses Hospitals 2017 Workflow tools Yes focused staffing for clients, agency candidate- focused services Placement agency Permanent Outpatient 2007 Workflow tools Yes that leverages physicians, nurse clinics, hospitals, for clients, internet and practitioners, managed care candidate- social network physician assistants, organizations, focused marketing specialists, nurses skilled nursing services facilities Managed service Contracted Ranges from 2003 Workflow tools No provider (and providers and critical access for clients (available vendor manage- nonproviders hospitals to multi- through ment system) hospital systems optional outsourcing) Algorithm- Travel nurses Hospitals 2015 Workflow tools Yes focused staffing for clients, agency candidate- focused services Algorithm- Travel nurses Academic medical 2017 Workflow tools Yes focused staffing centers, acute for clients, agency care facilities, candidate- post-acute care focused facilities services Health Workforce Recruitment Platforms www.chcf.org 7 About the Foundation Endnotes The California Health Care Foundation is dedicated to 1.Joshua D. Gottlieb and Avi Zenilman, When Nurses Travel: Labor Supply Elasticity During COVID-19 Surges (PDF), advancing meaningful, measurable improvements in the University of Chicago, November 19, 2020. way the health care delivery system provides care to the 2.Joanne Spetz, Janet Coffman, and Igor Geyn, California's people of California, particularly those with low incomes Primary Care Workforce: Forecasted Supply, Demand, and and those whose needs are not well served by the status Pipeline of Trainees, 2016–2030, Healthforce Center at UCSF, quo. We work to ensure that people have access to the August 15, 2017. care they need, when they need it, at a price they can 3.Joanne Spetz, Forecasts of the Registered Nurse Workforce in California (PDF), California Board of Registered Nursing, May 2020; afford. and Joanne Spetz, Regional Forecasts of the Registered Nurse Workforce in California (PDF), Healthforce Center at UCSF, CHCF informs policymakers and industry leaders, invests December 2018. in ideas and innovations, and connects with changemak- 4.2020 Survey of Temporary Physician Staffing Trends (PDF), Staff ers to create a more responsive, patient-centered health Care, 2020. care system. 5."Critical Access Hospitals," Rural Health Information Hub, last reviewed September 3, 2021. Critical access hospital is a designation given to eligible rural hospitals by the Centers for For more information, visit www.chcf.org. Medicare & Medicaid Services. Congress created the critical access hospital (CAH) designation through the Balanced Budget Act of 1997 (Public Law 105-33) in response to over 400 rural hospital closures during the 1980s and early 1990s. Congress has amended the CAH designation and related program requirements several times through additional legislation. 6.Xinxin Han, Candice Chen, and Patricia Pittman, "Use of Temporary Primary Care Providers in Federally Qualified Health Centers," Journal of Rural Health 37, no. 1 (Jan. 2021): 61– 68. 7."Temporary Employment in the U.S. to Grow Faster Than All Jobs Through 2025, According to New Job Forecast from TrueBlue and Emsi," Business Wire, November 1, 2019. 8.Joanne Spetz and Lela Chu, California Board of Registered Nursing 2018 Survey of Registered Nurses (PDF), California Board of Registered Nursing, May 2020. 9.Iakovos Theodoulou, Akshaya Mohan Reddy, and Jeremy Wong, "Is Innovative Workforce Planning Software the Solution to NHS Staffing and Cost Crisis? An Exploration of the Locum Industry," BMC Health Services Research 18, no. 1 (Mar. 20, 2018); and 2020 About the Innovation Landscape Series Survey, Staff Care. As part of its efforts to help promising products and 10.Catherine Birmingham et al., "The Experiences of the services succeed and scale among California's safety- Agency Registered Nurse: An Integrative Literature Review," net providers, the CHCF Innovation Fund conducts Journal of Nursing Management 27, no. 8 (Nov. 2019): 1580 – 87; high-level landscape analyses of issue areas especially and Kate Simpson et al., "What Do We Know About Our Agency ripe for tech-enabled innovation. The Innovation Fund Nurse Population? A Scoping Review," Nursing Forum 54, no. 4 publicizes the findings of these landscape analyses to (Oct./Dec. 2019): 492–98. inform other funders and customers seeking scalable 11.Amy Chang, "Moderating Growth in Healthcare Staffing; solutions to challenges faced by safety-net providers. MSP and VMS Penetration Continues," Staffing Industry Analysts, Readers should note that these reports are not intend- October 9, 2018. ed to be exhaustive, nor are they endorsements of the companies included in them. Finally, because solutions landscapes can evolve quickly, these reports may not fully reflect the current market. www.chcf.org/innovationfund California Health Care Foundation www.chcf.org 8