Identifying Strategies for Strengthening the Health Care Workforce in the Commonwealth of Virginia

Issue

Like the United States as a whole, the Commonwealth of Virginia faces a significant shortage of health care workers in primary care and behavioral health care across a variety of health care settings. For example, 102 of 133 Virginia counties and equivalents are federally designated primary care Health Professional Shortage Areas (HPSAs), accounting for 29 percent of the Commonwealth's population. Many of these shortage areas are in urban and rural regions, as opposed to suburban areas (Health Resources and Services Administration, 2023). Similarly, 93 of Virginia's 133 counties (and equivalents) are federally designated mental health care HPSAs, and about 32 percent of Virginians live in these areas (Virginia Health Care Foundation, 2022a; Virginia Health Care Foundation, 2022b).

In response to these health care workforce shortages, Virginia has passed nearly 60 related bills over the past ten years, with a notable increase in the number of health care workforce bills in 2022 and 2023 (BillTrack50, undated; National Conference of State Legislatures, 2023). Recently enacted legislation includes interstate compacts (i.e., agreements) for licensing and scope-of-practice regulations for behavioral health professionals, medical assistance payment for remote patient monitoring, and expanded midwife practice agreements.

Because of the limited evaluation research on existing practices, programs, and policies (hereafter “interventions”), it is unclear whether past and current interventions are likely to succeed in addressing the workforce shortages in Virginia. An evidence-based approach that carefully evaluates interventions across different contexts is needed to identify the most promising interventions to help retain and expand the health care workforce in Virginia.

The objective of this study was to identify interventions that can help the Virginia Health Workforce Development Authority (VHWDA) address nursing, primary care, and behavioral health workforce challenges and to define the role that the authority can play in facilitating such solutions. To accomplish this goal, we applied an analytic framework to existing or potential interventions for retaining, recruiting, and improving the structural efficiency (i.e., the efficient allocation of workers within a given health care system and efficient health care output using technology, policy changes, or other structural adjustments) of the nursing, primary care, and behavioral health workforces in Virginia. In this study, we highlight which interventions VHWDA should prioritize based on its desired outcomes and policy goals.

Overarching Findings

1. Medicaid reimbursement for primary care and behavioral health care needs to be increased.
2. Residency slots and funding for primary care fields and psychiatry should be increased.
3. Team-based care needs to be promoted and supported in Virginia through regulatory and reimbursement reform.
4. To help populate teams for team-based care, “health care highways”—ladders (or programs) for upward movement—need to be embraced.
5. Barriers to pursuing health care careers need to be removed, including the number of supervised training hours and related trainee expenses—particularly in behavioral health professions.
6. Tuition support and other incentives need to be expanded—especially for students in most need—and effectively advertised.
7. Support for faculty and clinical preceptors needs to be enhanced and more flexibility needs to be built into such positions.
8. Loan forgiveness opportunities for specific primary care fields should be instituted—for example, repay loans for those primary care physicians practicing in settings that qualify for the Public Service Loan Forgiveness Program.

Approach

We used results from a review of peer-reviewed and grey literature and analysis of multidisciplinary conference, interview, focus group, and quantitative data sources to arrive at recommendations for promising interventions to be implemented in Virginia for health care workforce retention, recruitment, and structural efficiency. Furthermore, we developed a system dynamics economic model to assess the shortages of nurses, primary care practitioners, and behavioral health providers in the next five, ten, and 15 years at baseline (i.e., if the status quo persists) and if (1) retention barriers (such as fatigue, distress, and disengagement) are decreased, (2) recruitment is increased, (3) wages are increased, or (4) all three interventions are implemented.

Key Findings

The results from the system dynamics model show that, if current trends persist, nursing, primary care, and behavioral health workforce shortages will increase across Virginia.

We forecast that, by reducing the barriers that cause reluctance to remain working in the field of nursing by half—barriers such as workplace violence, trauma, and stress—Virginia can effect a rapid increase in the number of registered nurses (RNs) retained in the field. However, over a period of 15 years, increased recruitment will have a more dramatic effect on workforce numbers, surpassing the effect of decreased barriers to retention. Increasing nurse wage growth from an average 2 percent annual growth to 3 percent annual growth also increases the number of nurses retained and recruited, though not as much as the other interventions do. As expected, a combination of all three interventions has the largest effect on the forecast of nurse employment, boosting the total number of full-time equivalent nurses employed in 2038 by a little more than 10,000 more than the baseline projection.

Unlike our forecasts for RNs, our forecast for the number of active primary care workers in the Commonwealth shows a decline under baseline conditions, making the future shortfall in primary care workers even more severe than for nursing alone. Similar to our model for nursing, the largest immediate boost to the workforce would come from cutting in half the number of barriers that make workers reluctant to remain working in the field. Over the course of 15 years, the effect on total employment of increasing wage growth catches up to the effect of decreasing retention barriers. The effect of increasing recruitment is more modest because baseline recruitment begins at very modest levels. An ambitious combination of all three interventions (the multi-intervention scenario) would boost total employment, which is forecast to slowly decline in the coming years, by more than 2,000 workers. Implementing any one of the three interventions promises to keep the existing workforce numbers at 2023 levels, but only by combining all three interventions can Virginia produce a sustainable increase in the number of behavioral health workers employed.

Recommendations

VHWDA should convene and lead a coalition of key stakeholders to implement the following recommendations to retain and expand the nursing, primary care, and behavioral health workforces in Virginia. These stakeholders include, but are not limited to, the Virginia legislature, state agencies, health care organizations, and educational entities. Implementation of many of the proposed interventions will require cross-sector, including public-private, collaboration. To ensure effective and efficient implementation of these recommendations, VHWDA should serve as the coordinating center for the coalition to help gather the needed collaborations, data, and funds and to leverage other political and social capital in the Commonwealth.

The guide to intervention recommendations by strength of evidence found in this study is outlined in Table 1. Tables 2 and 3 list retention and recruitment interventions, respectively.

Tier 1 interventions are strongly supported by the analyses. The interventions are supported by the literature review (evaluation studies) and were identified multiple times across the multi-stakeholder conference, interviews, and/or focus group data.*

Tier 2 interventions are moderately supported by the analyses. These interventions are supported by the literature review (non-evaluation studies) and were identified multiple times across the multi-stakeholder conference, interviews, and/or focus group data.

Tier 3 interventions have some support in the literature review or were identified in the multi-stakeholder conference, interviews, and/or focus group data.

*Support for an intervention in the qualitative work indicates that the intervention has valence—or is deemed an attractive option by interviewees—but it does not indicate whether the intervention will have a positive effect on retention, recruitment, or productivity.

Tier	Retention Intervention Category (Key Implementation Stakeholders)	Specific Intervention
Tier 1	Resiliency and well-being (health care organizations)	Implement programs to address mental health and well-being among health care workers—especially in behavioral health professions. Address underlying causes of health care worker stress and burnout, such as inappropriate patient-provider ratios, throughput requirements, documentation requirements, low and/or differential compensation for care provided, and lack of basic supplies.
Tier 1	Scope of practice and practice agreement (legislature)	Reevaluate license restrictions for physician assistants (PAs) and nurse practitioners (NPs) to increase the appeal of primary care for these health professionals and to expand primary care capacity.
Tier 2	Team-based care (health care organizations)	Implement team-based care to mitigate the stresses of high patient-to-provider ratios and large patient panels and take patient complexity and acuity into account when assigning patients to providers.
Tier 2	Pay increase and other incentives (health care organizations)	Increase pay for nursing, primary care, and behavioral health providers and provide appropriate benefits—including health insurance coverage commensurate with risks involved in health care delivery (e.g., exposure to disease, despair, and violence). Provide assistance with transportation, child care, and housing.
Tier 2	Documentation burden (health care organizations, systems, legislature)	Evaluate technologies—such as voice recognition and artificial intelligence—that may assist with reducing documentation burden.* Revisit documentation requirements to identify areas of redundant and/or unnecessary documentation that could be removed from documentation requirements.
Tier 2	Workplace diversity (health care organizations, educational entities)	Develop retention strategies centered around creating more diverse workplaces for nursing, primary care, and behavioral health.*
Tier 2	Personal and professional development (health care organizations)	Invest in making professional development opportunities available to staff and increase recognition efforts.
Tier 3	Workplace violence (health care organizations, legislature)	Evaluate legislation to increase legal consequences related to violence toward health care providers—on par with those currently in place for assaulting prehospital providers and first responders.* Evaluate health care organization policies around violence toward health care providers and identify strategies for more strict enforcement of those policies.
Tier 3	Cross-sector collaboration (health care organizations, educational entities)	Identify and leverage opportunities for cross-sector collaboration among the health care sector, educational organizations, and public and private entities to increase opportunities and funding for nursing, primary care, and behavioral health exposure and training.
Tier 3	Continuing education (health care organizations, educational entities)	Evaluate mechanisms to increase continuing education opportunities and funding—especially through leveraging collaboration between health care organizations and educational entities.

*Designates an innovative intervention.

Tier	Recruitment Intervention Category (Key Implementation Stakeholders)	Specific Intervention
Tier 1	Scholarship, loan forgiveness, and other support (private entities, health care organizations, educational entities)	Increase scholarship opportunities in Virginia. Raise public awareness of loan forgiveness and scholarship opportunities. Develop mechanisms for rural applicants and first-generation students to receive loan forgiveness up front.* Include support for housing, transportation, and food for rural and first-generation students.
Tier 1	Wages and regulations for educators (private entities, health care organizations, educational entities, Virginia Department of Health Professions)	Increase wages for nursing faculty and preceptors to levels similar to engineering, business, and other faculty that receive higher wages. Loosen strict behavioral health preceptorship/licensed supervising requirements, such as educational degree requirements for preceptors, preceptor-to-student ratios, and need for preceptors in community settings.* Create mechanisms to pay for behavioral health preceptorship and licensed supervisors to remove this financial burden from students/trainees.*
Tier 1	Work-based learn and earn (health care organizations, educational entities)	Offer work-based learning, paid and unpaid. Health care occupations have historically included more work-based learning in education and training than other occupations (e.g., clinical rotations, clinical intern or clerkships, and residencies). Health care stakeholders are increasingly interested in expanding these options across different health care occupations—particularly in nursing.
Tier 2	Recruiting youth and members of underserved communities (health care organizations, educational entities)	Develop (and/or expand on current programs) to expose K–12 children to health professions. Such programs should include collaboration between educational and health care entities. Specific outreach strategies for youth from underrepresented communities are needed. Such interventions should aim to include both children and their parents in outreach efforts and should, ideally, be delivered by health care professionals from similar backgrounds.*
Tier 3	Preceptor/licensed supervisor capacity (health care organizations, educational entities)	Leverage nursing and behavioral health retirees to increase the pool of preceptors/licensed supervisors.* Create mechanisms to compensate preceptors/licensed supervisors—including ability to bill for supervised visits.*
Tier 3	Outreach and public image (health care organizations, educational entities)	Change the image of health professions through public education campaigns. Such efforts should focus on highlighting the rewarding nature of nursing and behavioral health work, and removing the stigma associated with becoming a behavioral health professional.
Tier 3	Online instruction (health care organizations, educational entities)	Increase opportunities for online learning to increase access and flexibility to local and nonlocal clinical introductory level education.
Tier 3	New pathways (health care organizations, educational entities)	Create multiple entry ramps and educational pathways to nursing and behavioral health careers as a recruitment strategy. This includes developing academic programs at different levels, such as associate's and bachelor's degrees for behavioral health, to provide more immediate relief to the workforce shortage. Offer paid internships at the high school level so students can be exposed to health professions; match undergrads with medical students and promote mentorship alongside internship.
Tier 3	Licensing exam and licensure (Department of Health professions)	Significantly truncate the duration of application for licensure in behavioral health fields and allow students that need to retake the licensure exam to have more frequent opportunities to sit for the examination.
Tier 3	Advanced education/training technology (health care organizations, educational entities)	Increase access to simulation-based learning in nursing. Increase access to training opportunities in telepsychology.

NOTE: K–12 = kindergarten through 12th grade.

*Designates an innovative intervention.

Interventions for Increasing Structural Efficiency and Other Innovations

In addition to retention and recruitment interventions, the Commonwealth should consider strategies that optimally use the existing workforce through increasing structural efficiency. Some of the interventions that we identified have little evidence behind them to determine whether they increase the number of available health care professionals or otherwise address critical health care workforce issues (e.g., burnout). Nonetheless, some are innovative and worth considering:

• Incentivizing existing nursing, primary care, and behavioral health workers to move from areas of more provider capacity to those of less capacity in Virginia may help to achieve an allocation of labor that maximizes overall health outcomes.
  • In the case of primary care and behavioral health, some of this reallocation of labor may be achieved by increasing opportunities for telehealth for providers, effectively (though not physically) moving labor to the locations with the highest need.
• Removing work barriers—such as reducing documentation, reporting, and regulatory requirements, and/or leveraging such technologies as voice recognition and artificial intelligence to help with these tasks—can both create efficiency and potentially increase worker job satisfaction to reduce attrition.
• One strategy that can help increase structural efficiency in both primary care and behavioral health is to increase locations in the Commonwealth that offer both services in the same setting—implementing a team-based approach to more efficiently address related mental health illnesses.

Transitioning service members (as well as military spouses)—many of whom are qualified health care experts—into civilian employment and anchoring them in Virginia is a strategy that may help retain talent in the Commonwealth and expand the health care workforce.

Furthermore, regular health care workforce data-tracking may be an effective strategy to inform interventions for retention, recruitment, and structural efficiency and to pivot as needed to ensure that the health care needs of Virginia residents are met. Health care workforce data exist in Virginia Commonwealth University's Virginia Ambulatory Care Outcomes Research Network (ACORN) (Virginia Commonwealth University, undated), in the Virginia Longitudinal Data System (Virginia Longitudinal Data System, undated), and at the George Mason University Center for Health Workforce (Mason Center for Health Workforce, undated). Similar data-tracking should be implemented by health professions colleges and universities to inform strategies to retain graduates in the Commonwealth.

Although there are promising programs in Virginia focused on health care workforce retention and recruitment, there is currently no mechanism for tracking and disseminating these programs. A clearinghouse for tracking and sharing current practices and programs can facilitate dissemination of promising interventions. The newly established Virginia Department of Workforce Development and Advancement will play a key role in supporting workforce data infrastructure across different industries.

Health Care Workforce Retention and Recruitment in Rural Settings

Many of the identified interventions apply to urban, suburban, and rural settings in Virginia. However, there are some unique considerations for health care workforce development in Virginia's rural communities.

• Recruiting local students from these communities as a retention strategy to bolster rural workforces, rather than convincing providers from elsewhere to move. Such recruitment would be most effective if it is paired with providing up-front financial support for education and life-expenses.
• Developing infrastructure, such as housing, transportation, and child care, in rural areas as both a retention and recruitment tool.

In closing, Virginia can address these shortages by implementing practical strategies to enhance retention and recruitment, and by changing (or removing) rules, regulations, and policies that degrade efficiency; make it difficult for eager students to enter the workforce; or pull dedicated and experienced nurses, primary care, and behavioral health professionals away from what they do best: caring for patients.