Recommendations for Strengthening the Health Care Workforce in the Commonwealth of Virginia

Virginia, like the United States as a whole, faces a significant shortage of health care workers in nursing, primary care, and behavioral health. If current trends persist, these shortages will increase across the Commonwealth of Virginia. In a study funded by the Virginia Health Workforce Development Authority, a team of RAND researchers identified promising strategies for retaining and expanding these workforces in the Commonwealth. The study used an economic model designed to predict the size of Virginia's future health care workforce through 2038 if current conditions persist and in scenarios in which different interventions are implemented.

Developing the Nursing Workforce

Exposure to workplace violence, high stress, and burnout accelerate workforce attrition. Improving the work environment will improve retention of nurses. Over time, implementing strategies that boost recruitment will have an even greater effect on nursing numbers. Increasing real wage growth from 2 to 3 percent annually will help retention and recruitment. Offloading nonnursing tasks to other team members will increase work efficiency and allow nurses to practice at the top of their license. Modeling suggests that a combination of all three interventions will have the largest effect, increasing the number of full-time equivalent (FTE) nurses employed by 11 percent in 2038, compared with the scenario in which current conditions persist.

Maintaining and Expanding the Primary Care Workforce

The quickest way to increase the size of Virginia's primary care workforce is to reduce work barriers. Because primary care is compensated at lower rates than specialty care, it will be difficult to reverse current trends without a major boost in payments for primary care services. Increasing real annual wage growth to 3 percent over a 15-year period would have a greater effect than cutting barriers in half or increasing the recruitment rate by 25 percent. In the absence of these efforts, steps to increase recruitment will likely have a small effect on expanding the primary care workforce, because recruitment of primary care providers begins at modest levels. However, a combination of all three interventions could increase total FTE primary care physician employment by 12 percent by 2038.

Boosting the Behavioral Health Workforce

Behavioral health recruitment and retention is hindered by high barriers to entry, high stress, and low rates of pay. As a result, under current conditions, the number of behavioral health workers in Virginia is projected to steadily decline in the coming years. Focusing on recruitment, retention, or efficiency alone could keep numbers steady over next 15 years, but all three interventions will be needed to produce a sustainable increase in employment.

Strategies for Increasing Retention

• Promote team-based care through regulatory and reimbursement reform and by creating career ladders for upward movement.
• Implement programs to address mental health and well-being among workers.
• Address underlying causes of stress and burnout, such as inappropriate patient-provider ratios, unrealistic throughput requirements, and heavy documentation burdens.
• Reduce license restrictions on physician assistants and nurse practitioners.
• Streamline documentation requirements by eliminating redundant and needless paperwork.
• Create more-diverse health care workplaces.
• Increase the legal consequences of violence toward health care providers.
• Recruit local students from rural communities to bolster rural workforces.

Strategies for Increasing Recruitment

• Increase Medicaid reimbursement for primary care and behavioral health.
• Increase residency slots and funding for primary care and psychiatry.
• Increase scholarships and loan forgiveness programs and advertise their availability.
• Craft targeted loan forgiveness opportunities in primary care fields. For example, repay loans for physicians practicing in settings that qualify for the Public Service Loan Forgiveness Program.
• Enable rural applicants and first-generation students to receive loan forgiveness up front.
• Increase wages for nursing faculty and preceptors to match those in engineering and business.
• Reduce stringent supervision requirements for behavioral health trainees.
• Develop and expand programs to expose children in kindergarten through 12th grade to health professions.
• Implement outreach strategies for youth from underrepresented communities.
• Leverage nursing and behavioral health retirees to increase the pool of licensed supervisors.
• Shorten the duration of application for licensure in behavioral health.

Strategies for Increasing Structural Efficiency

• Incentivize health workers to move from areas with more provider capacity to those with less capacity.
• Increase the use of telehealth to support rural practitioners.
• Leverage technologies, such as voice recognition and artificial intelligence, to reduce documentation burdens.
• Enable colocation of primary care and behavioral health services in the same setting.