Health Center Work Conditions Drop After Practice Transformation

August 08, 2017 - Improving work conditions for clinicians and staff members may be key to implementing practice transformations for value-based care in federally qualified health centers (FQHCs), a new Health Affairs study suggested.

Recent survey results showed that stressors stemming from practice transformations, such as EHR adoption, alternative payment model implementation, and value-based care redesigns, could be contributing to declining working conditions among staff members at FQHCs.

Researchers from RAND Corporation surveyed clinicians and other employees at 296 FQHC sites that participated in the CMS-run FQHC Advanced Primary Care Practice Demonstration between 2011 and 2014.

CMS expected the health centers to earn recognition as a Level 3 patient-centered medical home under 2011 criteria from the National Committee for Quality Assurance by the end of the demonstration. Seventy-percent of the FQHCs achieved the recognition.

However, clinicians and other employees reported significant declines in working conditions as the demonstration progressed.

Overall professional satisfaction among health center clinicians and staff dropped from 84.2 percent in the first wave of surveys in April to August 2013 to 74.4 percent in the late survey wave between June and October 2014.

Staff and physician burnout also worsened as the FQHCs engaged in practice transformations. The burnout rate increased from 23 percent during the first wave to 31.5 percent in the late wave.

Consequently, more survey respondents indicated that they were likely to leave their health centers within two years. The share of clinicians and staff planning to leave grew from 29.3 percent to 38.2 percent.

Additionally, researchers reported that clinician and employee satisfaction with their health center’s environment and practice culture dropped during practice transformation. Key survey results related to work environment included:

• Health center staff reported an 8.3 percent drop in work control between survey waves

• About 11 percent less staff stated that their health center was a low-stress environment by the second survey wave

• The number of staff reporting a hectic or chaotic practice atmosphere rose from 31.6 percent in the early wave to 40.1 percent in the late wave

Survey findings also showed no statistically significant changes in the top-of-license activity for clinicians, nurses, educators, and clerks employed by the health centers.

In terms of practice culture, major declines in working conditions between the two survey waves included:

• Reports of teamwork dropped 26.4 percent between the two survey waves

• Facilitative leadership declined 23.3 percent

• Overall work environment fell 18.6 percent

• Communication openness decreased 16.3 percent

• Team structure, including better skill mix and role clarity, fell 15.8 percent

Researchers noted that only the measure for values alignment did not experience a significant change over time.  About 40 percent of clinicians in the first wave reported that site managers shared their values. That number dropped just 6.7 percent by the second wave.

While researchers could not definitively link the demonstration or value-based care practice transformation to worsening working conditions, they advised healthcare leaders to use the survey’s findings in future healthcare reform policies.

“Our analysis could not identify the factors contributing to these declines,” they wrote. “However, as additional health system changes accumulate under the Medicare Access and CHIP Reauthorization Act of 2016 and new legislative and regulatory activity, policy makers should consider further study of how these forces could affect primary care working conditions—especially in FQHCs and other safety-net clinics.”

Factors, such as quick EHR adoption, coverage expansions under the Affordable Care Act, and medical home transformations, are all likely stressors resulting in worsening working conditions in health centers, researchers pointed out.

As FQHCs transition to value-based care, health center leaders also should be aware that working condition measures are likely related, researchers added.

“We observed simultaneous, similar changes in multiple measures of working conditions—a result consistent with previous studies documenting strong associations between measures of clinician and staff experience, job satisfaction, and work environments in safety-net clinics,” they wrote. “Taken together, these findings suggest that professional satisfaction, work experience, and clinic culture are likely to change in unison.”