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6 Education and Training Like allied health itself, the education and training of allied health workers are varied, complex, and changing. Three speakers addressed components of the education and training system while acknowledging that many things must change in parallel to respond to changing needs. M. LaCheeta McPherson, executive dean of Health and Legal Studies at El Centro College in Dallas and president of the board of directors for the Commission on Accreditation for Allied Health Education Programs (CAAHEP), described the challenges and opportunities of accreditation in allied health. Susan Skillman, deputy director of the Center for Health Workforce Studies and the Rural Health Research Center (RHRC) of the University of Washington, presented preliminary results from a research project that is looking at access to allied health programs at community colleges and in rural areas. Maria Flynn, vice president of the Building Economic Opportunity Group for Jobs for the Future, described an effort to “grow your own” allied health workers by providing frontline workers1 with on-the-job and classroom training. 1 Frontline workers are those individuals who may serve as the first or most frequent point of contact for patients in the health care system, and provide direct patient care and client services (RWJF, 2007). Examples include home health aides, medical assistants, laboratory technicians, and substance abuse workers (Jobs to Careers, 2011a). 39

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40 ALLIED HEALTH WORKFORCE AND SERVICES ACCREDITATION OF ALLIED HEALTH PROGRAMS CAAHEP was organized as a separate organization in 1994 after origi- nating in the Committee on Allied Health Education Accreditation of the American Medical Association (AMA). It is the largest programmatic and specialized accreditor in the health sciences field in the United States. McPherson stated that CAAHEP currently accredits more than 2,200 programs across the country in 1,300 sponsoring institutions, including colleges and universities as well as technical schools. CAAHEP accredits programs in 23 health sciences occupations: 1. Advanced cardiac sonographer 2. Anesthesia assistant 3. Anesthesia technology 4. Cardiovascular technology 5. Cytotechnology 6. Diagnostic medical sonography 7. Electroneurodiagnostic technology 8. Emergency medical technician–paramedic 9. Exercise physiology 10. Exercise science 11. Kinesiotherapy 12. Lactation consultant 13. Medical assisting 14. Medical illustration 15. Orthotic and prosthetic technician 16. Orthotist and prosthetist 17. Perfusion 18. Personal fitness training 19. Polysomnographic technology 20. Recreational therapy 21. Specialist blood bank technology/transfusion 22. Surgical assisting 23. Surgical technology This is a very diverse list, which creates both advantages and chal- lenges, observed McPherson. First, the diversity of the fields accredited by CAAHEP is reflected in the diversity of the commission itself, which in- cludes educators, professionals from societies and organizations, represen- tatives of the Department of Defense, members of the general public, and recent graduates of allied health programs. The 15 members of the board of directors, who establish policies for the commission, are drawn from the more than 250 commissioners.

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41 EDUCATION AND TRAINING Each profession has a committee on accreditation consisting of people who represent that profession. These committees work directly with the in- dividual programs to develop and enforce standards based on the CAAHEP model. CAAHEP is a third-body accreditor with a board that is inde- pendent of the committees of accreditation. The board looks carefully at recommendations made by the boards of the committees on accreditation, raising questions about issues. CAAHEP also draws on its diverse member- ship to maintain standards. For example, it holds two workshops a year to bring the professions together and address common issues. Though the professions represented through the programs it accredits are very different, they have common concerns, said McPherson. For ex- ample, they have many of the same legal and organizational issues. They also are addressing new questions raised by distance education and the increasing number of programs that are online. “How are they different from a brick-and-mortar program?” asked McPherson. “Should there be any difference, and how do we measure those differences? It’s not unique to just one profession. It spans all of these professions.” The professions may not always agree on outcomes, McPherson emphasized. But they listen to each other and have the option of using each other’s models, so they do not have to reinvent the wheel. CAAHEP encourages collaborations among levels of education. Some of the programs it accredits are at the associate’s degree level while others are at the master’s degree level. Also, representing multiple educational lev- els can promote career pathways, said McPherson. A student who starts off as a medical assistant might eventually want to move into sonography or nursing, and the common focus and common voice provided by CAAHEP can help that process. Several years ago CAAHEP decided to focus on emergency prepared- ness. Using a government grant, it asked how emergency preparedness can be included in the curricula of all the programs it accredits. “One may think that emergency preparedness may not always be applicable to all 23 profes- sions in the programs we accredit. For example, one of the professions is a medical illustrator. How in the world could a medical illustrator work in emergency preparedness within the curriculum? In fact, the medical illustra- tors were the first people to write that particular topic into the curriculum and get it approved.” CAAHEP provides a template with which programs can write their own standards, and it was within the standards template that member professions addressed emergency preparedness. “We saw that emergency preparedness was, indeed, an obligation of all people in health careers and all phases of health readiness.” CAAHEP also provides training for site visitors. Accreditors’ greatest impact is at the program level during a site visit, said McPherson, “and it can be really great or it can be absolutely horrible.” CAAHEP provides site

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42 ALLIED HEALTH WORKFORCE AND SERVICES visitors with the information and background they need to be effective. It also offers assistance to program directors, information on outcome mea- sures, and grants to improve the accreditation process. CAAHEP faces several challenges, said McPherson. The first is that allied health is like an iceberg. People see a small portion of it, but it has a huge part that people tend not to see. The commission is also struggling with the problems uncovered at some for-profit schools. CAAHEP offers only programmatic accreditation. Institutional accreditation is typically performed by a national or regional accreditor. Many for-profit schools use national accreditation as a way of becoming accredited and recognized to get federal funding. Unfortunately, said McPherson, some national accredi- tors are not as strict in their requirements as other accreditors. The Depart- ment of Education and the Council for Higher Education Accreditation (CHEA) have issued calls for accreditation to become more transparent, and “If we don’t do it, it’s going to be forced upon us,” said McPherson. For example, the CHEA is asking to see the reasons for accreditation deci- sions. “That’s going to be a challenge for accreditors in trying to explain why accreditation decisions were made,” said McPherson. The allied health professions can come together to achieve mutual benefits. They also need to be more stringent in the requirements for their programs, and CAAHEP can help them achieve both goals, McPherson concluded. COMMUNITY COLLEGES AND THE EDUCATION OF ALLIED HEALTH PROFESSIONALS IN RURAL AREAS The RHRC at the University of Washington, with support from the Health Resources and Services Administration’s Office of Rural Health Policy, has been studying • w hy community colleges are important to the allied health work- force and to rural communities, • w hich allied health occupations are most relevant to rural areas and can be educated in community colleges, • h ow many allied health programs are (and are not) located within commuting distance of rural populations, and • h ow many small rural hospitals are located near allied health edu- cation programs. The yet-unpublished study has drawn expert input from the American Association of Community Colleges, the National Network of Health Ca- reer Programs in Community Colleges, and the Rural Community College Alliance. Its main data source has been the U.S. Department of Education’s

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43 EDUCATION AND TRAINING Interdisciplinary Postsecondary Education Data System, and it has used definitions of allied health programs from the U.S. Department of Educa- tion’s Classification of Instruction Programs. Community colleges are extremely important to rural economic devel- opment, said Skillman, and in many rural communities they are the only higher education institutions accessible to their populations. “They work generally with their communities, so to the extent to which rural folks can train in their own communities, it will greatly increase the likelihood that they will work in those communities,” said Skillman. Furthermore, many students in allied health education programs can be job ready after com- pleting community college programs. For this reason, many rural health care programs use a “grow your own” approach. They attract people from rural areas and train them in rural areas to increase the chances that they will stay in those areas. Skillman and her colleagues developed a list of 18 “rural-relevant allied health occupations” that can be job ready after training at a community college: 1. Dental assistant 2. Dental hygienist 3. Health information/medical records technician 4. Medical assistant 5. Occupational therapist assistant 6. Pharmacy technician/assistant 7. Physical therapist assistant 8. Veterinary technician/assistant 9. Cardiovascular technologist 10. Electrocardiograph technician 11. EMT/paramedic 12. Nuclear medical technologist 13. Radiation therapist 14. Respiratory care therapist 15. Surgical technologist 16. Diagnostic sonographer/ultrasound technician 17. Radiographer 18. Clinical/medical laboratory technician Education for these professions can also occur at institutions other than community colleges, or training can be on the job for some. But com- munity colleges play a major role in educating people in these occupations. For example, half of all medical assistants in 2000–2008 were educated in community colleges, while 72 percent of surgical technologists and 82 percent of physical therapy assistants were educated in community colleges.

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44 ALLIED HEALTH WORKFORCE AND SERVICES Skillman and her colleagues mapped community colleges that had at least one of these rural-relevant 18 allied health programs to find areas that lacked access to these programs. Not surprisingly, large areas of the United States, especially in the Midwest and West, did not have community college allied health programs. Overall, they found, 78 percent of rural popula- tions in the country are within a 60-minute drive of a community college program with at least one of those 18 allied health occupations, with a lower percentage in smaller towns. In isolated rural areas in the West, only 35 percent are within an hour drive of a community college allied health education program. By occupation, 55 percent of rural populations nationwide are within a 60-minute drive of a program for medical assistants, but only 35 percent nationwide of rural populations are within a 60-minute drive of a dental hygienist program. “We are hoping that this can be used by individual programs and educators to make arguments for ways to expand education opportunities and identify gaps,” said Skillman. As a proxy for demand data, the researchers looked at hospitals, since they are major employers of the health workforce. For critical access hospitals, 33 percent were within a 60-minute drive of a community college with a surgical technologist pro- gram. However, the percentages are lower for other programs, and in some parts of the country the percentages are quite low. Identifying these kinds of gaps is essential for education program plan- ning, according to Skillman. “We need data to begin getting the right people at the right places at the right times.” Rural communities often struggle to get the health workforce they need. Working with local community colleges is one way for health care organizations to address these needs. But health occupations education is expensive, and most students need on-site clinical training, which is more difficult to arrange in rural areas than urban areas. Community colleges also must compete with health care institutions and with 4-year institutions and medical schools for faculty, which limits their ability to offer allied health programs. Distance education could alleviate many of the problems of rural allied health education programs, said Skillman, but much more information is needed on online programs. Also, clinical training can be difficult to ar- range with distance education. Simulations may be able to substitute for some clinical training, but more evidence is needed on its use in allied health education. Collaboration is needed among all of the different stakeholders in the system to address these and other issues. CAREER ADVANCEMENT THROUGH WORK-BASED LEARNING Frontline workers fill about half of all health care jobs and deliver most of the nation’s direct care and health services. Leading-edge employers are

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45 EDUCATION AND TRAINING realizing the potential of this workforce to deliver more and better care, fill critical vacancies in professional positions, and meet the needs of today. Frontline workers tend to be female; they are often English language learn- ers, especially in some parts of the country; they traditionally have high turnover rates; and, they tend to have little, if any, postsecondary education. “In fact, a lot of them may have had very difficult experiences with formal education in the past,” said Flynn. Employers tend to put most of their training resources into the higher rungs of the career ladder, so much more funding goes to physician train- ing than to training for frontline workers, said Flynn. But training at the frontline level can reduce turnover and improve the quality of care. Such training “can make these frontline workers more a part of the care team and improve the quality of care as a result.” For example, Flynn noted the Virginia Mason Hospital and Medical Center in Seattle did an analysis of the high costs of training new medi- cal assistants in their facilities. These costs were attributed to high annual turnover rates, the number of days to fill a single medical assistant position, and the costs related to the temporary employment of medical assistants during this process. The hospital found that a much more cost-effective way to meet this need was to work with a local community college using a “grow your own” model. Flynn acknowledged that training frontline workers is not easy. Many of them have basic skill deficiencies, so they need assistance and remedial work to enter college-level courses. Also, many employers lack transparent career pathways, so individuals who come in at lower rungs of the career ladder do not know how to move up that ladder. Many educational institu- tions do not design their program offerings in ways that make them easy to access for adult learners or for people who are working full time, and many workers cannot afford to leave the workforce to pursue full-time education. Finally, some regulatory bodies have been reluctant to accept alternative ways of education and training. Jobs to Careers Flynn described in some detail the Jobs to Careers initiative, which was funded by the Robert Wood Johnson Foundation, the Hitachi Foundation, and the U.S. Department of Labor (Jobs to Careers, 2011b). They invested about $16 million over 4 years to promote skill and career development in frontline health care workers. At 17 sites around the country, the initiative served about 900 individuals. It worked with 34 employers, ranging from hospitals in urban and rural areas to community health centers, behavioral health facilities, and long-term care facilities. The initiative also worked with about two dozen educational institutions, primarily community col-

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46 ALLIED HEALTH WORKFORCE AND SERVICES leges, along with local workforce investment boards or union training and upgrading bodies. The key strategies were testing models of work-based learning, design- ing systems to support learning and career growth of frontline workers, and developing partnerships of employers, educational institutions, and others. “Employers or community colleges can’t do this on their own,” said Flynn. Through work-based learning, frontline employees master occupational and academic skills in the course of their job tasks and day-to-day responsibili- ties. The training model is based on the idea of clinicals, preceptors, and other methods common in health care education and training. It uses job responsibilities to achieve learning objectives and measured achievement of specific competencies. Supervisors took on the new role of coach and teacher to guide the workers through the learning process. Mastery was rewarded with academic or industry-recognized credentials. So far the credential attainment rate is about 60 percent, which for this population is fairly high, according to Flynn. Work-based learning is not enough in many cases, so the program included online learning and traditional classroom learning. It also promoted opportunity for reflection and critical thinking among both workers and supervisors. Competencies were drawn from evi- dence-based research and uniformly linked to workplace skills. They were standardized across diverse work settings—such as hospital settings and residential settings—as was the instructional methodology. Attainment of competencies was linked to college credits and career ladder advancement. According to a third-party evaluation, the frontline workers involved in the program gained tangible benefits. They had access to a seamless educational pathway and to college credits and credentials. In Fall River, Massachusetts, for example, individuals going through the program were earning community college credits without having to take a class in the community college. They had increased confidence and job performance, understanding the “why” and not just the “how.” In addition, cohorts of Fall River workers had 100 percent pass rates, and students had the highest test scores in the state of Massachusetts. Employers benefit from the engagement of employees in improving competency-based skills and from increased employee effectiveness and performance. The initiative created a cohesive patient care team and maxi- mized investment in training. Supervisors by and large found the training to be a satisfying and effective part of their job. In Medford, Oregon, Asante Health Systems was so impressed by the initiative that it redirected several hundred thousand dollars from recruiting to investing in its workforce. Many of the hospitals involved with the initiative have changed their policy to pay for tuition for frontline workers, and studies have shown that they did not lose money by doing that. They also have created new posi- tions that include wage increases to motivate workers. An Austin, Texas,

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47 EDUCATION AND TRAINING hospital, for example, created clinical tech assistant level one, two, and three. A person at level three has the option of staying at that level, going into other allied health professions, or following a prenursing track. Interesting issues that arose in the initiative include how to award credit for prior learning, how to use supervisors from the work site as ad hoc fac- ulty, and matching supply with demand for specific occupations. An under- lying need is to learn how to offer core components of the curriculum, such as algebra, medical terminology, or anatomy and physiology, so individuals are ready to progress educationally regardless of how demand changes. DISCUSSION In response to a question about the mismatch between many educa- tional programs and the scientific and technological sophistication of health care workplaces, McPherson observed that one response to changing tech- nology is to require higher educational degrees of workers. Credentialing standards also must change as technologies evolve (e.g., transition in medi- cal imaging from film toward digital technologies). Students must be able to pass their boards to get jobs, which means working with credentialing boards and professional associations to keep curricula up to date. “Degree creep” can be a problem, McPherson said. When a program moves from the associate’s level to the bachelor’s level, entirely different institutions may be involved. On this issue, Skillman added that evidence is for the most part lacking about what degree level produces the best out- come. Furthermore, research will not be entirely sufficient to make these decisions, which means that common sense also must be used. The empha- sis on interprofessional teams requires looking across the team to determine how one profession depends on others and what skill sets are needed. Another workshop participant asked about the potential oversaturation of markets when programs produce too many graduates and people can- not find jobs. Skillman agreed that programs need to be flexible to adjust to regional needs. Working with hospitals, clinics, and other institutions can help them determine the demand for employees. Also, emphasizing core academic subjects can help people move in new directions if neces- sary. McPherson added that community colleges are very aware of the job demand and do adjust their enrollments based on the job markets, assisted by information provided by advisory committees. But the proliferation of for-profit institutions has complicated this process. For-profit institutions can flood a region with people trained in a particular area, particularly in lower-level programs, even when jobs are not available. Flynn mentioned a new technology that can assess a regional labor market and provide up-to-date information on vacancies, required skills, and needed credentialing levels. Jobs for the Future is starting to test this

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48 ALLIED HEALTH WORKFORCE AND SERVICES technology in partnership with community colleges to help them align their program offerings with demand. “It’s very new, but I think it has a lot of potential,” she said. Finally, a question about guidance for students who do not know what kinds of programs and jobs are available led Flynn to mention two efforts: a program to train counselors to make them more aware of career op- portunities, and a virtual career network for health care that will provide information about education providers and job opportunities. Skillman added that the Area Health Education Centers, which began in the 1970s to help support primary care physicians in underserved areas, have evolved to promote career pathways across the spectrum of the health workforce. “This is very much part of their mission.”