NOVEMBER 2021 Solving Shortages: A Snapshot of the Temporary Workforce in California's Safety-Net Hospitals and Clinics Overview Solving Shortages Solving Shortages A Snapshot of the Temporary Workforce in California's Safety- In the health care system, safety-net facilities - a patchwork of programs and providers that serves Net Hospitals and Clinics Californians with low incomes - struggle with recruiting and retaining staff. These facilities may be more susceptible to provider shortages because of size, location, and pay competition. Given these staffing challenges, the temporary workforce can fulfill short-term needs. Safety-net hospitals are more likely to Contents utilize registry nurses to fill staffing gaps, and high-registry-use safety-net hospitals are more likely to 2 Safety-Net Hospitals be rural and critical access hospitals. Safety-net clinics are also more likely to utilize contract physicians than other types of contract providers. This snapshot outlines data on key characteristics of vacancies, 4 RN Staffing perceived recruitment challenges, and hiring of registry and contract providers in the safety net. 8 Registry Use The data used for this snapshot came from the following sources: 17 Safety-Net Clinics ➤ Departmentof Health Care Access and Information (formerly the Office of Statewide Health Planning and Clinician Staffing and Development) hospital data were used to analyze hospital employment of temporary nursing 21 Appendix personnel. ➤ The Hospital Association of Southern California's quarterly survey of hospital human resources managers was utilized to assess hospital employment, turnover, and vacancies. ➤ The most recent University of California, San Francisco (UCSF) survey of hospital chief nursing officers (PDF) provided information about perceptions of the registered nurse labor market in their area, hiring of newly graduated nurses, and use of temporary and traveling nurses. ➤ Department of Health Care Access and Information Annual Utilization Reports of Primary Care Clinics were used to analyze clinic staffing, including of contract personnel, at licensed community and free clinics. For more information about the data sources, please see the appendix. CALIFORNIA HEALTH CARE FOUNDATION 1 Defining California Safety-Net Hospitals Solving Shortages Solving Shortages Safety-Net Hospitals To categorize hospitals as safety-net hospitals, the authors first identified hospitals that were county government operated, rural, or critical access,* as well as hospitals that were in the top quartile of percentage Medi-Cal and There is no universal indigent patient days, percentage of charity and bad debt revenue, and percentage of disproportionate share consensus on how to define payments. This resulted in a list of 150 hospitals. The authors then narrowed this list to the hospitals most important to safety-net hospitals. providing services to Californians without insurance and those with low incomes: ➤ All county hospitals ➤ Hospitals that were in the top quartile for at least two of the percentage Medi-Cal and indigent patient days, percentage charity and bad debt revenue, or percentage disproportionate share payments ➤ Hospitals that were critical access hospitals and in the top quartile for at least one of the following: percentage Medi-Cal and indigent patient days, percentage charity and bad debt revenue, or percentage disproportionate share payments. These criteria identified 99 hospitals that the authors categorized as "safety-net hospitals" in this analysis. The remaining 51 hospitals from the initial list were placed in an "intermediate" category, and 174 hospitals were labeled "non-safety-net." * "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 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. CALIFORNIA HEALTH CARE FOUNDATION 2 Characteristics of California Safety-Net Hospitals vs. Other Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot RN Staffing of the Safety-net hospitals tended SAFETY-NET INTERMEDIATE NON-SAFETY-NET CHARACTERISTIC (n = 99) (n = 51) (n = 174) to be smaller than non-safety- Average available beds 197.5 189.3 259.5 net hospitals, with an average Average staffed beds 136.4 116.9 163.9 of 136.4 staffed beds versus Nonprofit religious hospital 7.1% 9.8% 12.1% 163.9 staffed beds. Nonprofit secular corporation 25.3% 47.1% 61.5% Safety-net hospitals were Nonprofit other type 2.0% 7.8% 3.4% also more often controlled For-profit partnership 3.0% 2.0% 2.9% For-profit corporation 22.2% 19.6% 16.7% by a for-profit corporation County hospital 18.2% 0.0% 0.0% (22.2% vs. 16.7%) than non- District hospital 22.2% 13.7% 3.4% safety-net hospitals and less Rural hospital 17.2% 21.6% 0.0% often controlled by nonprofit Critical access hospital 28.3% 7.8% 0.0% secular corporations (25.3% Medi-Cal and indigent as percentage of patient days 57.6% 39.5% 21.0% vs. 61.5%) or religious Charity and bad debt as percentage of gross revenue 2.9% 2.3% 1.0% organizations (7.1% vs. Disproportionate share payments as percentage of gross revenue 1.8% 0.2% 0.01% 12.1%). Source: Hospital Annual Financial Disclosures (2018-19), Dept. of Health Care Access and Information. CALIFORNIA HEALTH CARE FOUNDATION 3 Average RN Vacancy Rates, California Safety-Net vs. Non- Safety-Net Hospitals, Fall 2018 Solving Shortages Solving Shortages A Snapshot RN Staffing of the Registered nurse (RN) vacancy Staff + New Graduate RN rates represent the number of 3,767 3,089 5.2% unfilled positions relative to all possible RN positions within 14.7% each department. A higher vacancy rate suggests greater Operating Room RN difficulty in filling open 5.3% positions. In the fall quarter of 2018, RN vacancy rates were 11.8% higher for California safety-net hospitals than other hospitals Critical Care RN ■ Non-Safety-Net for every department, with 3.7% the highest vacancy rates ■ Safety-Net for emergency department 10.3% (20.6%) and general staff nurses (including newly Emergency Department RN graduated RNs) (14.7%). 5.4% 20.6% Labor and Delivery RN 3.9% 7.3% 0 5 10 15 20 25 Notes: Analysis includes 160 non-safety-net hospitals and 35 safety-net hospitals. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Quarterly Vacancy and Turnover Survey (Fall 2018), Hospital Assn. of Southern California. CALIFORNIA HEALTH CARE FOUNDATION 4 Perceived Demand for RNs, California Safety-Net vs. Non- Safety-Net Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot RN Staffing of the Safety-net hospitals in 3.0% 4.2% California more often 4.2% reported that they faced high 10.0% demand with difficulty filling open positions for registered 41.7% ■ Demand Less Than Supply nurses (RNs) than did other ■ Balanced Market 51.7% hospitals (50.0% vs. 33.3%) ■ Some Difficulty Filling Open Positions and less often reported a balanced labor market (4.2% ■ High Demand, Difficult to Fill Positions vs. 10.0%). 50.0% 33.3% Non-Safety-Net Safety-Net (n = 60) (n = 24) Note: Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Lela Chu and Joanne Spetz, Survey of Nurse Employers in California, Fall/Winter 2018-19, UCSF, April 23, 2020. CALIFORNIA HEALTH CARE FOUNDATION 5 Perceived Difficulty Filling Positions, California Safety-Net vs. Non-Safety-Net Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot RN Staffing of the Percentage Reporting "High Demand: Difficult to Fill Open Positions" California safety-net hospitals Perioperative RNs were more likely to report 62.5% difficulty filling positions for 72.7% direct care registered nurses (RNs) compared with other Critical Care RNs other hospitals. However, 47.2% compared with other 70.0% hospitals, safety-net hospitals were less likely to report Emergency Department RNs difficulty filling non-direct care 39.6% RN positions. ■ Non-Safety-Net 50.0% ■ Safety Net Labor and Delivery RNs 54.6% 61.1% Non-Direct Care RNs (e.g., managers) 27.1% 21.7% Nurse Practitioners 31.3% 26.7% 0 10 20 30 40 50 60 70 Notes: Analysis includes 60 non-safety-net and intermediate hospitals and 24 safety-net hospitals. Please see "Defining California Safety-Net Hospitals" 80 on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Lela Chu and Joanne Spetz, Survey of Nurse Employers in California, Fall/Winter 2018-19, UCSF, April 23, 2020. CALIFORNIA HEALTH CARE FOUNDATION 6 Distribution of Average Hourly Rates of Staff Registered Nurses in California Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot RN Staffing of the On average, California safety- ALL HOSPITALS SAFETY-NET INTERMEDIATE NON-SAFETY-NET (N = 290) (n = 98) (n = 51) (n = 141) net hospitals paid their staff Average $55.44 $48.82 $55.77 $59.92 registered nurses lower hourly Standard Deviation 13.65 10.65 12.53 14.11 rates ($48.82) compared 25th Percentile $45.93 $43.27 $45.68 $50.61 to intermediate hospitals 50th Percentile (median) $53.66 $47.17 $53.68 $56.78 ($55.77) and non-safety-net 75th Percentile $62.62 $54.90 $63.12 $70.93 hospitals ($59.92). Notes: Some hospitals did not report average hourly rates for RNs and thus are not included in the table. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 7 Use of Registry Nurses in California Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the California safety-net hospitals ALL HOSPITALS SAFETY-NET INTERMEDIATE NON-SAFETY-NET CHARACTERISTIC (N = 324) (n = 99) (n = 51) (n = 174) used more registered nurse Average 7.6% 9.6% 8.2% 6.2% (RN) registry hours than their Standard Deviation 0.102 0.15 0.104 0.057 non-safety-net counterparts 25th Percentile 2.1% 2.2% 1.8% 2.2% (9.6% of total RN staffing on 50th Percentile (median) 5.3% 5.3% 5.0% 5.3% average vs. 6.2%). 75th Percentile 9.2% 12.0% 9.6% 8.7% Note: Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 8 Distribution of Average Hourly Rates of Registry Nurses in California Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the Similar to the pattern ALL HOSPITALS SAFETY-NET INTERMEDIATE NON-SAFETY-NET (N = 266) (n = 86) (n = 48) (n = 132) observed for staff nurse hourly Average $76.66 $71.69 $76.39 $79.99 rates, California safety-net Standard Deviation 20.24 19.16 20.27 20.39 hospitals also had the lowest 25th Percentile $64.94 $59.91 $62.25 $69.66 average hourly rates for 50th Percentile (median) $77.60 $74.65 $75.16 $81.01 registry or traveling nurses 75th Percentile $89.21 $85.00 $89.79 $93.31 ($71.69) than intermediate hospitals ($76.39) and non- safety-net hospitals ($79.99). Notes: These rates are not reported for hospitals that did not employ registry nurses, and thus the number of hospitals included is lower than for staff registered nurse rates. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 9 High- vs. Low-Registry-Use Hospitals in California, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the Safety-net hospitals make ALL HOSPITALS SAFETY-NET INTERMEDIATE NON-SAFETY-NET (N = 324) (n = 99) (n = 51) (n = 174) up a larger proportion of Top Quartile of High-Registry-Use hospitals classified as "high 81 (25.0%) 33 (33.3%) 13 (25.5%) 35 (20.1%) Hospitals registry use," which means All Other Hospitals 243 (75.0%) 66 (66.7%) 38 (74.5%) 139 (79.9%) those hospitals for which the percentage of registred nurse (RN) hours provided by registry nurses is greater than the statewide 75th percentile (33.3% vs. 20.1%). Note: Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 10 Characteristics of California High-Registry-Use Safety-Net Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the Rural and Critical Access Hospital Status High-registry-use safety-net hospitals in California were 33.3% more often rural (24.2% vs. ■ Safety-Net, Not High-Registry 13.6%) and more often critical ■ Safety-Net, High-Registry access hospitals (33.3% vs. 25.8%) compared with other safety-net hospitals that 25.8% were not high-registry-use 24.2% hospitals. High-registry-use safety-net hospitals were also more often operated by investor-owned corporations, nonprofit corporations, and hospital districts (not shown). 13.6% Rural Hospital Critical Access Hospital Notes: Based on 66 non-high-registry safety-net hospitals and 33 high-registry safety-net hospitals. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 11 California High-Registry-Use Safety-Net Hospitals: FTE Employment of Staff and Registry Nurses, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the High-registry-use safety-net 307.2 hospitals on average had fewer full-time equivalent ■ Non-Safety-Net (FTE) staff nurses (133.7 FTEs) ■ Safety-Net, Not High-Registry than safety-net hospitals that did not fall into the high- 238.8 ■ Safety-Net, High-Registry registry-use category (238.8 FTEs) and non-safety-net hospitals (307.2 FTEs). This is not surprising given that safety-net hospitals that have a high use of registry nurses 133.7 tend to be smaller than safety- net hospitals that do not have high use of registry nurses. However, even with their smaller size, high-registry- use safety-net hospitals used more registry registered nurse 21.3 24.0 (RN) FTEs than non-safety-net 10.5 hospitals (24.0 FTEs vs. 21.3 FTEs). Staff RN FTEs in Daily Services Registry RN FTEs in Daily Services Notes: Based on 172 non-safety-net hospitals, 66 non-high-registry safety-net hospitals, and 33 high-registry safety-net hospitals. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 12 Average RN Vacancy Rates in California High-Registry-Use Safety-Net Hospitals, 2018 Solving Shortages Solving Shortages A Snapshot Registry Use of the High-registry-use safety- Staff + New Graduate net hospitals did not have 5.6% consistently higher registered ■ Safety-Net, Not High-Registry nurse (RN) vacancy rates than 6.5% other safety-net hospitals. ■ Safety-Net, High-Registry However, for emergency Operating Room RN department positions, there 15.2% was a higher vacancy rate for high-registry-use safety-net 4.6% hospitals (46.4% vs. 10.1%). This is consistent with data Critical Care RN indicating that safety-net 11.6% hospitals in general had the highest vacancy rates in the 8.0% emergency department. Emergency Department RN 10.1% 46.4% Labor and Delivery RN 7.6% 6.7% 0 10 20 30 40 Notes: Thirteen of the 40 safety-net hospitals that responded to the HASC survey were high-registry users. Please see "Defining California Safety-Net 50 Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Healthcare Workforce Survey, Fall 2018, Hospital Assn. of Southern California. CALIFORNIA HEALTH CARE FOUNDATION 13 Perceived Demand for RNs Overall in California High- Registry-Use Safety-Net Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the High-registry-use safety- 7.1% 10.0% net hospitals in California 17% reported greater difficulty filling open registered nurse 17% 42.9% 40.0% ■ Demand Less Than Supply (RN) positions than other safety-net hospitals, with ■ Balanced Market 50% saying they faced high 35% ■ Some Difficulty Filling Open Positions demand and that it was 19% ■ High Demand, Difficult to Fill Positions difficult to fill positions, while no non-high-registry-use hospitals reported this level of difficulty filling positions. 24% 50.0% 50.0% 29% 31% Safety-Net, Safety-Net, Not High-Registry High-Registry (n = 14) (n = 10) Note: Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Lela Chu and Joanne Spetz, Survey of Nurse Employers in California, Fall/Winter 2018-19, UCSF, April 23, 2020. CALIFORNIA HEALTH CARE FOUNDATION 14 Perceived Difficulty Filling Positions, California High-Registry- Use Safety-Net Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the Percentage Reporting "High Demand: Difficult to Fill Open Positions" High-registry-use safety-net Perioperative RNs hospitals more often reported 69.2% high demand for registered 77.8% nurses (RNs) and also more often reported difficulty filling Critical Care RNs positions for RNs compared 61.5% with other other safety-net 85.7% hospitals, particularly for perioperative RNs, critical Emergency Department RNs care RNs, labor and delivery 50.0% RNs, and nurse practitioners. ■ Safety-Net, Not High-Registry 50.0% ■ Safety-Net, High-Registry Labor and Delivery RNs 50.0% 83.3% Non-Direct Care RNs (e.g., managers) 23.1% 20.0% Nurse Practitioners 12.5% 42.9% 0Notes: Based on 14 non-high-registry 20 safety-net hospitals and4010 high-registry safety-net hospitals. 60 Please see "Defining California 80 Safety-Net 100 Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Lela Chu and Joanne Spetz, Survey of Nurse Employers in California, Fall/Winter 2018-19, UCSF, April 23, 2020. CALIFORNIA HEALTH CARE FOUNDATION 15 Average Spending on Registered Nurse Staffing in California Hospitals, 2018–19 Solving Shortages Solving Shortages A Snapshot Registry Use of the In millions California safety-net SAFETY-NET, NOT SAFETY-NET, NON-SAFETY-NET HIGH-REGISTRY HIGH-REGISTRY hospitals with high registry Staff RN Expenditures $32.2 $21.1 $12.3 expenditures averaged Registry RN Expenditures $2.5 $1.5 $3.1 $12.3 million per year in Percentage of Overall RN Expenditures 7.8% 6.9% 24.9% staff registered nurse (RN) Spent on Registry RNs wages and nearly $3.1 million per year in registry nurse expenditures, or 24.9% of total expenditures. Other safety-net hospitals had higher spending on staff nurses but less spending on registry nurses, or 6.9% of total expenditures. Note: Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Hospital Annual Financial Disclosures (2018–19), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 16 Defining California Safety-Net Clinics Solving Shortages Solving Shortages A Snapshot Safety-Net of the Clinics California clinics are included in this snapshot if they are either community clinics or free clinics, classifications and Clinician Staffing assigned by the Office of Statewide Health Planning and Development (now the Department of Health Care Access and Information). Community and free clinics serve patients with low incomes and Medicaid coverage, California clinics are included and thus are considered safety-net providers. Clinics identified as nonoperational during 2019, clinics with in this snapshot if they are missing data across all metrics, as well as clinics with duplicate entries spanning two reporting periods were classified as either community removed. Using these criteria, the overall data set was narrowed to 1,161 clinics. clinics or free clinics. CALIFORNIA HEALTH CARE FOUNDATION 17 Contract Provider Staffing in California Safety-Net Clinics, 2019 Solving Shortages Solving Shortages A Snapshot Safety-Net of the Clinics and Clinician Staffing Only 39.4% of all clinics used PHYSICIANS, PHYSICIANS NPS PAS NPS & PAS RNS LVNS RNS & LVNS TOTAL any contract providers. Of COMBINED COMBINED those, clinics hired more Clinics with Contract Providers (N = 1,161) contract physician full-time Number of Clinics with equivalents (FTEs) than nurse 374 174 132 441 24 8 29 457 Contract Providers Percentage of Clinics practitioner (NP), physician with Contract Providers 32.2% 15.0% 11.4% 38.0% 2.1% 0.7% 2.5% 39.4% assistant (PA), registered nurse Relative to All Clinics (RN), and licensed vocational Contract Provider Staffing (in FTEs) nurse (LVN) FTEs on average Average 0.31 0.08 0.04 0.43 0.01 0.01 0.02 0.45 (0.31 FTEs) and at the 75th Standard Deviation 1.77 0.35 0.25 1.96 0.11 0.14 0.18 1.97 percentile (0.10 FTEs). 75th Percentile 0.10 0.00 0.00 0.23 0.00 0.00 0.00 0.28 Maximum 44.95 6.60 4.84 45.20 1.63 4.55 4.55 45.20 Notes: The combined data represent unique clinics - that is, clinics that used more than one type of contract provider were counted only once. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Annual Utilization Reports of Primary Care Clinics (2019), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 18 Contract Provider Staffing in California Safety-Net Clinics, 2019 Solving Shortages Solving Shortages A Snapshot Safety-Net of the Clinics and Clinician Staffing In FTEs Out of 1,161 safety-net clinics PHYSICIANS, PHYSICIANS NPS PAS NPS & PAS RNS LVNS RNS & LVNS TOTAL in California, 291 represent COMBINED COMBINED the top quartile of clinics High-Contract-Use 341.32 85.45 50.61 477.38 16.00 6.55 22.55 499.93 that used the most contract (n = 291) (%) (95.7%) (97.8%) (97.2%) (96.2%) (99.3%) (99.2%) (99.3%) (96.3%) providers in terms of FTEs Non-High-Contract-Use 15.50 1.94 1.48 18.92 0.12 0.05 0.17 19.09 (n = 870) (%) (4.3%) (2.2%) (2.8%) (3.8%) (0.7%) (0.8%) (0.7%) (3.7%) and are referred to as "high- All Clinics contract-provider users" in 356.82 87.39 52.09 496.30 16.12 6.60 22.72 519.02 (N = 1,161) this snapshot. These 291 clinics utilized 96.3% of all contract provider FTEs. Notes: NP is nurse practitioner; PA is physician assistant; RN is registered nurse; LVN is licensed vocational nurse. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Annual Utilization Reports of Primary Care Clinics (2019), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 19 Contract Provider Staffing in High-Contract-Use Safety- Net Clinics, California, 2019 Solving Shortages Solving Shortages A Snapshot Safety-Net of the Clinics and Clinician Staffing Contract Provider Staffing in High-Contract-Provider-Use Safety-Net Clinics (in FTEs) For all California safety-net PHYSICIANS, PHYSICIANS NPS PAS NPS & PAS RNS LVNS RNS & LVNS TOTAL clinics in the "high-contract- COMBINED COMBINED provider-use" category, Average 1.17 0.29 0.17 1.64 0.05 0.02 0.08 1.72 physicians were the most Standard Deviation 3.39 0.66 0.47 3.65 0.22 0.28 0.35 3.65 common contract provider 50th Percentile (median) 0.48 0.00 0.00 0.80 0.00 0.00 0.00 0.86 type on average (1.17 FTEs) and at the median in terms of FTEs. High-Contract-Provider-Use Safety-Net Clinics (N = 291) Additionally, physicians PHYSICIANS, PHYSICIANS NPS PAS NPS & PAS RNS LVNS RNS & LVNS TOTAL were the most used contract COMBINED COMBINED provider type across the 291 Number of Clinics with 240 134 100 276 23 7 28 291 high-contract-use clinics. Of Contract Providers Percentage of Clinics with 82.5% 46.0% 34.4% 94.8% 7.9% 2.4% 9.6% 100.0% these 291 clinics, 240 (82.5%) Contract Providers Relative hired contract physicians. to All High-Use Clinics Notes: NP is nurse practitioner; PA is physician assistant; RN is registered nurse; LVN is licensed vocational nurse. The combined data represent unique clinics - that is, clinics who used more than one type of contract provider were counted only once. Please see "Defining California Safety-Net Hospitals" on page 2 and "Appendix: Data Sources" on page 21 for details on the criteria authors used to categorize hospitals for this snapshot and how data were accessed. Source: Annual Utilization Reports of Primary Care Clinics (2019), Dept. of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development). CALIFORNIA HEALTH CARE FOUNDATION 20 Appendix: Data Sources Solving Shortages Solving Shortages A Snapshot of the Four key data sources were used as part of this analysis. Data from the Department of Health Care Access and Information (formerly the Office of Statewide Health Planning and Development) were used to analyze hospital employment of temporary nursing personnel. The most recent data available are for hospital fiscal years ending between July 1, 2018, and June 30, 2019. The data thus span 2017 through 2019, depending on when hospitals' fiscal years ended. The Hospital Association of Southern California (HASC) conducts a quarterly survey of hospital human resources managers about hospital employment, turnover, and vacancies. The HASC survey asks respondents to report the numbers of full-time, part-time, and per-diem registered nurses (RNs) they employ in each of several units and departments. The survey also requests information about the numbers of vacancies in each of these departments. These data were analyzed from fall 2018 to align with the Department of Health Care Access and Information data. Forty of the 241 hospitals in the HASC survey were safety-net hospitals. The University of California, San Francisco (UCSF) conducts a survey of hospital chief nursing officers (CNOs) every 12–18 months. The CNO survey asks respondents to report their perceptions of the RN labor market in their area, hiring of newly graduated nurses, and use of temporary and traveling nurses. The most recent data are from fall/winter 2018–19, with 125 respondents. Thirty of the 125 hospitals in the UCSF CNO survey were safety-net hospitals. Data from the Annual Utilization Reports of Primary Care Clinics, which are reported by licensed community and free clinics to the Department of Health Care Access and Information, were used to analyze clinic staffing, including of contract personnel. The most recent data available are for the calendar year 2019. These data provide information about the number of full-time equivalent staff for physicians, physician assistants, nurse practitioners, nurse midwives, behavioral health professionals, clinical support staff (e.g., licensed vocational nurses, medical assistants, registered nurses), and administrative staff. For each of the types of staff, the number of salaried, contract, and volunteer full- time equivalents are reported. The data set also has information about the services provided by the clinic, insurance coverage of patients, race/ethnicity of patients, age distribution of patients, income of patients, and languages spoken by staff and patients. Additional information is available about the numbers of encounters and contacts by type of provider, principal diagnosis, and type of service provided (e.g., evaluation and management, counseling, vaccination). Community and free clinics serve patients with low incomes and Medicaid coverage and thus are considered to be safety-net providers. CALIFORNIA HEALTH CARE FOUNDATION 21 About the Authors This snapshot was authored by Joanne Spetz, PhD, director of the Philip R. Lee Institute for Health Policy Studies, and by Amy Quan, a research analyst at Healthforce Center at UCSF. Spetz is a health economist whose fields of specialty are the health care workforce, organization and quality of health care services, and the evaluation of health care policy and programs. She has conducted studies of the registered nurse, nurse practitioner, and long-term care workforces for nearly 30 years. Quan works on a variety of projects related to the health workforce, researching professions such as registered nurses, physicians, nurse practitioners, and community health workers. She is a master of public health candidate at UC Berkeley. About CHCF The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. CALIFORNIA HEALTH CARE FOUNDATION 22