One of the great challenges in modern healthcare is how to improve access to health services and medications in remote and underserved communities. Major barriers include financial viability, availability of personnel and transportation.
In particular, capital investment in permanent facilities and equipment can be infeasible due to the cost per person. It can be difficult to find medical professionals to provide full-time care to these communities. And bringing healthcare to remote/rural communities often requires covering large geographic areas that have less-than-desirable infrastructure.
In July, Indiana University professor Jonathan Helm discussed these challenges and potential solutions as part of CARISCA’s Distinguished Lecture Series. The focus of his talk was on mobile healthcare resources.
Mobile resources can provide services that rotate between multiple underserved communities and deliver medications in a more cost-effective manner. They reduce the financial and logistical burden while providing much higher access to care for residents of regions that have historically been lacking.
Examples Helm described included projects to address the critical nursing shortage in the U.S., deliver malaria medication in Malawi and prevent and treat addiction in the Democratic Republic of the Congo.
Addressing the nurse-shortage crisis
Health care facilities globally are facing a nurse-shortage crisis, Helm explained. In the United States, hospitals on average are 10% to 20% short staffed.
“A reason why we’re so short-staffed is that there’s a high turnover rate,” Helm said. “Nurses get overworked, and every year, hospitals lose about 20% of their nursing workforce because of burnout. So we have to be a little bit smarter and a little bit more efficient with how we use our limited resources.”
During COVID, many hospitals relied on nurses who would travel around the country to work under contract at hospitals where the need was greatest, said Helm. These travel nurses are expensive, however. They get paid about three times what a staff nurse makes.
“This is really putting a strain on our health system and our hospitals,” said Helm. “Underserved communities suffer the most because they have smaller hospitals. They can’t afford these kinds of large fluctuations in their budget.”
A lot of small, rural hospitals have been shutting down as a result, Helm noted. That leaves people living in health deserts with no access to a hospital in their community.
To address this challenge in Indiana, Helm and his co-researchers applied a traditional supply chain transshipment model to human resources. Transshipment involves shipping “products” from one destination to another based on demand.
Right nurse, right hospital, right time
The objective was to place the right nurse in the right hospital at the right time, Helm said. The team was able to achieve this goal by creating a dashboard that enabled hospitals to deploy staff nurses to different facilities within a reasonable driving distance, depending on the predicted need.
Key features of the dashboard tool are prediction, allocation and deployment, Helm explained. First, the tool predicts demand at each of 16 hospitals up to three weeks in advance. During the allocation phase, nurses are given a two-week advance notice to be on call for assignment at a specific hospital. Then an optimization algorithm determines the best deployment scenario, and nurses are given 24- to 48-hours’ notice of where they will be placed.
“It’s like the weather,” Helm said. “A typical weather forecast is going to give you a percentage, like 60% chance of rain.
“What if I just tell you, yes it will rain tomorrow or no it won’t rain? Is that as useful as knowing there’s a 60% chance of rain now? That’s exactly what we’re trying to do in predicting demand for health services among the patients in the hospital.”
After a six-week pilot test with 10 nurses, Helm’s model reduced understaffing by 17% and overstaffing by 43%. That resulted in direct savings of about $700,000, mostly from overtime pay.
“Moving beyond Indiana, we’re hoping to change the staffing model so that we’re making better use of existing nurses,” Helm said. “That will reduce the number of times that they’re overloaded and overworked, which means their job satisfaction increases, which increases retention. That results in better patient outcomes and greater patient satisfaction.”
Malaria medication distribution in Malawi
Helm explained during his lecture that the idea for the nurse transshipment model came from a project he worked on in Malawi while pursuing his doctoral studies. More than 110 people a day were dying from malaria in Malawi.
As with nurses in hospitals, the demand for malaria medication fluctuates across time and location. One clinic may have more medication than needed while another is completely out.
“Our goal was to develop a more-effective delivery system and delivery logistics to help get these medications more quickly into the hands of people who are suffering from malaria,” Helm said.
He created a transshipment model similar to what he later did for the Indiana health care system. Initially, medications were shipped to all the clinics and hospitals. Then, based on demand, clinics would ship some of their stock to other facilities with higher need.
“At approximately the same level of cost, we estimate that we could have reduced shortages of medications by about 80%, which is a huge improvement,” Helm said. That was very exciting to us, because to see such a large reduction is kind of uncommon in the supply chain world.”
Addiction prevention and treatment in Congo
Another transshipment project Helm is working on now is in the Democratic Republic of Congo, where a lack of economic opportunities drives youth to gang membership and drug addiction. The number of community workers who provide education and job-training services and medical professionals who provide drug-treatment services is insufficient to meet the need.
Helm is working with the Anglican Church in Aru, using data he has collected, to determine where to put more resources and how to design a transshipment plan. The idea is to move community workers and health care professionals around to various facilities where they are most needed at any given time.
“Transshipment is highly effective, not just for products and services but also for human resources,” Helm said as he concluded his lecture. “It can solve a lot of the problems that we see in limited resource settings, and particularly in health deserts or areas that are more rural and lower resourced. These programs tend to be pretty fair and equitable.”
About the speaker:
Jonathan Helm is a professor in the Kelley School of Business at Indiana University and W.W. Grainger Inc. Faculty Fellow. His research has been broadly implemented in the healthcare industry and published in top-ranked business, medical, analytics and healthcare engineering journals.
He has won upwards of 20 international research awards. In 2024, he won first place in the Innovative Application of Analytics Awards for a project that combines human expertise and machine learning to battle the nursing- shortage crisis.