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Confronting the Diabetes Epidemic

The policy forum of this issue reviews activities to prevent and control diabetes in North Carolina. Topics considered include the epidemiologic characteristics of the diabetes burden, the role of community health workers in diabetes education and care, and the influence of federal and state policies on programs and services for individuals with or at risk for diabetes. Original articles in the issue complement the policy forum by looking at characteristics associated with glycemic control, diabetes care provided by school nurses, a program to increase retinal screening among diabetic individuals, and diabetes prevention and control services in North Carolina health departments. Elsewhere in the issue, experts review allied health's contributions to health reform in North Carolina.


The Role of Allied Health in Health Care Reform

Stephen W. Thomas, Lee McLean, Alisa Debnam

N C Med J. 2011;72(5):417-419.PDF | TABLE OF CONTENTS

The wide-ranging and significant disciplines representing allied health constitute the largest and one of the most rapidly growing health care workforces in North Carolina. With anticipated increases in patients’ access to care, allied health professionals will need to call on their full scope of practice as part of a comprehensive health care team.

Full appreciation of the role allied health can play in national and state health care reform first requires an understanding of the diversity of disciplines within the allied health alliance, the many levels of educational preparation required for practice in the field, and workforce supply and demand. The goal of increasing access through the Affordable Care Act requires a large and varied workforce that includes the full range of allied health disciplines. This commentary describes the wide variety of interprofessional roles that the allied health workforce can effectively contribute to health care reform.

Defining “Allied Health”
The term “allied health” is used to refer to >100 classifications of health care professionals. These practitioners provide a range of critical health care functions, including delivering preventive and rehabilitative therapies and conducting an increasingly complex array of diagnostic procedures. A few examples of allied health professions include audiology, clinical laboratory science, cytotechnology, dental hygiene, diagnostic imaging (radiography), occupational therapy, physical therapy, radiation therapy, polysomnography, respiratory therapy, health information management, and speech-language pathology. Allied health professionals work in widely diverse settings, including clinics, hospitals, rehabilitation centers, laboratories, schools, long-term care facilities, medical homes, and home health agencies.

According to federal regulations, the term “allied health professional” is defined as “a health professional (other than a registered nurse or physician assistant) who has received a certificate, an associate’s degree, a bachelor’s degree, a master’s degree, a doctoral degree, or postbaccalaureate training, in a science relating to health care; who shares in the responsibility for the delivery of health care services or related services…and who [is not a physician, dentist, veterinarian, podiatrist, pharmacist, chiropractor, clinical psychologist, counselor, health administrator, or public health professional]” [1]. Perhaps a more meaningful way to understand the broad grouping of “allied health” disciplines is as an alliance of many essential health care professionals who serve as critical partners, or allies, to the more commonly identified physicians and nurses on the health care team. In many instances, physician assistants, health managers/administrators, and counselors can be found in allied health colleges and schools that can provide leverage in funding and the acquisition of facilities and other resources that affiliation with a larger academic unit can offer.

The very broad definition of allied health and the frequent changes in health care technology and professional standards make it virtually impossible to come up with an all inclusive list of every allied health discipline practicing in North Carolina (or the nation) at any one point in time. In 2010, the US Department of Labor Bureau of Labor Statistics provided employment data for 41 distinct employment titles that clearly meet the definition of allied health, plus a broad category of “all other healthcare practitioners and technical workers” [2].

Workforce Supply and Demand
The disparate job titles, employment settings, and licensure regulations for these many different allied health disciplines make it very difficult to project the degree to which our colleges and universities will be able to meet future allied health workforce demand. In terms of employment growth and job opportunities, the North Carolina Health Professions Data System showed that employment in allied health positions grew by 67% during 1999-2009, a time when general state employment grew by only 3% [3]. Clearly, this is a large and growing part of the health care workforce. Projecting the supply of and demand for qualified professionals in all the different allied health disciplines will be critical to the ability of the North Carolina health care system to meet the state’s health care needs. The Council for Allied Health in North Carolina (CAHNC) was formed in 1991, with support from the North Carolina Area Health Education Centers program, to bring together allied health practitioners, educators, and employers from across the state to provide a forum for these groups to exchange information about the allied health workforce and to coordinate educational planning with predicted labor demands. Today, the CAHNC continues to pursue this goal and has contracted with the University of North Carolina–Chapel Hill Sheps Center for Health Services Research to produce a series of reports on the ever-changing allied health workforce picture in North Carolina.

Allied health education is offered in almost every type of postsecondary educational institution. By 2006, in >60 allied health occupations in >2,500 institutions, there were approximately 7,000 programs with >225,000 enrolled students and nearly 100,000 graduates. In North Carolina, allied health programs can be found in state-supported universities, community colleges, private institutions, proprietary schools, correspondence schools, hospital-based programs, and on-the-job training programs. North Carolina has followed the national trends in educational growth for allied health professionals.

North Carolina public postsecondary educational institutions (consisting of 2-year community colleges and 4-year colleges and universities) offer a variety of allied health programs and are supplying large numbers of qualified allied health care professionals to the state. In times of economic uncertainty, fiscal constraints, changes in the health industry, emphasis on cost efficient solutions to health care delivery, and changing demographic characteristics, public institutions must strategically plan for the future to meet increased health care needs with fewer resources.

According to Renee Batts, education consultant for Health Sciences Academic Programs in the North Carolina Community College System, “allied health programs are overwhelmingly among the most popular at community colleges” and waiting lists are among the longest for programs at community colleges. Over the past 5 years, there has been a 21.8% growth in associate degree programs and a 17.4% increase in diploma programs. One important reason for this success is the success graduates have in finding work in these professions.” Approximately 85% of individuals enrolled in allied health education programs in the state are in the North Carolina Community College System. Community colleges educate a large proportion of all allied health professionals who are necessary to ensure effective health care delivery in all parts of the state.

Data describing the number of allied health educational programs in North Carolina are somewhat fragmented. In the allied health area, North Carolina offers >75 different programs at all levels from area vocational technical schools to 2- and 4-year schools. There are approximately 30 public and private universities that offer roughly 114 baccalaureate, Master’s and doctoral level allied health degree programs, and a draft inventory of these degree programs is accessible via the CAHNC Web site (available at: In the community college system, there are >50 health care programs offered. The 2-year community college listing is specified on the North Carolina Community College System Web site (available at://

According to recent data distributed by the Council for Allied Health in North Carolina, allied health professionals made up the largest proportion of the health care workforce in the state, at 35% (128,150 of 364,000 health care jobs) [3, 4]. In contrast, nurses occupied 24% of all health care jobs; nurse aides, orderlies, and attendants, 28%; and physicians, 5%.

The Evolving Role for Allied Health
The allied health professional is an integral member of the health care team and makes a significant contribution to health care services. These professionals are highly skilled and share in the delivery of health care services, including services related to the identification, evaluation and prevention of disease and disorders; dietary and nutritional services; health promotion services; rehabilitation services; and health system management services. Under health care reform, there is decreased emphasis on individual professions in the delivery of health care; rather, care will be about an interprofessional team working together to address the needs of the patient. By 2019, the health care reform laws will expand insurance coverage to >32 million Americans (resulting in coverage for 94% of nonelderly uninsured US citizens), and allied health will see a dramatic demand for new and existing professionals and disciplines.

Health care reform legislation has challenged states such as North Carolina to find cost-effective ways to ensure the efficient delivery of quality health care to a significantly larger, culturally and geographically diverse patient population. Regardless of what is ultimately implemented, one of the primary goals will be to increase access for uninsured and underinsured individuals and families, which will place a considerable burden on today’s medical and health care workforce. Expansion of public access to health care requires increased numbers and types of allied health professionals and technicians prepared at the university, community college, diploma, certificate, and on-the-job training levels, to address a broad range of health challenges. Major challenges in North Carolina include the prevalence of chronic health conditions, health disparities, and delivery of health services to rural areas.

New occupations that are described in health care reform legislation, such as patient navigators, may already exist in some allied health professions or in curriculums within these disciplines that can be expanded or modified to provide the workforce needed to offer services such as medical case management. Community health educators typically employed in public health centers and public schools can apply their skills to meeting health reform mandates for prevention and health promotion services. Nutrition counselors, mental health counselors, and substance abuse counselors have routinely provided health promotion services. Traditional allied health positions that offer hands-on services (eg, occupational therapists, physical therapists, audiologists, respiratory therapists, and dental hygienists) have the ability to increase their involvement in health promotion activities related to their patients’ particular health needs. Health information administrators have explored the concept of instructing patients (and their families) in how to use personal electronic health records in managing and taking responsibility for their own health.

Incorporating discipline-specific prevention and health promotion activities into the scope of practice and educational curriculums of existing allied health professions emphasizes the importance of this aspect of the clinical role that may already be performed with patients but not to a discernible degree. Simply modifying or tweaking existing curriculums to include related prevention and health promotion activities will ensure that they become a routine part of the health care delivery process. Scope of practice defines what a professional can and cannot do with a patient. The details of the various allied health professions’ scope of practice are not always known by other health professionals and, as a result, may not always be fully appreciated or used.

In large clinics or hospitals where a wide range of health professionals are employed, allied health practitioners may not be called on to use the full extent of their scope of practice skills, since they may overlap with those of other professionals. However, in small clinics and rural environments where there are fewer health team members, use of the full scope of practice takes on greater importance, and these settings will need to rely on the professional’s use of existing skills to fill in the service gaps. For example, a part of the scope of practice and state licensure of physical therapists is wound care. Taking advantage of this skill set in settings where other wound care providers may not be available expands services of physical therapists beyond what is sometimes expected of that profession.

Allied health professionals in rehabilitation centers have often worked together as a team to bring about the best possible functional outcomes of the patient in a reasonable period. Even today, this concept of interprofessional education and service delivery has not been practiced to the patient’s fullest benefit. Cost containment and the delivery of high-quality services are essential to the success of health care reform efforts. Interprofessional service delivery will be vital to curbing rising costs and improving outcomes, and patient-centered medical homes are an excellent example of this successful team approach. Over time, allied health professionals will find greater opportunities in medical homes and within new models of care as their unique skills are recognized and tapped. Whether in response to the goals of health care reform or to the needs of traditional health care delivery systems, allied health services are crucial to the patient’s overall health, well-being, and quality of life.

Allied health professions are an integral part of an interprofessional approach to cost-effective and high-quality health care delivery. Innovative settings that offer a team approach will be able to address the intent of health care reform and the challenges facing North Carolina. The allied health community must partner with state medical and health care organizations, such as the North Carolina Institute of Medicine, to plan a coordinated effort to successfully address statewide access, health delivery, and workforce development issues.

Additional information about allied health is accessible via the Web sites of the following organizations: the Association of Schools of Allied Health Professions (available at:, the Council for Allied Health in North Carolina (available at:, the Health Professions Network (available at:, and the National Network of Health Career Programs in Two-Year Colleges (

Potential conflicts of interest. All authors have no relevant conflicts of interest.

1. 42 USC §295p (2010).

2. Bureau of Labor Statistics, US Department of Labor. May 2010 state occupational employment and wage estimates: North Carolina. Bureau of Labor Statistics Web site. Modified May 17, 2011. Accessed August 2011.

3. North Carolina Health Professions Data System [database online]. Chapel Hill, NC: Sheps Center for Health Services Research, University of North Carolina–Chapel Hill; 2009. Accessed August 2011.

4. Kimball M, Fraher E, Gaul K, Lyons J. Allied Health Job Vacancy Tracking
Report. Chapel Hill, NC: Sheps Center for Health Services Research, University of North Carolina–Chapel Hill; 2011.

Stephen W. Thomas, EdD professor and dean, College of Allied Health Sciences, East Carolina University, Greenville, and chair, Council for Allied Health in North Carolina, Chapel Hill, North Carolina.
Lee McLean, PhD professor, associate dean, and chair, Department of Allied Health Sciences, School of Medicine, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.
Alisa Debnam, MPH executive director, Council for Allied Health in North Carolina, Department of Allied Health Sciences, School of Medicine, University of North Carolina–Chapel Hill, Chapel Hill, North Carolina.

Address correspondence to Dr. Stephen W. Thomas, College of Allied Health Sciences, Mail Stop 668, Health Sciences Bldg 3206H, East Carolina University, Greenville, NC 27858-4353 (