Manual 21130725

Manual 21130725
Retooling for an Aging America: Building the
Health Care Workforce
Committee on the Future Health Care Workforce for
Older Americans, Institute of Medicine
ISBN: 0-309-11588-4, 316 pages, 6 x 9, (2008)
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Retooling for an Aging America: Building the Health Care Workforce
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RETOOLING FOR AN
AGING AMERICA
B U I L D I N G T H E H E A LT H C A R E W O R K F O R C E
Committee on the Future Health Care Workforce for Older Americans
Board on Health Care Services
Copyright © National Academy of Sciences. All rights reserved.
Retooling for an Aging America: Building the Health Care Workforce
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NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for their
special competences and with regard for appropriate balance.
This study was supported by contracts between the National Academy of Sciences and AARP;
Archstone Foundation (Contract No. 07-01-07); The Atlantic Philanthropies (Contract No.
14984); The California Endowment (Contract No. 20062172); The Commonwealth Fund
(Contract No. 20070140); The Fan Fox and Leslie R. Samuels Foundation, Inc.; The John
A. Hartford Foundation, Inc. (Contract No. 2006-0133); The Josiah Macy, Jr. Foundation
(Contract No. B06-07); The Retirement Research Foundation (Contract No. 2006-278); and
Robert Wood Johnson Foundation (Contract No. 57803). Any opinions, findings, conclusions,
or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Retooling for an aging America : building the health care workforce / Committee on the
Future Health Care Workforce for Older Americans, Board on Health Care Services.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-309-11587-2 (hardcover)
1. Older people—Medical care--United States. 2. Caregivers—United States. 3.
Geriatricians—Supply and demand--United States—Forecasting. I. Institute of Medicine
(U.S.). Committee on the Future Health Care Workforce for Older Americans.
[DNLM: 1. Health Services for the Aged—manpower—United States. 2. Aged—United
States. 3. Caregivers—United States. 4. Health Manpower—trends—United States. WT 31
R438 2008]
RA564.8.R48 2008
618.97`023—dc22
2008024225
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Copyright 2008 by the National Academy of Sciences. All rights reserved.
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the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche
Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2008. Retooling for an aging America: Building the health care workforce. Washington, DC: The National Academies Press.
Copyright © National Academy of Sciences. All rights reserved.
Retooling for an Aging America: Building the Health Care Workforce
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Advising the Nation. Improving Health.
Copyright © National Academy of Sciences. All rights reserved.
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COMMITTEE ON THE FUTURE HEALTH CARE
WORKFORCE FOR OLDER AMERICANS
JOHN W. ROWE (Chair), Professor, Department of Health Policy and
Management, Mailman School of Public Health, Columbia University
PAULA G. ALLEN-MEARES, Dean, Norma Radin Collegiate Professor
of Social Work and Professor of Education, School of Social Work,
University of Michigan
STUART H. ALTMAN, Dean and Sol C. Chaikin Professor of National
Health Policy, The Heller School for Social Policy and Management,
Brandeis University
MARIE A. BERNARD, The Donald W. Reynolds Chair in Geriatric
Medicine, Professor and Chairman, Reynolds Department of
Geriatrics, University of Oklahoma College of Medicine
DAVID BLUMENTHAL, Director, Institute for Health Policy,
Massachusetts General Hospital/Partners HealthCare System; Samuel
O. Thier Professor of Medicine and Professor of Health Care Policy,
Harvard Medical School
SUSAN A. CHAPMAN, Director of Allied Health Workforce Studies,
Center for the Health Professions; Assistant Professor, School of
Nursing, University of California, San Francisco
TERRY T. FULMER, Erline Perkins McGriff Professor and Dean,
College of Nursing, and Co-Director, The Hartford Institute for
Geriatric Nursing, New York University
TAMARA B. HARRIS, Chief, Geriatric Epidemiology Section Laboratory
of Epidemiology, Demography, and Biometry, National Institute on
Aging, National Institutes of Health
MIRIAM A. MOBLEY SMITH, Associate Dean and Associate Professor,
Chicago State University College of Pharmacy
CAROL RAPHAEL, President and Chief Executive Officer, Visiting Nurse
Service of New York
DAVID B. REUBEN, Archstone Foundation Chair and Professor;
Director, Multicampus Program in Geriatric Medicine and
Gerontology; Chief, Division of Geriatrics, David Geffen School of
Medicine, University of California, Los Angeles
CHARLES F. REYNOLDS III, UPMC Professor of Geriatric Psychiatry,
University of Pittsburgh School of Medicine; Professor of Behavioral
and Community Health Science, Graduate School of Public Health,
University of Pittsburgh
JOSEPH E. SCHERGER, Clinical Professor, University of California, San
Diego; Medical Director, AmeriChoice
v
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PAUL C. TANG, Vice President, Chief Medical Information Officer,
Palo Alto Medical Foundation; Consulting Associate Professor of
Medicine (Biomedical Informatics), Stanford University
JOSHUA M. WIENER, Senior Fellow and Program Director of Aging,
Disability, and Long-Term Care, RTI International
Study Staff
ROGER HERDMAN, Director, Board on Health Care Services1
MICHELE ORZA, Acting Director, Board on Health Care Services2
MEGAN McHUGH, Study Director3
TRACY HARRIS, Study Director
BEN WHEATLEY, Program Officer
MICHELLE BRUNO, Research Associate
REDA URMANAVICIUTE, Administrative Assistant
MICHAEL PARK, Senior Program Assistant
1 Starting
October 2007.
October 2007.
3 Through November 2007.
2 Through
vi
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Reviewers
This report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s (NRC’s) Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
KATHLEEN C. BUCKWALTER, The John A. Hartford Center of
Geriatric Nursing Excellence, The University of Iowa
SARAH GREENE BURGER, The Hartford Institute for Geriatric
Nursing, College of Nursing, New York University
CHRISTINE K. CASSEL, American Board of Internal Medicine
STEVEN L. DAWSON, PHI
DON DETMER, American Medical Informatics Association
WALTER H. ETTINGER, University of Massachusetts Memorial
Medical Center
NATHAN HERSHEY, University of Pittsburgh, Professor Emeritus
ULA HWANG, Department of Emergency Medicine and Geriatrics,
Mount Sinai School of Medicine
JUDY R. LAVE, Pennsylvania Medicaid Policy Center, Graduate
School of Public Health, University of Pittsburgh
vii
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viii
REVIEWERS
BRIAN W. LINDBERG, Consumer Coalition for Quality Health
Care
MARILYN MOON, American Institutes for Research
JOSEPH G. OUSLANDER, Division of Geriatric Medicine and
Gerontology, Wesley Woods Center of Emory University
ROBYN I. STONE, Institute for the Future of Aging Services,
Association of Homes and Services for the Aging
DONALD H. TAYLOR, JR., Benjamin N. Duke and Trinity
Scholarship Program and Terry Sanford Institute of Public Policy,
Duke University
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations nor did they see the final draft of the report before
its release. The review of this report was overseen by NEAL VANSELOW,
Tulane University, Professor Emeritus, and EDWARD B. PERRIN, School
of Public Health, University of Washington, Professor Emeritus. Appointed
by the NRC and the Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out
in accordance with institutional procedures and that all review comments
were carefully considered. Responsibility for the final content of this report
rests entirely with the authoring committee and the institution.
Copyright © National Academy of Sciences. All rights reserved.
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Foreword
The retirement of the baby boom generation is rapidly approaching.
Between 2005 and 2030, the number of adults aged 65 and older in the
United States will almost double. This dramatic shift in the age distribution of America’s population will place accelerating demands upon the U.S.
health care system.
For the health care workforce, the challenges presented by the aging of
America are multifaceted. The sheer volume of older adult patients threatens to overwhelm the number of physicians and other professionals who
will be available, unless more is done to ensure an adequate supply. Specific
skill sets are required to treat older patients, and our country is unlikely
to have enough geriatricians to meet the needs. The vast majority of older
adults have chronic illnesses that take them to multiple providers each year,
and the management of chronic illness depends on better coordination and
team-based care.
The Institute of Medicine’s (IOM’s) Committee on the Future Health
Care Workforce for Older Americans, chaired by John W. Rowe, was
formed to probe these challenges and to set out a course of action that will
improve our nation’s readiness to care for an aging population. The committee conducted a thorough analysis of the forces that shape the health
care workforce, including education, training, modes of practice, and the
financing of public and private programs.
During the course of its work, the committee sought to answer a number of questions that will be crucial in determining our readiness to meet
the health care needs of a rapidly aging society, including: what is the best
use of the paid health care workforce and informal caregivers in meeting
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x
FOREWORD
the needs of older adults? What new roles or new types of providers might
be necessary to facilitate efficient, high-quality care? How should the health
care workforce be educated and trained to deliver high-value care to older
adults, and how should this training be financed? And, what will strengthen
the recruitment and retention of the needed workforce?
This year marks the 30th anniversary of the first IOM report on the
workforce for geriatric patients, Aging and Medical Education (1978).
While the aging of the U.S. population as a whole has been projected for decades, we are now on the cusp of this change. The actions called for in this
report to bolster the health care workforce will take years to reach their full
effect. We can no longer afford to delay these changes that will ultimately
help ensure that all older Americans will receive adequate health care.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
April 2008
Copyright © National Academy of Sciences. All rights reserved.
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Preface
In 2007, the Institute of Medicine convened the Committee on the
Future Health Care Workforce for Older Americans to recommend steps
to improve health care for the growing number of adults over age 65. The
committee envisions a future health care system in which the health needs
of the older population are addressed comprehensively, services are provided efficiently, and older patients are encouraged to be active partners in
their own care.
In the near future, the nation will be aging dramatically, primarily due
to increases in life expectancy and the aging of the baby boom generation.
Together, these factors will contribute to the largest-ever proportion of
older adults, increasing from 12 percent of the U.S. population in 2005 to
almost 20 percent by 2030. The 78-million member baby boom generation
born between 1946 and 1964 begins turning 65 in 2011. While a large segment of this group will maintain health and independent functioning well
past the age of 65, reaching traditional retirement age is generally accompanied by an increasing number of personal health challenges. More than
three-fourths of adults over age 65 suffer from at least one chronic medical
condition that requires ongoing care and management. Currently, 20 percent of Medicare beneficiaries have five or more chronic conditions.
Caring for the elderly population poses a unique set of challenges. In
addition to geriatric syndromes, such as falls and malnutrition, which often
lead to acute health care problems, older adults also suffer from a range
of cognitive impairments that can impact their ability to perform as active
participants in their own care. Moreover, older adults are complex because
they often suffer from a range of ailments, including chronic conditions
such as hypertension and congestive heart failure, which require ongoing
care and active management from multiple providers simultaneously.
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xii
PREFACE
The Medicare program has tested various methods for improving its
fee-for-service financing system, which is broadly regarded as promoting
fragmented care delivery. The imminent increase in the number of complex
patients will require further innovations in financing and care delivery as
the need for more effectively coordinated care becomes more pressing. The
health care system as a whole must do better in ensuring that complex
older patients are provided with care that is streamlined and coherent, and
the committee supports various approaches to promote this, including the
improvement of education and training, increases in recruitment and retention, and the development of new models of care.
The health care workforce in general receives very little geriatric training and is not prepared to deliver the best care to older patients. Geriatric
care has not attracted health care professionals in sufficient numbers in the
United States and clearly more professionals specializing in geriatrics will be
needed to meet the needs of the coming elderly population both because of
their clinical expertise as well as their role in educating and training the rest
of the health care workforce in geriatric principles. Since virtually all health
care workers care for older adults to some degree, the geriatric competence
of all providers must also be improved more generally, through significant
enhancements in educational curricula and training programs.
Meeting the demand that is expected in coming years will require expansion of the roles of many members of the health care workforce, including technicians, direct-care workers and informal caregivers, all of whom
already play significant roles in the care of older adults. Patients, as well as
their families and friends, also need to be considered essential parts of the
health care team and learn how to be active and effective participants in
the care plan. As the roles and responsibilities of individual members of the
health care workforce change, the Medicare system will need to be flexible
in paying for innovative models of care and perhaps emerging types of providers that have new designations and training requirements. Interdisciplinary models that support collaboration among multiple types of providers
will be essential in improving care delivery for older adults.
This report calls for fundamental reform in the way that care is delivered to older adults and puts forth a plan to help ensure that the health
care workforce is sufficient in both size and skill to handle the needs of a
new generation of older Americans. These changes are urgently needed to
prepare for a sizeable demographic shift that threatens to overwhelm present and future capacity.
John W. Rowe, M.D.
Chair
April 2008
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Acknowledgments
Retooling for an Aging America: Building the Health Care Workforce
benefited from the contributions of many individuals. The committee takes
this opportunity to recognize those who so generously gave their time and
expertise to inform its deliberations.
The committee benefited from presentations made by a number of
experts. The following individuals shared their experiences and perspectives during public meetings of the committee: Marcia K. Brand, Health
Resources and Services Administration (HRSA); Eric Coleman, University
of Colorado Health Sciences Center; Steven Dawson, PHI; Steven DeMello,
HealthTech; Federico Girosi, RAND; Stephen Goss, Social Security Administration; Jennie Chin Hansen, University of California, San Francisco;
Charlene Harrington, University of California, San Francisco; Barbara
Harvath, HealthTech; Jeanie Kayser-Jones, University of California, San
Francisco; Bruce Leff, Johns Hopkins University Schools of Medicine
and Public Health; Sharon A. Levine, Boston University School of Medicine; David B. Reuben, University of California, Los Angeles; Michèle J.
Saunders, The University of Texas Health Science Center at San Antonio;
Robyn I. Stone, Institute for the Future of Aging Services, American Association of Homes and Services for the Aging; Alice Wade, Social Security
Administration; Gwen Yeo, Stanford University School of Medicine; and
Dan Zabinski, MedPAC.
The committee commissioned several papers to provide background information for its deliberations and to synthesize the evidence on particular
issues. We thank the following individuals for their contributions to these
papers: Chad Boult, Johns Hopkins Bloomberg School of Public Health;
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xiv
ACKNOWLEDGMENTS
Lisa B. Boult, Johns Hopkins University School of Medicine; Ariel Green,
Johns Hopkins University School of Medicine; The Health Technology
Center (HealthTech); Wendy King, Stanford University School of Medicine;
R. Tamara Konetzka, University of Chicago; Bruce Leff, Johns Hopkins
University School of Medicine; Mark Mather, Population Reference Bureau;
James T. Pacala, University of Minnesota Medical School; Claire Snyder,
Johns Hopkins University School of Medicine; Jennifer L. Wolff, Johns
Hopkins Bloomberg School of Public Health; and Gwen Yeo, Stanford
University School of Medicine.
We extend special thanks to the following individuals who were essential sources of information, generously giving their time and knowledge
to further the committee’s efforts: Dana Goldman, RAND; Seth Landefeld,
University of California, San Francisco; Linda Martin, Institute of Medicine; and Joan Weiss, HRSA. We also thank Robert Pool, copyeditor.
Finally, the committee gratefully acknowledges the assistance and support of individuals instrumental in developing this project: Jeane Ann
Grisso, Robert Wood Johnson Foundation; Sarah Handley, The Atlantic
Philanthropies; Marilyn Hennessy, The Retirement Research Foundation;
Linda Hiddemen, American Geriatrics Society; Gavin Hougham, The John
A. Hartford Foundation, Inc.; Marvin A. Kauffman, The Fan Fox and Leslie
R. Samuels Foundation, Inc.; Mary Jane Koren, The Commonwealth Fund;
Mary Ellen Kullman, Archstone Foundation; Christopher Langston, The
John A. Hartford Foundation, Inc. (formerly of The Atlantic Philanthropies); June E. Osborn, formerly of the Josiah Macy, Jr. Foundation; Corinne
H. Rieder, The John A. Hartford Foundation, Inc.; Laura Robbins, The
Atlantic Philanthropies; John Rother, AARP; George E. Thibault, Josiah
Macy, Jr. Foundation; Julio Urbina, The Fan Fox and Leslie R. Samuels
Foundation, Inc.; Dianne Yamashiro-Omi, The California Endowment; and
Nancy Zweibel, The Retirement Research Foundation.
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Contents
SUMMARY
1
1
INTRODUCTION
Chapter Summary, 15
Challenges to Improving Care for Older Adults, 17
Study Charge and Approach, 25
Overall Conclusions, 29
Overview of the Report, 31
2
HEALTH STATUS AND HEALTH CARE SERVICE
UTILIZATION
Chapter Summary, 39
The Health and Long-Term Care Needs of Older Adults, 40
Current Utilization of Health Care Services, 45
Differences by Demographic Characteristics, 49
Projections, 52
Implications for Financial Resources, 65
Conclusion, 66
3
NEW MODELS OF CARE
Chapter Summary, 75
A Vision for Care in the Future, 76
New Models of Care Delivery, 78
Paying for New Models of Care, 96
Dissemination of New Models of Care, 101
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15
39
75
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xvi
CONTENTS
Development of Future Models and Further Research, 108
Implications for the Workforce, 111
Conclusion, 115
4
THE PROFESSIONAL HEALTH CARE WORKFORCE
Chapter Summary, 123
Supply and Distribution, 124
The Current State of Geriatric Education and Training, 128
Trends Affecting the Future of Education and Training, 162
Recruitment and Retention, 167
Conclusion, 181
123
5
THE DIRECT-CARE WORKFORCE
Chapter Summary, 199
Direct-Care Occupations, 201
Workforce Demographics, 203
Education and Training Requirements, 204
Recruitment and Retention Challenges, 209
Improving Recruitment and Retention, 214
Conclusion, 232
199
6
PATIENTS AND INFORMAL CAREGIVERS
Chapter Summary, 241
Patients, 242
Informal Caregivers, 247
Conclusion, 263
241
APPENDIXES
A
B
C
Committee Biographies
Commissioned Papers
Workshop Presentations
INDEX
271
279
281
285
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Summary
In 2011 the first baby boomers will turn 65, ushering in a new generation of older Americans. The 65-and-older population of the future will be
markedly different from previous generations, with higher levels of education, lower levels of poverty, more racial and ethnic diversity, and fewer
children. Their most striking characteristic, however, will be their numbers.
The aging of the baby boom population, combined with an increase in life
expectancy and a decrease in the relative number of younger persons, will
create a situation where older adults make up a much larger percentage of
the U.S. population than has ever before been the case. Between 2005 and
2030 the number of adults aged 65 and older will almost double, from 37
million to over 70 million, accounting for an increase from 12 percent of
the U.S. population to almost 20 percent. While this population surge has
been foreseen for decades, little has been done to prepare the health care
workforce for its arrival.
Older Americans use considerably more health care services than
younger Americans and their health care needs are often complex. The
health care system often fails to deliver high-quality services in the best
manner to meet their needs. Indeed, the education and training of the entire
health care workforce with respect to the range of needs of older adults
remains woefully inadequate. Recruitment and retention of all types of
health care workers is a significant problem, especially in long-term care
settings. Unless action is taken immediately, the health care workforce
will lack the capacity (in both size and ability) to meet the needs of older
patients in the future.
To address major shortages, steps need to be taken immediately to increase overall workforce numbers and to use every worker efficiently (i.e.,
1
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2
RETOOLING FOR AN AGING AMERICA
to each individual’s maximum level of competence and with an increased
flexibility of roles). Additionally, the entire health care workforce, including both formal and informal caregivers, need to have the requisite data,
knowledge, and tools to provide high-quality care for older patients. To improve the ability of the health care workforce to care for older Americans,
the committee proposes a three-pronged approach:
•
•
•
Enhance the competence of all individuals in the delivery of geriatric care
Increase the recruitment and retention of geriatric specialists and
caregivers
Redesign models of care and broaden provider and patient roles to
achieve greater flexibility
STUDY CHARGE AND SCOPE
This year marks the 30th anniversary of the first report published by
the Institute of Medicine (IOM) on the health care workforce for older
patients, Aging and Medical Education. That report and others have called
for an expansion of geriatric training, but so far the geriatric discipline has
grown little in numbers or in stature. This current report builds upon the
IOM’s broader work in the area of quality. In 2001, the IOM’s Crossing
the Quality Chasm noted that a major challenge in transitioning to a 21stcentury health system is preparing the workforce to acquire new skills and
adopt new ways of relating to patients and to each other.
The IOM charged the Committee on the Future Health Care Workforce
for Older Americans with determining the health care needs of Americans
over 65 years of age and analyzing the forces that shape the health care
workforce for these individuals (Box S-1).
This study considers a range of care settings and health care team members, including professionals, direct-care workers, informal caregivers, and
patients. The committee focused on a target date of 2030—by which time
all baby boomers will have reached age 65—because it allows enough time
to achieve significant goals, yet it is not so far in the future that projections
become highly uncertain or advances in health care treatment or technologies change the medical landscape too greatly. Although the target year of
2030 may not seem to imply a sense of urgency, the contrary is true, as the
preparation of a competent health care workforce and widespread diffusion
of effective models of care will require many years of effort.
TODAY’S OLDER AMERICANS
The health status of older Americans has improved over the past several
decades. Today, older adults (defined here as those 65 and older) live longer
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3
SUMMARY
BOX S-1
Statement of Task
This study will seek to determine the health care needs of the target population—
the rapidly growing and increasingly diverse population of Americans who are over
65 years of age—then address those needs through a thorough analysis of the
forces that shape the health care workforce, including education, training, modes
of practice, and financing of public and private programs.
Starting with the understanding that health care services provided to older Americans should be safe, effective, patient centered, timely, efficient, and equitable,
the committee will consider the following questions:
1. What is the projected future health status and health care services utilization
of older Americans?
2. What is the best use of the health care workforce, including, where possible,
informal caregivers, to meet the needs of the older population? What models
of health care delivery hold promise to provide high-quality and cost-effective
care for older persons? What new roles and/or new types of providers would
be required under these models?
3. How should the health care workforce be educated and trained to deliver highvalue care to the elderly? How should this training be financed? What will best
facilitate recruitment and retention of this workforce?
4. How can public programs be improved to accomplish the goals identified
above?
and have less chronic disability than those in previous generations. Still,
almost all Medicare spending is related to chronic conditions. Many older
adults also experience one or more geriatric syndromes—clinical conditions
that do not fit into discrete disease categories (e.g., falls and malnutrition).
Older adults also tend to experience more mental health conditions (e.g.,
depression and anxiety). Many community-dwelling older adults need assistance with one or more activities of daily living (ADLs), such as bathing,
and dressing, or with instrumental activities of daily living (IADLs), such as
shopping for groceries and preparing meals. Severely disabled adults—that
is, those who have difficulty with three or more ADLs—generally require
more intensive care if they are to remain in the home.
Older adults receive health care in many different settings and are particularly high-volume users. Although older adults make up only about 12
percent of the U.S. population, they account for approximately 26 percent
of all physician office visits, 47 percent of all hospital outpatient visits
with nurse practitioners, 35 percent of all hospital stays, 34 percent of all
prescriptions, 38 percent of all emergency medical service responses, and
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RETOOLING FOR AN AGING AMERICA
90 percent of all nursing-home use. Just over 60 percent of disabled older
adults living in the community obtain some long-term care services, most
commonly in the form of help with personal care and household chores.
The vast majority of these services are provided by informal caregivers,
typically a spouse or child.
OLDER AMERICANS IN THE FUTURE
The future elderly population will be different from today’s older adults
in a number of ways. The demographic characteristics of older Americans
will differ from previous generations in terms of their race, family structure,
socioeconomic status, education, geographic distribution, and openness
regarding their sexual orientation. All of these factors can affect health
status and utilization of services. Trends in illness and disability will influence the need for services among the future older adult population, though
the direction and the magnitude of the effects cannot be predicted with
certainty. Declines in smoking rates, for example, could lead to a decreased
need for health care services, but that decrease could be offset by increased
utilization associated with high rates of obesity. Medical advances and technologies may extend or improve life for older patients. In the future, more
health care may be provided remotely, and older adults may be better able
to monitor their conditions and communicate with health care providers
from home. Finally, older adults in the future may simply have different
preferences for care than their predecessors.
Changes in Medicare or Medicaid policies could also have a significant
effect on service utilization by older adults—and, given that a severe cost
crisis in the Medicare program is widely expected, such changes are likely.
While a full consideration of likely health expenditures is beyond the scope
of the committee’s charge, committee members were mindful of financial
realities during the course of their deliberations. Whether or not the current
patterns of health status and utilization continue, one prediction is certain:
the future elderly population will have a greater collective need for health
care services than those who have come before it.
BUILDING THE CAPACITY OF THE HEALTH CARE WORKFORCE
With few exceptions, all types of health care workers need to be educated and trained in the care of older adults. First, while efforts to educate
and train the formal (i.e., paid) workforce in geriatrics have improved,
they remain inadequate in both scope and consistency. Second, much of
the care for older adults falls to informal caregivers, yet these unpaid
workers receive very little preparation for their responsibilities. Finally, the
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management of chronic illness requires daily decision making, and patients
often lack the knowledge or the skills to be effective members of their own
health care team. To the extent that patients are better able to manage their
conditions, they will be less likely to depend upon members of the already
limited health care workforce.
Besides being inadequately prepared in geriatrics, the current workforce is not large enough to meet older patients’ needs, and the scarcity of
workers specializing in the care of older adults is even more pronounced.
Among direct-care workers, nursing assistants provide 70 percent to 80
percent of the direct-care hours to those older adults who receive long-term
care, but their shortage is well documented. Older adults account for about
one-third of visits to physician assistants (PAs), but less than 1 percent of
PAs specialize in geriatrics. Less than 1 percent of both pharmacists and
registered nurses are certified in geriatrics. In 1987 the National Institute
on Aging predicted a need for 60,000 to 70,000 geriatric social workers by
2020, yet today only about 4 percent of social workers—one-third of the
needed number—specialize in geriatrics.
These shortages will only be worse in the future. By 2030 the United
States will need an additional 3.5 million formal health care providers—a
35 percent increase from current levels—just to maintain the current ratio
of providers to the total population. The Bureau of Labor Statistics predicts
that personal- and home-care aides and home health aides will represent
the second- and third-fastest growing occupations between 2006 and 2016,
which will exacerbate current shortages. As of 2007, there were 7,128
physicians certified in geriatric medicine and 1,596 certified in geriatric
psychiatry. According to one estimate, by 2030 these numbers will have increased by less than 10 percent; others predict a net loss of these physicians
because of a decreased interest in geriatric fellowships and the decreasing
number of physicians who choose to recertify in geriatrics. According to
the Alliance for Aging Research, by 2030 the United States will need about
36,000 geriatricians. It may well not be possible to reach this goal, but the
projection underscores the need for immediate and dramatic increases in the
numbers of workers who care for older patients in order to close the gap
between current supply and future demand. All segments of the health care
workforce face significant barriers to recruitment and retention, but in the
case of the older-adult health care workforce there are additional obstacles,
including negative perceptions about working with older patients, concerns
about physically and emotionally demanding working conditions, and misgivings about the financial disadvantages of such work. These issues merit
persistent attention and the development of an evidentiary basis to monitor
the progress made in increasing the capacity of this future workforce.
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RETOOLING FOR AN AGING AMERICA
Recommendation 1-1: Congress should require an annual report from
the Bureau of Health Professions to monitor the progress made in
addressing the crisis in supply of the health care workforce for older
adults.1
While increasing the supply of workers is important, numbers alone
will not solve the impending crisis. Current models of care delivery often
fail to provide the best care possible to older adults, and they often do not
promote the most efficient use of existing workers. While a number of innovative models have been developed to address these shortcomings, most
have not been widely adopted. In short, to meet the health care needs of
the next generation of older adults, the geriatric competence of the entire
workforce needs to be enhanced, the number of geriatric specialists and
caregivers needs to be increased, and innovative models need to be developed and implemented such that the workforce is used more efficiently and
the quality of care is improved (Box S-2).
Enhancing the Competence of All Providers
The geriatric competence of virtually all members of the health care
workforce needs to be improved through significant enhancements in educational curricula and training programs and then assessed through careerlong demonstrations of this competence. There are a number of challenges
to the geriatric education and training of health care workers, including a
scarcity of faculty, variable curricula, and a lack of training opportunities.
Furthermore, both education and training need expanded content in order
to address the diversity of health care needs among older adults.
Professionals
For professionals, one notable way in which training is inadequate is
the lack of exposure to settings of care outside of the hospital. Since 1987
hospitals have been allowed to count the time that residents spend in settings outside the hospital for graduate medical education funding purposes,
but many residents still do not spend significant amounts of time in these
alternative settings. Because most care of older patients occurs outside the
hospital, the committee concluded that preparation for the comprehensive
care of older patients needs to include training in non-hospital settings.
1 The committee’s recommendations are numbered according to the chapter of the main
report in which they appear. Thus, Recommendation 1-1 is the first recommendation in
Chapter 1.
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SUMMARY
BOX S-2
Recommendations
Recommendation 1-1: Congress should require an annual report from the
Bureau of Health Professions to monitor the progress made in addressing
the crisis in supply of the health care workforce for older adults.
Enhancing Geriatric Competence
Recommendation 4-1: Hospitals should encourage the training of residents
in all settings where older adults receive care, including nursing homes,
assisted-living facilities, and patients’ homes.
Recommendation 4-2: All licensure, certification, and maintenance of certification for health care professionals should include demonstration of competence in the care of older adults as a criterion.
Recommendation 5-1: States and the federal government should increase
minimum training standards for all direct-care workers. Federal requirements
for the minimum training of certified nursing assistants (CNAs) and home
health aides should be raised to at least 120 hours and should include
demonstration of competence in the care of older adults as a criterion for
certification. States should also establish minimum training requirements for
personal-care aides.
Recommendation 6-2: Public, private, and community organizations should
provide funding and ensure that adequate training opportunities are available
in the community for informal caregivers.
Increasing Recruitment and Retention
Recommendation 4-3: Public and private payers should provide financial incentives to increase the number of geriatric specialists in all health
professions.
Recommendation 4-3a: All payers should include a specific enhancement of reimbursement for clinical services delivered to older adults by
practitioners with a certification of special expertise in geriatrics.
Recommendation 4-3b: Congress should authorize and fund an enhancement of the Geriatric Academic Career Award (GACA) program to
support junior geriatrics faculty in other health professions in addition to
allopathic and osteopathic medicine.
Recommendation 4-3c: States and the federal government should institute programs for loan forgiveness, scholarships, and direct financial
incentives for professionals who become geriatric specialists. One such
mechanism should include the development of a National Geriatric Service Corps, modeled after the National Health Service Corps.
Recommendation 5-2: State Medicaid programs should increase pay and
fringe benefits for direct-care workers through such measures as wage passcontinued
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«
BOX S-2
Continued
throughs, setting wage floors, establishing minimum percentages of service
rates directed to direct-care labor costs, and other means.
Redesigning Models of Care
Recommendation 3-1: Payers should promote and reward the dissemination of those models of care for older adults that have been shown to be
effective and efficient.
Recommendation 3-2: Congress and foundations should significantly increase support for research and demonstration programs that
• promote the development of new models of care for older adults in areas
where few models are currently being tested, such as prevention, longterm care, and palliative care; and
• promote the effective use of the workforce to care for older adults.
Recommendation 3-3: Health care disciplines, state regulators, and employers should look to expand the roles of individuals who care for older
adults with complex clinical needs at different levels of the health care system
beyond the traditional scope of practice. Critical elements of this include
• development of an evidence base that informs the establishment of
new provider designations reflecting rising levels of responsibility and
improved efficiency;
• measurement of additional competence to attain these designations;
and
• greater professional recognition and salary commensurate with these
responsibilities.
Recommendation 6-1: Federal agencies (including the Department of Labor and the Department of Health and Human Services) should provide support for the development and promulgation of technological advancements
that could enhance an individual’s capacity to provide care for older adults.
This includes the use of activity-of-daily-living (ADL) technologies and health
information technologies, including remote technologies, that increase the
efficiency and safety of care and caregiving.
Recommendation 4-1: Hospitals should encourage the training of residents in all settings where older adults receive care, including nursing
homes, assisted-living facilities, and patients’ homes.
After receiving formal training, the mechanisms used most often to ensure the general competence of health care workers are state- or jurisdiction-
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SUMMARY
based licensure and national board certification. Often, neither licensure nor
certification examinations have explicit geriatric content, or the content is
inadequate to ensure competency in the area of geriatrics. Since educational
curricula are often devised to prepare students for these examinations, the
explicit inclusion of geriatrics in standardized examinations may encourage
programs to enhance geriatric content.
Recommendation 4-2: All licensure, certification, and maintenance of
certification for health care professionals should include demonstration
of competence in the care of older adults as a criterion.
Direct-Care Workers
Similar mechanisms are needed to enhance the competence of the
direct-care workforce in caring for older adults. Direct-care workers are the
primary providers of paid hands-on care and emotional support for older
adults, yet the requirements for their training and testing are minimal. Furthermore, even though patient care has become much more complex, the
federal minimum of 75 hours of training for nurse aides has not changed
since it was mandated in 1987 (although many states have higher numbers
of required hours). Home health aides have similarly low requirements, and
very little is done to ensure the competence of personal-care aides. The committee concluded that current federal training minimums are inadequate
to prepare direct-care workers and that the content of the training lacks
sufficient geriatric-specific content.
Recommendation 5-1: States and the federal government should increase minimum training standards for all direct-care workers. Federal
requirements for the minimum training of certified nursing assistants
and home health aides should be raised to at least 120 hours and
should include demonstration of competence in the care of older adults
as a criterion for certification. States should also establish minimum
training requirements for personal-care aides.
Informal Caregivers
Informal caregivers—most often family members and friends of the
patient—play an enormous role in the care of older adults, and there is
growing awareness of the benefits of providing them with better training
and improving their integration with the formal health care team. Informal
caregivers often feel insufficiently prepared to assist with home-based technologies, medically oriented treatments, or even basic tasks such as lifting
and feeding.
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RETOOLING FOR AN AGING AMERICA
Recommendation 6-2: Public, private, and community organizations
should provide funding and ensure that adequate training opportunities
are available in the community for informal caregivers.
Increasing Recruitment and Retention
Professionals
Among most health care professions, the opportunities for advanced
training in geriatrics are scarce or nonexistent and among the professionals
who do have the opportunity to pursue advanced geriatric training, very
few take advantage of these programs. Aside from their clinical expertise,
specialists in geriatrics are needed because of their role in educating and
training the rest of the workforce in geriatric issues. Resistance to entering
geriatric fields may arise from significant financial issues.
Recommendation 4-3: Public and private payers should provide financial incentives to increase the number of geriatric specialists in all
health professions.
The costs associated with extra years of geriatric training do not translate into additional income, and geriatric specialists tend to earn significantly less income than other specialists or even generalists in their own
disciplines. In part, this income disparity is due to the fact that a larger
proportion of a geriatric specialist’s income comes from Medicare and Medicaid, which have low rates of reimbursement for primary care activities in
general. Moreover, reimbursements fail to fully account for the fact that
the care of more frail older patients with complex needs is time consuming,
leading to fewer patient encounters and fewer billings.
Recommendation 4-3a: All payers should include a specific enhancement of reimbursement for clinical services delivered to older adults by
practitioners with a certification of special expertise in geriatrics.
Similar financial burdens affect the recruitment and retention of faculty
in geriatrics. For example, in spite of their extra training, junior faculty in
geriatric medicine have lower compensation than junior faculty in family
medicine or internal medicine. The Geriatric Academic Career Awards
(GACAs), awarded by the Bureau of Health Professions, have been instrumental in the development of academic geriatricians. Similar opportunities
for geriatric faculty in other health professions are rare.
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Recommendation 4-3b: Congress should authorize and fund an enhancement of the Geriatric Academic Career Award (GACA) program
to support junior geriatrics faculty in other health professions in addition to allopathic and osteopathic medicine.
Many efforts to recruit and retain health professionals seek to relieve at
least part of the financial burden associated with the personal cost of their
education and training. The committee concluded that programs linking
financial support to service have been effective in increasing the numbers
of health care professionals who care for underserved populations and that
they would serve as a good model for the development of similar programs
to address the shortages of professionals in geriatrics.
Recommendation 4-3c: States and the federal government should institute programs for loan forgiveness, scholarships, and direct financial
incentives for professionals who become geriatric specialists. One such
mechanism should include the development of a National Geriatric
Service Corps, modeled after the National Health Service Corps.
Direct-Care Workers
Recruitment and retention is especially dire among direct-care workers. They receive low wages and few benefits, they have high physical and
emotional demands placed on them, and they are at significant risk for
on-the-job injuries. These workers report high levels of job dissatisfaction
resulting from poor supervision, a lower level of respect among colleagues,
and few opportunities for advancement. Not surprisingly, then, there are
high levels of turnover among these workers. Overall, the successful recruitment and retention of direct-care workers depends on a significant culture
change to increase the quality of these jobs through improvements in the
job environment and adequate financial compensation for their current and
expanding roles.
Recommendation 5-2: State Medicaid programs should increase pay
and fringe benefits for direct-care workers through such measures as
wage pass-throughs, setting wage floors, establishing minimum percentages of service rates directed to direct-care labor costs, and other
means.
Redesigning Models of Care
The U.S. health care system suffers from deficiencies in quality, and
the health and long-term care services provided to older patients are no
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RETOOLING FOR AN AGING AMERICA
exception. Simply expanding the capacity of the current system to meet the
rising needs of older adults would not address the serious shortcomings in
the care of this population. The committee created a vision for the future
that rests on three key principles:
•
•
•
The health needs of the older population need to be addressed
comprehensively.
Services need to be provided efficiently.
Older persons need to be active partners in their own care.
The committee’s vision represents a vast departure from the current
system, and implementation will require a shift in the way that services
are organized, financed, and delivered. Several models have been shown to
improve quality and patient outcomes, sometimes at a lower cost. Other
newer models have not been adequately tested, but appear promising. After
reviewing the available evidence on a variety of models of care for older
adults, the committee determined that there is no single approach or best
model that could be broadly adopted for all older patients. Older adults
have diverse health care needs and a variety of models are necessary to
meet those needs.
Identifying successful models of care is only the first challenge to improving the delivery of care to older adults. The models need to be replicated
widely to reach the larger patient population. However, the dissemination
of successful models has been slow and some of the interventions have
been unsustainable due to a number of challenges, including an inadequate
mechanism for reimbursement. Many of the models require the delivery of
services that are not typically reimbursed under Medicare.
The committee concluded that a new method of reimbursement is
needed to support the implementation of effective and efficient models of
care.
Recommendation 3-1: Payers should promote and reward the dissemination of those models of care for older adults that have been shown
to be effective and efficient.
The committee supports reimbursement for services that are not currently covered (e.g., interdisciplinary teams); provision of capital for infrastructure (e.g., health information technology); and the streamlining of
administrative and regulatory requirements. Payers need to also eliminate
existing impediments to the use of innovative models by older patients, such
as Medicare’s copayment disparity for mental health services.
The broad efforts to develop new models of care indicate not only a
recognition that services for older adults need to be improved, but also a
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SUMMARY
willingness among providers, private foundations, and federal and state
policy makers to commit resources to learning about better ways to finance
and deliver care. The committee supports the continued development of
newer models, especially in areas that have traditionally been overlooked
or for more effective use of the workforce.
Recommendation 3-2: Congress and foundations should significantly
increase support for research and demonstration programs that
• promote the development of new models of care for older adults
in areas where few models are currently being tested, such as
prevention, long-term care, and palliative care; and
• promote the effective use of the workforce to care for older
adults.
Delivering care within all of these new models will require adaptations
by the workforce. For example, many successful models require providers
of different disciplines to work collaboratively in interdisciplinary teams,
but reimbursement for team care is currently lacking, and many providers
are not trained to work effectively in teams. Also, several successful models
of care require members of the health care team, including patients and
their families, to take on new roles and assume greater levels of responsibility. Shifting various patient-care responsibilities (e.g., through job delegation) will be essential to create meaningful improvements in the efficiency
of the health care workforce, but will require the training of many workers
both in the skills needed to deliver more technical services, as well as the
skills needed to be effective delegators and supervisors.
Recommendation 3-3: Health care disciplines, state regulators, and
employers should look to expand the roles of individuals who care for
older adults with complex clinical needs at different levels of the health
care system beyond the traditional scope of practice. Critical elements
of this include
• development of an evidence base that informs the establishment
of new provider designations reflecting rising levels of responsibility and improved efficiency;
• measurement of additional competence to attain these designations; and
• greater professional recognition and salary commensurate with
these responsibilities.
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RETOOLING FOR AN AGING AMERICA
Finally, many new models incorporate the use of various technologies. Health information technologies, such as electronic health records,
facilitate the sharing of information among providers and improve their
ability to coordinate the complex care of older patients. Remote-monitoring
technologies can efficiently extend the reach of health care professionals
into the home. ADL technologies can extend the independent functioning
of older adults and reduce the demands placed on direct-care workers and
informal caregivers.
Recommendation 6-1: Federal agencies (including the Department of
Labor and the Department of Health and Human Services) should provide support for the development and promulgation of technological
advancements that could enhance an individual’s capacity to provide
care for older adults. This includes the use of ADL technologies and
health information technologies, including remote technologies, that
increase the efficiency and safety of care and caregiving.
CONCLUSION
The United States today faces enormous challenges as the baby boom
generation nears retirement age. The impending crisis, which has been
foreseen for decades, is now upon us. The nation needs to act now to prepare the health care workforce to meet the care needs of older adults. If
current reimbursement policies and workforce trends continue, the nation
will continue to fail to ensure that every older American is able to receive
high-quality care. The dramatically rising number of older Americans,
along with changes in their demographic characteristics, health needs, and
settings of care will necessitate transformations related to the education,
training, recruitment, and retention of the health care workforce serving
older adults. This in turn will require the commitment of greater financial
resources, even at a time when program budgets will already be severely
stretched.
The committee asserts, however, that throwing more money into a system that is not designed to deliver high-quality, cost-effective care would
be largely a wasted effort. Instead, this report serves as an appeal for fundamental reform in the way that care is delivered to older adults. In doing
so, it provides a vision for how the workforce can best be developed and
organized to improve its capacity to deliver the care that a new generation
of older adults will soon be needing.
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1
Introduction
CHAPTER SUMMARY
By 2030 the number of adults in the United States who are 65 years old
or older is expected to be almost double what it was in 2005, and the nation is not prepared to meet their social and health care needs. If current
patterns of utilization continue, there will be a tremendous shortage of
health care workers, and many of these providers will lack the appropriate geriatric training to provide high-quality care to these older adults. At
the same time, Medicare and Medicaid budgets are facing tremendous cost
pressures, with the Medicare hospital trust fund projected to be depleted
by 2019. This impending crisis needs to be addressed immediately.
The Institute of Medicine (IOM) charged the Committee on the Future
Health Care Workforce for Older Americans to identify models of care
that hold promise to provide high-quality, cost-effective care to older
adults, and to analyze the factors that shape the health care workforce,
including education and training as well as recruitment and retention.
While this report builds on other IOM studies on health care quality and
the workforce, it is unique in that it defines the health care workforce
broadly, including consideration of both the professional and direct-care
workforces, as well as the roles of informal caregivers and patients.
The next generation of older adults will be like no other before it. It
will be the most educated and diverse group of older adults in the nation’s
history (U.S. Census Bureau, 2008). They will set themselves apart from
their predecessors by having fewer children, higher divorce rates, and a
lower likelihood of living in poverty (He et al., 2005; U.S. Census Bureau,
15
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RETOOLING FOR AN AGING AMERICA
2008). But the key distinguishing feature of the next generation of older
Americans will be their vast numbers.
According to the most recent census numbers, there are now 78 million
Americans who were born between 1946 and 1964 (U.S. Census Bureau,
2006). By 2030 the youngest members of the baby boom generation will be
at least 65, and the number of older adults (defined in this report as ages 65
and older) in the United States is expected to be more than 70 million—or
almost double the nearly 37 million older adults alive in 2005. The number
of the “oldest old,” those who are 80 and over, is also expected to nearly
double, from 11 million to 20 million. In percentage terms, the portion of
the U.S. population that is 65 or older is expected to rise from 12 percent
to almost 20 percent.
The major reason for the growing number of older adults in the United
States will be the aging of the baby boom generation, but increased longevity will also contribute. During the lifetime of the baby boomers, there has
been a variety of improvements in personal health behaviors (e.g., smoking
cessation) and advances in medical technologies (e.g., diagnostic imaging
technologies and prescription drugs) (Cutler et al., 2007), and these changes
have helped to increase life expectancy. For example, the widespread use of
cholesterol- and hypertension-lowering medications contributed to a decline
in the rate of deaths from cardiovascular disease (NCHS, 2006).
Although advances in longevity are to be applauded, increased life
expectancy coupled with new treatments that convert once-fatal disease to
lifelong conditions is giving rise to what some observers call “an epidemic of
chronic disease” (Anderson and Horvath, 2004). The vast majority of older
adults (80 percent) suffer from at least one chronic condition (e.g., dementia, diabetes, hypertension, heart disease) (Anderson, 2003), and chronic
diseases are the leading causes of death for older adults in the United States
(Kramarow et al., 2007). Chronic disease also brings an increased risk of
major depression, which is associated with substantial disability (Moussavi
et al., 2007) along with non-adherence to treatment of co-existing medical
illness and increased utilization of health care resources (Ciechanowski et
al., 2000). Unlike most infectious diseases or acute illnesses, chronic conditions may last for years, place limits on the activities of older adults, and
require ongoing care (Anderson and Horvath, 2002). As a result, individuals with chronic conditions tend to use far more health services than others,
and care of chronic conditions has fueled much of the increase in Medicare
spending over the past two decades (MedPAC, 2007).
The nation needs to prepare to meet the social and health care needs of
an older adult population of an unprecedented size. Additionally, as Americans live longer, the composition of the population that is 65 or older will
also become more complex with varying characteristics and demands due
to the inclusion of multiple generations of older adults (i.e., the 65-year-old
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INTRODUCTION
17
adult will be much different from the 85-year-old adult). A necessary step is
the development of a health care workforce (including health care professionals, direct-care workers and informal caregivers) sufficient in size and
skill to serve this growing number of older adults.
Health services provided to older adults today are not as effective as
they could or should be. The quality of care provided to older adults often
falls short of acceptable levels for a variety of conditions (Wenger et al.,
2003), and the proportion of recommended care that patients actually
receive declines with age (Asch et al., 2006). One of the greatest challenges will be reorganizing the health care system and its workforce so
that older adults have access to quality services at a cost that the country
can afford. Care coordination and other health-management practices that
may facilitate this have not been widely adopted. These practices involve
restructuring how the health care workforce operates, but they provide an
opportunity to reform service delivery so that the next generation of older
adults will receive more effective health care services than their parents.
CHALLENGES TO IMPROVING CARE FOR OLDER ADULTS
In addition to having a higher prevalence of chronic disease, older
adults have greater vulnerability to injury (e.g., falls) and to acute illness
(e.g., pneumonia) and have more limitations on their activities of daily living (ADLs).1 As a result, older adults use health services at far higher rates
than the rest of the population. These high rates of health service utilization
coupled with the large rise in the number of older adults can be expected
to result in a dramatic increase in the demand for health and long-term
care services in the coming decades. This escalation in demand for health
care services will in turn create a number of challenges that will need to
be addressed, including inadequate numbers of health care workers, the
limited training of those workers in geriatric skills, the misalignment of the
payment system, and scarce financial resources.
Shortages in the Supply of Health Care Workers
The rising demand for services places increasing pressure on the health
care workforce to expand its capacity. The Bureau of Labor Statistics (BLS)
reports that the aging of the population will make the health care industry
a major source of overall projected employment growth in the United States
between 2006 and 2016 (BLS, 2007b). Employment in the home health
and the residential-care industries is rising particularly quickly (Table 1-1).
1 Activities
of daily living (ADLs) relate to personal care needs, including eating, bathing,
using the toilet, dressing, and transferring from bed to chair.
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RETOOLING FOR AN AGING AMERICA
TABLE 1-1 Health and Home-Care Jobs Among the Top 30 FastestGrowing Occupations in the United States, 2006 to 2016
Employment by Year
(in Thousands)
Occupation
2006
2016
Percent
Increase (%)
Personal- and home-care aides
Home health aides
Medical assistants
Physical therapist assistants
Pharmacy technicians
Dental hygienists
Mental health counselors
Mental health and substance abuse social workers
Dental assistants
Physical therapists
Physician assistants
767
787
417
60
285
167
100
122
280
173
66
1,156
1,171
565
80
376
217
130
159
362
220
83
50.6
48.7
35.4
32.4
32.0
30.1
30.0
29.9
29.2
27.1
27.0
SOURCE: BLS, 2007a.
However, the population that has traditionally worked in those industries
is expected to increase only slightly, and this increase will likely not be
enough to satisfy the growing need for these types of workers, especially
considering persistent challenges in recruitment and retention (DHHS and
DOL, 2003).
Just over two-thirds of older adults will need some form of long-term
care at some point in their lives (AAHSA, 2007; Kemper et al., 2005), and
the dominant providers of long-term care services are families and friends,
referred to as informal caregivers (also known as unpaid or family caregivers) (Johnson and Wiener, 2006). Estimates of the number of informal
caregivers for older adults vary, but they most likely number in the tens
of millions. The economic value derived by the collective involvement of
informal caregivers has been estimated at hundreds of billions of dollars
annually (Arno et al., 1999; ASPE, 2005; Gibson and Houser, 2007; Langa
et al., 2001, 2002; LaPlante et al., 2002).
Unfortunately, the next generation of older adults may be less able to
rely on informal caregivers because they have fewer children and higher divorce rates than their parents (Center for Health Workforce Studies, 2005;
Johnson et al., 2007). And while the geographic dispersion of families has
been generally constant over the past several decades (Wolf and Longino,
2005), it continues to limit the availability of informal care (Donelan et al.,
2002). The lack of available informal caregivers may exacerbate the growing need for paid long-term care providers.
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INTRODUCTION
Health care professionals will have difficulty meeting the increased
need for services for older adults. Shortages of nurses (Gerson et al.,
2005; HRSA, 2004), certain types of physicians (AMA, 2005), pharmacists (HRSA, 2000), dentists (Ryan, 2003), and many others are already
apparent, particularly in non-urban areas (Box 1-1). Enrollment in medical schools (AAMC, 2007b), nursing schools (AACN, 2006), pharmacy
schools (AACP, 2006), and certain other institutions training health care
professionals is on the rise, but in some fields, such as dentistry, student
enrollment is stagnant (Luke, 2007). Overall, the workforce is not growing
at a rate commensurate with the projected rise in need.
The shortage of geriatric specialists is even worse. This is important
not only because of the need for specialist care, but also for the need for
these specialists to train the entire workforce in geriatric principles. For
the year 2000, the Alliance for Aging Research estimated that the United
States needed about 20,000 geriatricians to provide adequate health care
to older adults (Alliance for Aging Research, 2002). At the time, however,
there were only 9,000 practicing geriatricians. The number of geriatric
specialists is no better today. In fact, the number of geriatricians and geriatric psychiatrists has declined over the past decade, as many do not seek
recertification (ADGAP, 2007b). In 1987, the National Institute on Aging
predicted a need for 60,000 to 70,000 geriatric social workers, but today
we still only have about one-third of that number (NIA, 1987). In fact, very
few geriatric specialists exist among all types of health care professions.
The estimated needs for the year 2030 are even more dire. As depicted in
Figure 1-1, while it is projected that the United States will require 36,000
geriatricians, it will fall far short of that number.
BOX 1-1
Reports of Current or Projected
Health Care Workforce Shortages
•
•
•
•
Twenty-nine of 38 states surveyed indicate that a shortage of direct-care
workers is currently a “serious” or “very serious” issue (Harmuth and Dyson,
2005).
There is currently a shortage of approximately 12,000 geriatricians; by 2030
the shortage will be about 28,000 (ADGAP, 2007a; Alliance for Aging Research, 2002).
By 2025 there is projected to be a shortage of 100,000 physicians (AAMC,
2007a).
The shortage of registered nurses overall is projected to be as high as 808,000
by 2020 (Auerbach et al., 2007; HRSA, 2002).
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RETOOLING FOR AN AGING AMERICA
Projected Number of Needed Geriatricians
Actual and Estimated Number of Geriatricians
Number of Geriatricians
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1990
1995
2000
2005
2010
2020
2030
Year
FIGURE 1-1 Projected number of needed geriatricians.
SOURCE: Alliance for Aging Research, 2002. Copyright 2002 by the Alliance for
1-1.eps
Aging Research.
One of the challenges to retention in many health professions is the
aging of the workforce itself. As of January 2007, 23.3 percent of all active
physicians were 60 or older (AAMC, 2007a), and by 2020 almost half of
all registered nurses are expected to be over age 50 (AHA, 2007; Buerhaus
et al., 2000). Large numbers of health care workers are also expected to
retire just as the need for services increases. For example, more dentists
are retiring now than are entering practice (Center for Health Workforce
Studies, 2005). Based on current trajectories, many health professions will
struggle just to replace the current workforce and will not be able to meet
increases in demand.
Overall, the committee recognized the difficulty and inaccuracy associated with attempting to predict specific numbers of future health care
workforce supplies. Instead, the committee chose to present some previously reported predictions of shortages in an attempt to highlight the relative scale of the needed increases in workers rather than determine a specific
number needed for every profession. Box 1-1 highlights just a few of the
current and future shortages.
Discussions of health care workforce shortages often focus solely on
professionals,2 but direct-care workers (i.e., nursing assistants, home health
aides, and personal- and home-care aides) warrant at least equal consider2 For
the purposes of this report, the term “professional” is meant to imply a professional
in a health care field.
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INTRODUCTION
ation. These workers, also known as paraprofessionals, provide hands-on
care, supervision, and support to millions of older adults, particularly for
long-term care. However, long-term care organizations struggle to recruit
and, in particular, to retain workers to fill current positions (Harmuth,
2002). The annual turnover rate for certified nursing assistants is 71 percent (AAHSA, 2007), and 91 percent of nursing homes report that they do
not have adequate staff to provide basic care (Lawlor, 2007). Home-care
workers often stay with an agency for only a few months (PHI, 2003b).
Although many direct-care workers find their work to be rewarding, the
positions tend to be poorly paid with limited or no fringe benefits and to
involve heavy workloads, unsafe working conditions, inadequate training,
a lack of respect from supervisors, and few opportunities for advancement
(PHI, 2003a; Stone and Wiener, 2001). Because of the low pay and frequently poor working conditions, long-term care employers compete for
entry-level workers with other service industries, which may offer higher
pay and better work environments (Wright, 2005).
Limited Provider Training in Geriatrics
Unfortunately, the size of the health care workforce is only a part of
the problem. Another challenge is that the general health care workforce
receives relatively little geriatric training and may not be prepared to deliver the best care to older patients. Not only do older patients have greater
health care needs, but their conditions are often complex with multiple comorbidities. The average 75-year-old has three chronic conditions and uses
more than four prescription medications; furthermore, 42 percent of those
85 and older have Alzheimer’s disease (Alzheimer’s Association, 2007).
Some evidence indicates that patient outcomes improve when providers
receive specialized training in the skills needed to care for older patients
(Kovner et al., 2002). For example, studies show that patients treated by
nurses prepared in geriatrics are less likely to be physically restrained, have
fewer readmissions to the hospital, and are less likely to be transferred
inappropriately from nursing facilities to the hospital (Evans et al., 1997;
Naylor et al., 1999).
A very small percentage of professional health care providers specialize
in geriatrics. Only 4 percent of social workers and less than 1 percent of
physician assistants identify themselves as specializing in geriatrics (AAPA,
2007; Center for Health Workforce Studies, 2006). Less than 1 percent
of both pharmacists (LaMascus et al., 2005) and practicing professional
nurses (Alliance for Aging Research, 2002) are certified in geriatrics. For
professionals who do not specialize, exposure to geriatric issues during
training has generally improved in recent years, motivated in part by financial support from both public and private organizations. Still, many
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RETOOLING FOR AN AGING AMERICA
professionals tend to receive very little specific training in caring for older
people, and the adequacy of the education and training varies widely. Thus,
many providers delivering care to older adults have relatively little exposure
to the complexities of aging patients.
Training is particularly important for direct-care workers, who interact
closely with adults who tend to be very old and disabled, many of them
with cognitive limitations. However, the training of direct-care workers is
very limited. Federal requirements for training do exist for some types of
direct-care workers, but they tend to be minimal. For example, home health
aides and certified nurse assistants employed by nursing homes or home
health agencies must have 75 hours of training (PHI, 2003b); by way of
comparison, state laws often require more training for cosmetologists, dog
groomers, and crossing guards (Direct Care Alliance, 2005). No federal requirements exist for workers employed directly by consumers or by agencies
that provide non-skilled home services, although many states do set minimum training levels. The limited training that does occur tends to focus on
discrete clinical tasks instead of core competencies for interpersonal communication or clinically informed problem-solving and decision-making
skills that can guide caregivers in their interactions with clients. Finally,
while some resources are available to support and educate informal caregivers, they generally receive no formal training (Wolff and Kasper, 2006), and
older patients are often not educated on self-management principles.
Misaligned Payment Systems
Current Medicare and Medicaid policies do not encourage the delivery of the best care for older patients or the development of an adequate
workforce. The Medicare program was originally designed to address acute
illnesses, as these posed the major threats to health for older adults in the
1960s when the program was created. Under fee-for-service, a physician is
paid based on the services performed during an in-person visit. However,
current Medicare enrollees are more likely to need assistance with chronic
illness and geriatric syndromes, which require ongoing monitoring and
self-management. Medicare does not provide reimbursement for the timeconsuming and ongoing education that patients need to better manage
chronic conditions (Brown et al., 2007). Payment under fee-for-service is
made regardless of the quality of those services and often pays more for
newer and more complicated procedures, which may lead to overuse and
misuse of services and procedures (IOM, 2007e).
Additionally, chronically ill patients typically receive services from
multiple clinicians and across many sites, but Medicare does not provide
reimbursement for providers to communicate and collaborate with one another (Guterman, 2007; IOM, 2003; MedPAC, 2006). It also does not pay
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INTRODUCTION
23
for services provided by non-physicians, except under limited circumstances
(Lawlor, 2007). Legislation to provide reimbursement to physicians, social
workers, or others for medical care management has been proposed but not
passed (Cigolle et al., 2005).
Although older adults are more likely to see a primary care physician
than any other type of physician, Medicare payment levels serve as a deterrent to the practice of primary care. The Medicare reimbursement system
allocates more generous payments for procedures and specialist services—a
policy that some have suggested discourages physicians from entering primary care practice (ADGAP, 2007a; Guterman, 2007; LaMascus et al.,
2005). Medicare does not have a risk adjuster to account for the additional
time and complexity involved with treating frail, older patients. Patients
with complex health care needs are more likely to be found in geriatricians’ practices. Geriatricians and geriatric psychiatrists rely heavily on
Medicare reimbursement for their income, and surveys indicate that they
have lower incomes on average than almost every other type of physician
(ADGAP, 2004), which may further discourage physicians from specializing
in geriatrics.
Medicare’s teaching and supervision guidelines for resident physicians
also make it difficult to collect reimbursement for services provided in the
home and in nursing-home settings, which may limit training opportunities outside of the hospital setting (Warshaw et al., 2002). For example, a
faculty preceptor must accompany a resident to the setting in order for the
clinician to receive reimbursement for the visit; few residency programs can
accommodate this one-on-one teaching (Mold, 2003). The vast majority of
Medicare graduate medical education (GME) support is directed to physician training, though some funding is available to hospitals for the training
of nurses and other health care professionals (MedPAC, 2001).
Other problems exist with Medicaid. While states are working to expand home- and community-based long-term care services, a bias remains
toward institutional settings, especially nursing homes (Wiener, 2007). As
a result, beneficiaries often can receive only nursing home care, even when
they would prefer community-based services. Additionally, nursing home
providers contend that low Medicaid payments challenge their ability to
provide high-quality care. The integration of services between Medicare and
Medicaid for more than 7 million dually eligible individuals is especially
difficult (Holahan and Ghosh, 2005; Tritz, 2005; Wiener, 1996). The lack
of coordination between the programs often results in inefficiencies and
fragmented services for the most vulnerable members of the older population. For example, while Medicare has a financial incentive to shift dually
eligible patients into a Medicaid-funded long-term-care facility, Medicaid
has an incentive to shift beneficiaries toward Medicare-funded hospital
stays (Tritz, 2006).
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RETOOLING FOR AN AGING AMERICA
Inadequate Financial Resources
Even if the workforce is adequate in size and training to meet the need
for care of older adults in the future, simply continuing to operate under
current patterns of care will put an extreme financial strain on health care
budgets. Not only will enrollment in Medicare greatly expand in the future,
but the cost per beneficiary will also rise if Medicare policy and patterns of
care remain the same. The main factors contributing to rising health care
costs overall include increases in the use of technology and greater service
intensity (CBO, 2007b,c).
The Medicare program, the primary payer for services to older adults,
spent about $10,200 per beneficiary in 2006, and that figure is projected to
rise to $16,800 by 2016 (in 2006 dollars) (Federal HI and SMI Trust Funds
Board of Trustees, 2007). Perhaps the most important signal is that the
Hospital Insurance Trust Fund, which funds Medicare Part A, is projected
to be exhausted by 2019 (see Table 1-2 for intermediate projections). This
will result in a rapidly growing need for additional funding from taxes or
a substantial increase in patient deductibles.
The Medicaid program finances much of long-term care for older adults
and will face similar pressures, assuming no changes in policy or patterns of
care. Projections show that Medicaid spending will grow 8 percent per year
between 2007 and 2017 (CBO, 2007a). As a percentage of gross domestic
product (GDP), Medicaid spending is projected to increase from 2.6 percent
in 2006 to 4.1 percent in 2025 (Kronick and Rousseau, 2007). Medicaid
spending accounts for approximately 16.5 percent of state budgets today,
and is projected to rise to 19 percent by 2045. As state Medicaid spending
rises, it competes with investments in other areas, such as education and
transportation.
Future Medicare and Medicaid policy cannot be predicted, but financial
TABLE 1-2 Intermediate Projections for the Medicare Program, 2007,
2016, and 2030
Medicare enrollment
Medicare expenditures
HI trust fund assets
Medicare spending as a percentage of gross
domestic product
Number of workers per Medicare beneficiary
2007
2016
2030
44 million
$438 billion
$305 billion
3.2%
55 million
$863 billion
$221 billion
3.9%
(2015)
3.2
(2015)
79 million
NA
$0
6.5%
3.9
(2006)
2.4
NOTE: NA = Not Available; HI = Hospital Insurance.
SOURCE: Federal HI and SMI Trust Funds Board of Trustees, 2007; Moon and Storeygard,
2002.
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25
INTRODUCTION
pressures to control costs will surely increase while spending continues to
rise faster than economic growth. The Congressional Budget Office reports that if health care costs continue growing at the current rate, federal
spending on Medicare and Medicaid will rise to 20 percent of the GDP by
2050, roughly the same share of GDP that the entire U.S. federal budget
accounts for today (CBO, 2007b; Orszag and Ellis, 2007). It is unlikely that
there will be adequate funds to support all desirable models of care for the
future older population, and changes in benefits and taxes are likely to occur. Retirees are experiencing reductions in Medicare supplemental benefits
provided by their prior employers, a trend that will likely continue (AHRQ,
2004; Zabinski, 2007). Moreover, many older adults in the future may not
have the coverage or resources needed to pay out of pocket for some clinically indicated services.
In coming years the health care system as a whole will be faced with a
number of pressing concerns, including children’s health, obesity, emerging
infections, HIV/AIDS, and other challenges that will compete for scarce
public resources. While the committee recognizes the tensions that are likely
to arise as policymakers are forced to prioritize among multiple need areas,
it maintains that workforce shortages in the care of older adults (in terms
of both size and competence) is a looming crisis that demands significant
attention.
STUDY CHARGE AND APPROACH
The Institute of Medicine (IOM) formed the Committee on the Future
Health Care Workforce for Older Americans in January 2007 to determine
the best use of the health care workforce to meet the needs of the growing number of adults 65 and older (Box 1-2). To address this charge, the
committee sought to describe promising models of health care delivery and
the workforce that will be necessary in the future to serve the medically
indicated, culturally conditioned, and satisfiable health care needs of the
population of older adults, recognizing that any or all of these needs may
be modified.
The committee met four times during the course of the 15-month study.
It commissioned six technical papers (see Appendix B) and heard testimony
from a wide range of experts (see Appendix C) during two public workshops. Staff and committee members also met with and received information from a variety of stakeholders and interested individuals. Support for
the study was provided by 10 organizations: AARP, the Archstone Foundation, the Atlantic Philanthropies, the California Endowment, the Commonwealth Fund, the Fan Fox and Leslie R. Samuels Foundation, the John
A. Hartford Foundation, the Josiah Macy, Jr. Foundation, the Retirement
Research Foundation, and the Robert Wood Johnson Foundation.
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RETOOLING FOR AN AGING AMERICA
BOX 1-2
The Committee on the Future Health Care
Workforce for Older Americans
Statement of Task
This study will seek to determine the health care needs of the target population—
the rapidly growing and increasingly diverse population of Americans who are over
65 years of age—then address those needs through a thorough analysis of the
forces that shape the health care workforce, including education, training, modes
of practice, and financing of public and private programs.
Starting with the understanding that health care services provided to older Americans should be safe, effective, patient centered, timely, efficient, and equitable,
the committee will consider the following questions:
1. What is the projected future health status and health care services utilization
of older Americans?
2. What is the best use of the health care workforce, including, where possible,
informal caregivers, to meet the needs of the older population? What models
of health care delivery hold promise to provide high-quality and cost-effective
care for older persons? What new roles and/or new types of providers would
be required under these models?
3. How should the health care workforce be educated and trained to deliver highvalue care to the elderly? How should this training be financed? What will best
facilitate recruitment and retention of this workforce?
4. How can public programs be improved to accomplish the goals identified
above?
Scope
In addressing the statement of task, the committee focused on the
period of time from the present through 2030, by which point all baby
boomers will have reached age 65. The year 2030 was also selected because
it allows enough time to achieve significant goals, such as the establishment
of a workforce with enhanced geriatric training, but it is not so far in the
future that population projections are uncertain or that advancements in
health care treatment or technologies are expected to change substantially.
Although the choice of 2030 may not initially convey a sense of urgency,
the contrary is true. The first baby boomers turn 65 in 2011, and it will
require many years of effort to develop and train a health care workforce
prepared to meet the needs of future older adults and to develop effective
models of care and diffuse them widely. In order to achieve the committee’s
goals by the year 2030, immediate action needs to be taken.
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INTRODUCTION
27
The study focuses on primary health care (including both acute and
chronic care) and long-term care services for older adults, defined here as
those individuals ages 65 and older. Primary care is the provision of integrated, accessible health care services by clinicians who are accountable
for addressing a large majority of personal health care needs, developing a
sustained partnership with patients, and practicing in the context of family and community (IOM, 1996). Long-term care is broadly defined as an
array of health care, personal care, and social services generally provided
over a sustained period of time to persons with chronic conditions and
with functional limitations (IOM, 2001b). While the committee primarily
focused on the health care aspects of long-term care, it acknowledges that
these services are often intertwined with personal care and, in particular,
that many health care services are provided by the same workers who provide personal-care services.
The study considers a broad range of care delivery settings, including
ambulatory clinics, hospitals, and the home and other long-term care settings. Older Americans from across the entire spectrum of health care status
are included in the study, but the committee focused in particular on the
care of individuals with chronic conditions, who account for the bulk of
health care services and spending.
The committee defined the health care workforce broadly to encompass all personnel involved in the delivery of health care services, including
health care professionals (physicians, nurses, physician assistants, social
workers, oral-health care workers, pharmacists, allied health care workers,
and so on), and direct-care workers (e.g., nurse aides, home health aides,
and personal- and home-care aides). The committee recognized the significance of informal caregivers, not only because of the amount and breadth
of services they provide to older adults but also because the availability of
informal caregivers greatly affects the need for formal, or paid, services.
The committee also acknowledged the importance of consumers playing
an active role in their own care.
The committee also limited its consideration of models of care and
workforce challenges to the United States. While the committee recognized
that many unique efforts exist around the world, it concluded that the
systems of care are too different and heterogeneous to warrant extensive
examination of these systems in this report. Instead, the committee suggests
that lessons learned from these international models in general may help to
inform future research and development programs in the United States.
As seen in Box 1-2, the committee was charged with determining
the health care needs of older adults. The committee recognizes that the
term “need” can seem to be somewhat ambiguous and open-ended. An
individual asked to list his or her needs without regard to price might, for
instance, evince an almost unending desire for various services. It is for this
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RETOOLING FOR AN AGING AMERICA
reason that economists generally use the term “demand,” which refers to
the services an individual would be willing to pay for at a particular price.
In economic terms, “need” and “demand” are quite different things.
In the context of health care services for older adults, however, “need”
is understood to be “clinical need,” which is what a medical or social services professional believes is appropriate care for an individual, given his
or her medical condition. And since the public and private third-party payment system uses “clinical need” to determine which services will be paid
for, in practice the distinction between demand and clinical need is much
smaller. In this report most of the estimates concerning the “demand” for
aging services and for a workforce to provide such services are in reality
estimates based on clinical need.
Similar considerations apply to the term “supply.” The committee recognizes, for example, that the supply of health care workers available to
take care of older adults will depend on the expected wages or compensation paid to workers providing aging services. Thus baseline estimates of the
workforce that will be available to provide aging services in the future are
based on straightforward projections of the current compensation package
for such workers. Several of the committee’s recommendations to increase
the “supply” of personnel focus on increasing the compensation package in
order to attract more workers into the aging-services field. Therefore when
the committee speaks of supply and demand or supply and clinical need, it
does so with the recognition that all of these terms require an appreciation
for the prices paid for the services and the wages paid to workers. The level
of economic analysis needed to fully address these projections is beyond
the scope of this report.
While the committee concluded that a full consideration of likely health
expenditures was beyond the scope of its charge, committee members were
mindful of financial realities during the course of their deliberations. The
committee also focused their attention on those aspects of the health care
system that are unique or especially important to the care of older adults.
For example, while the committee explicitly recognized the importance
and influence of health information technology, care coordination, and
financing, it curtailed its discussion of these types of challenges that may
apply to the health care workforce and system of care delivery as a whole.
The committee concluded that fuller discussion of these general issues was
beyond the scope of its charge.
Previous Work
This year marks the 30th anniversary of the IOM’s first report on the geriatric workforce, Aging and Medical Education (IOM, 1978), which raised
national awareness of the challenges posed by the aging of the U.S. popula-
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INTRODUCTION
tion. That report, as well as several that followed, called for expansion of
geriatric training opportunities and offered a number of recommendations
for action. Over the past 30 years, opportunities for geriatric training for
professionals have expanded. For example, the John A. Hartford Foundation established centers of excellence in geriatric medicine and geriatric
psychiatry based on recommendations from a 1987 IOM report, Academic
Geriatrics for the Year 2000 (Rowe et al., 1987), and that foundation also
devotes significant financial and career support for geriatric nursing and
social work (Warshaw and Bragg, 2003). Still, the geriatric discipline has
failed to thrive in numbers and stature, and the level of geriatric training
among most providers remains too limited. Many recommendations from
previous IOM committees and other committees have had limited impact.
What makes this current effort different is the broad nature of the
study. It expands the scope of analysis well beyond physicians to consider
all formal and informal health care providers for older adults. It focuses
not only on the size and skills of the workforce but also on the models of
care—that is, on the ways in which health care services are provided to
older adults. We have known for decades that as the baby boom generation
aged it would challenge the capacity of the health care system (IOM, 1978;
NIA, 1987); that time is now upon us.
This current effort also builds upon the IOM’s broader work in the
area of quality. The landmark report, Crossing the Quality Chasm (IOM,
2001a), described quality care as being safe, timely, efficient, effective, equitable, and patient centered. However, there are strong indications that the
current system of care fails the older adult population in significant ways
along all of these dimensions of care. The report specifically noted that a
major challenge in transitioning to a twenty-first-century health system will
be preparing the workforce to acquire new skills and adopt new ways of
relating to patients and each other.
Since that report, the IOM has addressed workforce issues in a number
of areas—in emergency care (IOM, 2007b,c,d), public health (IOM, 2007f),
pharmacy (IOM, 2007a), mental health and substance abuse (IOM, 2006),
cancer care (IOM, 2005a), rural health (IOM, 2005b) and many others.
This report addresses workforce needs for older adults comprehensively,
across the spectrum of health services.
OVERALL CONCLUSIONS
After reviewing the evidence, the committee concluded the following:
1. The future health care workforce will be woefully inadequate in
its capacity to meet the large demand for health services for older
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RETOOLING FOR AN AGING AMERICA
2.
3.
4.
5.
adults if current patterns of care and of the training of providers
continue.
In all of the health professions where efforts to promote geriatric
specialization have been undertaken, these efforts have been mostly
insufficient to produce a larger number of geriatric leaders.
Informal caregivers provide a large amount of long-term care services to families and friends, and will continue to be a significant
part of the health care workforce.
The structure of public programs precludes both the effective delivery of care to many older adults and the development of an appropriate workforce.
Immediate and substantial action is necessary by both public and
private organizations to close the gap between the status quo and
the impending needs of future older Americans.
The nation is responsible for ensuring that older adults will be cared
for by a health care workforce prepared to provide high-quality care. If
current Medicare and Medicaid policies and workforce trends continue, the
nation will fail to meet this responsibility. This report is not simply a call
for more Medicare and Medicaid spending. Throwing more money into a
system that is not designed to deliver high-quality, cost-effective care or to
facilitate the development of an appropriate workforce would be a largely
wasted effort. Rather, this report serves as a call for fundamental reform. If
such reform is to occur, it will require both timely information and ongoing
reexamination.
The committee concluded that more needs to be done to ensure that
bold and appropriate actions are set in motion.
An important first step is to provide a reliable evidentiary basis to help
focus attention.
Recommendation 1-1: The committee recommends that Congress
should require an annual report from the Bureau of Health Professions
to monitor the progress made in addressing the crisis in supply of the
health care workforce for older adults.
This report needs to include regular reexamination of the health care
needs of older Americans so that workforce redesign strategies may be
properly adjusted. This report may also include monitoring of accomplishments toward national goals and milestones and needs to be inclusive of
the entire workforce with consideration for the interaction between the
informal and formal workforces.
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31
INTRODUCTION
The urgency for action cannot be overstated. Even with aggressive
implementation of reform, it will take years to reshape the workforce and
change delivery models. Deliberate workforce planning for the baby boom
generation should have begun years ago; the greater the delay, the more
difficult it will be to properly care for the nation’s future older adults.
OVERVIEW OF THE REPORT
Chapter 2 begins with a review of the current data and projections
of the composition and health status of the older population. Using current condition-specific rates of utilization of health services and available
estimates of future health care service utilization, the committee provides
a picture of the future demand for health services by older adults. These
estimates include several important assumptions that may prove incorrect.
Notably, they assume that Medicare’s benefits package will remain stable
and that current patterns of utilization and service delivery will continue.
These projections need to be viewed with caution. Baby boomers differ
from preceding generations with respect to levels of education, wealth, and
their access to health care services. These factors may yield a generation of
older adults whose demand for health care resources differs from their parents. At the same time, cost pressures under Medicare and Medicaid may
lead to policy changes aimed at improving the efficiency of care, including
efforts to reduce overutilization of health services. The net effect of these
changes cannot be predicted.
Concluding that the current approach to care for the next generation of
older adults is neither well-organized nor financially sustainable, the committee presents a discussion of models of care in Chapter 3. The committee
identified a number of models that have been created to improve patient
outcomes and to reduce utilization or cost. To date these models have not
been widely used, and the chapter discusses many of the challenges to their
dissemination. In addition, the chapter considers the implications of these
models for workforce training and care provision as well as the role that
cross-disciplinary training and evidence-based practice will likely play in
workforce training in the future. The remainder of the report considers additional changes that will be needed to transform our health care workforce
in order to better serve older patients and implement new models of care.
Chapter 4 focuses on health care professionals. In spite of expected
increases in need for geriatric services, the number of geriatric specialists
remains too low. While there have been improvements in the education and
training of the workforce in geriatrics, these efforts have failed to ensure
that all professionals who treat older adults have the necessary knowledge
and skills to provide high-quality care. The chapter concludes with an
examination of the challenges involved in the recruitment and retention
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RETOOLING FOR AN AGING AMERICA
of professionals in geriatric specialties. Many of the strategies to increase
recruitment and retention depend on overcoming financial barriers, such as
lower salaries and high costs of education.
Chapter 5 describes the direct-care workforce. These workers supply
a major portion of the formal services provided to older adults, including assistance with ADLs and with instrumental activities of daily living
(IADLs).3 Direct-care workers have difficult jobs, and they are typically
very poorly paid. As a result, turnover rates are high and recruitment and
retention of these workers is a persistent challenge. Chapter 5 discusses
a range of alternatives for bolstering the direct-care workforce, including
measures to increase pay and benefits. In addition, the chapter recommends
improvements in the education and training of these workers to ensure that
they have the core competencies required to meet the specific care needs of
older patients.
Chapter 6 discusses the role that informal caregivers play in providing
direct-care services to older adults. These individuals are integral members
of the patient’s overall care team. The chapter discusses the need to promote
the knowledge and skills of these caregivers in order to enhance their capabilities and strengthen their role as members of the workforce. The chapter
also focuses on the central role that patients play in the care process and
as members of the care team. Finally, the chapter describes the emergence
of new technologies that are likely to preserve and extend the capabilities
of older patients, thereby increasing their independence and reducing their
reliance on direct-care workers and informal caregivers.
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INTRODUCTION
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2
Health Status and Health
Care Service Utilization
CHAPTER SUMMARY
Older adults use far more health care services than do younger groups.
Although older adults vary greatly in terms of health status, the majority
of them have at least one chronic condition that requires care. Older adults
also vary in their demographic characteristics, which leads to differences in
their demand for and utilization of health services. Projections of the utilization of health and long-term care services often suffer from important
methodological limitations, but all projections indicate that the demand
for services for older adults will rise substantially in the coming decades,
which will put increasing pressure on Medicare and Medicaid budgets and
on the capacity of the health care workforce to deliver those services.
Over the coming decades, the total number of Americans ages 65
and older will increase sharply. As a result, an increasing number of older
Americans will be living with illness and disability, and more care providers
and resources will be required to meet their needs for health care services.
In order to design effective models of care delivery and prepare a health care
workforce to serve this future population, one needs to understand both
the projected health status of this population and the demand for health
services under the current system. Such an understanding will help identify
what changes will need to be made in the health care workforce (in terms
of its size, distribution, and training) to fulfill its looming charge.
This chapter begins with an overview of the current health status and
health services utilization patterns of older adults. Older adults today en39
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RETOOLING FOR AN AGING AMERICA
counter a number of health challenges as they age and, on average, use a
relatively large volume of health care services. However, the older adult
population is quite heterogeneous, with individual members displaying an
array of health statuses and needing a variety of services. Box 2-1 presents
some hypothetical examples to illustrate the diversity of the current older
population by describing several typical older adult profiles.
The chapter continues with a review of projections of the future health
status and utilization patterns of older adults as well as a description of the
assumptions and limitations of those projections. Although it is difficult to
predict with accuracy the number and types of health services that will be
demanded by older adults, it is clear that the total volume of health and
long-term care services needed in the future will be much greater than the
volume provided today.
The chapter concludes with a brief discussion of the implications of
these projections. If current patterns continue, the financial and human resources required to meet the projected demand for services will be strained
well beyond today’s supply.
THE HEALTH AND LONG-TERM CARE
NEEDS OF OLDER ADULTS
The health status of older Americans has improved over the past several decades (Crimmins, 2004). Older adults today have greater longevity
and less chronic disability than did those of previous generations (Federal
Interagency Forum on Aging Related Statistics, 2006; Manton et al., 1997,
2007). While these improvements appear to be related in part to declines
in smoking rates and better control of blood pressure (Cutler et al., 2007),
the causation has not been conclusively proven. Studies also show improvements in the reported physical functioning of older adults, such as the
ability to lift, carry, walk, and stoop (Freedman et al., 2002), as well as
declines in limitations in instrumental activities of daily living (IADLs), such
as shopping for groceries, preparing hot meals, using the telephone, taking
medications, and managing money. The evidence for declines in limitations
in activities of daily living (ADLs), such as eating, bathing, dressing, using
the toilet, transferring (such as from bed to chair), and walking across the
room is less strong (Freedman et al., 2004a). Finally, the percentage of older
adults who self-report their health as “fair” or “poor” has declined (Martin
et al., 2007). Despite these improvements, however, older adults still do
have high rates of chronic disease and disability, particularly as compared
to younger adults (Table 2-1), and disease prevalence has risen as longevity
has increased (Crimmins, 2004).
It is important to note that if one looks just at aggregate data, such as
those on disease prevalence (Table 2-1), it obscures important differences in
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HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION
BOX 2-1
Typical Profiles of the Older Adult Population
Mrs. S is a 75-year-old divorced woman who is retired from her job as an executive secretary and now lives in a retirement community where she plays golf three
times a week. She lives without assistance and frequently drives 45 minutes to
babysit for her daughter’s children. Mrs. S had breast cancer 20 years ago, which
was treated with a mastectomy, and now has hypertension, which is treated with
a diuretic. She sees her primary care physician twice a year and her oncologist
once a year.
Mr. Y is an 82-year old man who lives in an apartment with his wife. He has diabetes with peripheral neuropathy, hypertension, coronary artery disease, and chronic
obstructive pulmonary disease. He continues to drive and has been assuming
many of the instrumental activities of daily living because of his wife’s failing
health; she has moderate dementia. Mr. Y sees a primary care physician every
three months, a pulmonary specialist twice a year, a cardiologist once a year, and
a diabetes educator once a year. He participated in pulmonary rehabilitation following a hospitalization for pneumonia 3 months ago. His primary care physician
recently gave him the name of a social worker to consult with about possibilities
for getting additional support in the home (e.g., a homemaker and an attendant
to help bathe and dress his wife) and community-based resources (e.g., adult day
health programs, caregiver support).
Mrs. M is a 97-year-old woman who has had severe Alzheimer’s disease for 8
years. She recognizes her son and speaks to him, but her speech has no meaningful content other than to indicate when she is uncomfortable. Over the past
decade she has gotten progressively more immobile, and she stopped walking 3
years ago. She has been cared for at home by her son, who retired to be able to
care for his mother. Mrs. M takes no medications. Her course has been punctuated
by recurrent complications of immobility including pressure sores, contractures,
and recurrent pneumonias. She sees her primary care physician every 2 months
but also has several emergency department visits per year, occasional hospitalizations, and periodic care from home health for wound care.
Mr. R is an 88-year-old man who is widowed. His medical problems include heart
failure, hypertension, polymyalgia rheumatica, and prostate cancer. He has been
living in a nursing home since falling and sustaining a hip fracture 1 year ago.
Although he can ambulate with a walker, he is dependent in several activities of
daily living. He has a niece who visits approximately once a month. Prior to his
relocation to the nursing home, he saw several specialists, but none of them make
nursing home visits. His primary care physician sees him every 3 months as well
as in between these routine visits when an acute problem arises. None of his
specialist physicians sees him in the nursing home.
NOTE: These are hypothetical examples developed for illustrative purposes and are not actual
patient summaries.
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TABLE 2-1 Indicators of Health Status, by Age Group, 2006 (Percent)
Ages 18
and Over
Ages
65-74
Ages 75
and Older
Prevalence of Chronic Disease
Hypertension
Chronic joint symptoms
Heart disease
Any cancer
Diabetes
Stroke
Asthma
Chronic bronchitis
22.9
25.2
10.9
7.1
7.7
2.6
7.3
4.2
52.9
42.7
26.2
17.2
18.6
7.6
7.8
5.6
53.8
44.2
36.6
25.7
18.3
11.2
6.1
6.7
Prevalence of Disability/Limitations
Trouble hearing
Vision limitations, even with glasses or contacts
Absence of all natural teeth
Any physical difficulty
16.8
9.5
8.0
14.6
31.9
13.6
22.8
30.2
50.4
21.7
29.4
48.1
Overall Health Status
Self-assessed health status as fair or poor
12.1
22.5
27.5
NOTE: Does not contain information on the institutionalized adult population.
SOURCE: Pleis and Lethbridge-Çejku, 2007.
the health status among subgroups of older adults. Many older adults are
actually in very good health, for example—44 percent of adults in the 65-74
age range and 35 percent of adults 75 and older report their health status
to be “very good” or “excellent” (Pleis and Lethbridge-Çejku, 2007). And a
sizable minority, approximately 20 percent, have no chronic illnesses (AOA,
2006; CDC and Merck Company Foundation, 2007). These healthier older
adults tend to be community-dwelling individuals who require only preventive and episodic health services.
On the other hand, a large majority of older adults (approximately 82
percent) have at least one chronic disease that requires ongoing care and
management, with hypertension, arthritis, and heart disease being the most
common (Table 2-2). These chronic conditions damage older adults’ quality
of life, they contribute to a decline in functioning, and they have become
the primary reason why older adults seek medical care (Hing et al., 2006).
In fact, Medicare beneficiaries with more than one chronic condition visit
an average of eight physicians in a year (Anderson, 2003). An analysis of
Medicare expenditures shows that the 20 percent of Medicare beneficiaries
with five or more chronic conditions account for two-thirds of Medicare
spending (Partnership for Solutions National Program Office, 2004). Data
from the 2001 Medical Expenditure Panel Survey show that almost all
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HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION
TABLE 2-2 Chronic Disease Prevalence, Cost, and Physician Use Among
Medicare Beneficiaries
Number of Chronic Conditions
Percent of all Medicare
beneficiaries, 1999
Average Medicare expenditures,
1999
Percent that sees more than 10
different physicians per year,
2003
0
1
2
3
4 or more
18%
17%
22%
19%
24%
$211
$1,154
$2,394
$4,701
$13,973
6%
18%
40%
61%
Not available
SOURCE: MedPAC, 2006; Wolff et al., 2002.
Medicare spending and 83 percent of Medicaid spending is for the provision of services to individuals with chronic conditions.
In addition, many older adults experience one or more geriatric syndromes, clinical conditions common among older adults that often do not
fit into discrete disease categories. Examples include delirium, depression,
falls, sensory impairment, incontinence, malnutrition, and osteoporosis.
The syndromes tend to be multifactorial and result from an interaction between identifiable patient-specific impairments and situation-specific stressors (Flacker, 2003; Inouye et al., 2007). Geriatric syndromes are prevalent
conditions even among community-dwelling older adults and can have a
substantial effect on older adults’ quality of life (Cigolle et al., 2007). Estimates of incontinence, for example, range from 17 percent to 55 percent
in older women and from 11 percent to 34 percent in older men. Almost
half of older men and 34 percent of older women (ages 65 and older) report
trouble hearing.
Although estimates vary across surveys, data from the 2002 Health and
Retirement Study indicate that 27 percent of community-dwelling adults
ages 65 and older (8.7 million people) need assistance with one or more
ADLs or IADLs (Johnson and Wiener, 2006). Approximately 6 percent
of older adults living in the community (2.0 million people) are severely
disabled, reporting difficulty with 3 or more ADLs (Johnson, 2007). This
group of older adults requires more intensive care in the home, particularly
personal-care services.
Approximately 6.5 percent of older adults live in a long-term care facility. The majority, approximately 1.45 million, live in nursing homes, and
approximately 750,000 live in other residential-care settings that provide
some long-term care services (Spillman and Black, 2006). Those over age 85
are much more likely to live in a long-term care setting than younger older
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adults. In fact, those over age 85 are four times as likely to live in a nursing
home as those aged 75 to 84 (Jones, 2002). On average, older adults living
in nursing homes and residential care facilities tend to have more severe
disabilities than older adults living in their own private homes, although
more disabled older adults live in the community than in long-term care
settings. Residents of long-term care facilities often have the additional need
for symptom management and palliative care, that is, for noncurative care
that is focused on alleviating physical symptoms and addressing psychological, social, and spiritual needs (Moon and Coccuti, 2002).
Approximately 80 percent of deaths in the United States occur among
older adults (Kung et al., 2008). The leading causes of death among older
adults are diseases of the heart, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, and Alzheimer’s Disease (NCHS,
2007). Studies indicate that older adults follow different trajectories of
dying (IOM, 1997). Some have normal functioning but then die suddenly.
Others die after a distinct terminal phase of illness, such as occurs with
many types of cancer. Still others have a slower decline with periodic crises
before dying from complications, as is the case with stroke or dementia. On
average, about one-fourth of Medicare outlays occur in the beneficiary’s last
year of life, with 38 percent of beneficiaries spending at least some time in
a nursing home and 19 percent using hospice services (Hogan et al., 2001).
About half of Medicare patients who die from cancer use hospice services in
the last year of life. Deciding whether to use palliative care or curative treatment for illness during these times is a very personal choice and depends on
the individuals being affected (Moon and Coccuti, 2002).
Mental Health Conditions
Vulnerability to mental health conditions tends to increase as older
adults age and become more likely to encounter stressful events, including
declines in health and the loss of loved ones. Approximately 20 percent of
adults ages 55 and older have a mental health condition, the most common being anxiety disorders (e.g., generalized anxiety and panic disorders),
severe cognitive impairment (e.g., Alzheimer’s disease), and mood disorders
(e.g., depression and bipolar disorder) (AOA, 2001). Cognitive impairment with no dementia (CIND) has been described as the intermediate
state between normal cognitive function and dementia, a chronic illness
characterized by a decline in memory and other cognitive functions. The
prevalence of dementia increases with age, escalating from about 5 percent
among individuals aged 71 to 79 to about 37 percent among those aged 90
and older (Plassman et al., 2007). In 2007, 42 percent of adults 85 years
or older had Alzheimer’s disease (Alzheimer’s Association, 2007), although
estimates have varied somewhat. Additionally, suicide rates for men 65
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45
and older are higher than any other age group and are more than twice the
national rate for all persons (NCHS, 2007).
Mental health conditions are also more prevalent among communitydwelling older adults with ADL and IADL limitations. In 2002 approximately 31 percent of persons with disabilities and 45 percent of severely
disabled persons reported depressive symptoms, and 15 percent of older
adults with disabilities and 25 percent of severely disabled older adults
had cognitive impairments (Johnson and Wiener, 2006). The prevalence of
mental health conditions is even higher among nursing home residents. In
2005 nearly half of nursing home residents had dementia, and 20 percent
had other psychological diagnoses (Houser et al., 2006).
One reason for these trends may be that mental and physical health are
interrelated (New Freedom Commission on Mental Health, 2003). While
the direction of causality between the two remains unclear, the correlation
between them has been well documented. Persons with dementia and CIND
have more serious comorbidity than those without cognitive impairment
(Lyketsos et al., 2005). Physically disabled adults report higher rates of
mental health conditions. People with depressive symptoms often experience higher rates of physical illness, health care utilization, disability, and
an increased need for long-term care services (Federal Interagency Forum
on Aging Related Statistics, 2006; Ormel et al., 2002). In addition, depression in later life is associated with poor health habits and diminished adherence to treatment for co-existing medical disorders. Among older adults, the
combination of heavy alcohol or substance use with depressive symptoms
has been shown to be associated with high risk for suicidal ideation and
poor physical well-being (Bartels et al., 2006a,b).
CURRENT UTILIZATION OF HEALTH CARE SERVICES
Older adults have much higher rates of health services utilization than
do non-elderly persons. Although they represent about 12 percent of the
U.S. population, adults ages 65 and older account for approximately 26
percent of all physician office visits (Hing et al., 2006), 35 percent of all
hospital stays (Merrill and Elixhauser, 2005), 34 percent of prescriptions
(Families USA, 2000), and 90 percent of nursing home use (Jones, 2002).
Utilization data for several acute-care services are displayed in Table 2-3.
On average, older adults visit physicians’ offices twice as often as do
people under 65, averaging 7 office visits each year and totaling approximately 248 million visits in 2005 (NCHS, 2007). Older adults are more
likely to visit a physician’s office for a chronic problem or for a pre- or
post-surgery visit, but they are less likely than younger persons to seek preventive care. In 2004 the most common reasons for older adults to make
office visits were all related to chronic conditions: hypertension, malignant
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TABLE 2-3 Health Services Utilization by Age Group, 2005
Number of physician office visits per 100 persons
Number of preventive care visits per 100 personsa
Number of injury-related visits per 100 personsa
Number of hospital outpatient visits per 100 persons
(not including ED)
Number of ED visits per 100 persons
Number of days of hospital care per 100 persons
Average hospital length of stay
All Ages
Ages
65-74
Ages 75
and Over
329
51.0
36.5
31
647
50.6
60.0
41
768
48.1
73.6
38
40
55.4
4.8 days
37
139.8
5.3 days
60
259.4
5.7 days
NOTE: Data are for non-institutionalized persons. ED = Emergency Department.
aData are for 2004.
SOURCE: Hing et al., 2006; NCHS, 2007.
neoplasms (i.e., cancer), diabetes, arthropathies and related disorders (i.e.,
problems with joints), and heart disease (Hing et al., 2006). Older adults
frequently made visits to internal and family-medicine physicians, but more
than half of their visits were to specialists (NCHS, 2007). Older adults
also tend to visit multiple physicians. In 2003 half of Medicare patients
visited between two and five different physicians, 21 percent visited six
to nine physicians, and 12 percent visited ten or more different physicians
(MedPAC, 2006).
Although there are many specialists for which older adults constitute
a large percentage of visits (e.g., 35 percent for internal medicine, 30
percent for neurology), older adults account for only 9 percent of visits
to psychiatrists (ADGAP, 2007). The stigma associated with seeking mental health services presumably contributes in part to this low utilization,
but limited coverage by Medicare for psychiatric services is also a reason
(Manderscheid, 2007). Medicare requires a 50 percent copayment for outpatient mental health services as compared with only 20 percent for most
other outpatient services.
Older adults also receive a considerable amount of ambulatory care at
hospital outpatient departments. Older adults accounted for more than 13
million visits to hospital outpatient departments in 2004, not including visits to emergency departments (EDs); the reasons for these visits were similar
to those for visits to office-based physicians (Middleton and Hing, 2006).
Older adults account for a disproportionate share of emergency services. In fact, the rate of use of emergency medical services (EMS) by older
adults is more than four times that of younger patients, and older adults
account for 38 percent of all EMS responses (Shah et al., 2007). Between
1993 and 2003 ED visits by patients between the ages of 65 and 74 in-
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creased by 34 percent, and adults over age 65 had the greatest increase in
visit rate of all age groups (Roberts et al., 2008). In 2004 older adults made
15.7 million visits to EDs, which accounted for 14 percent of all ED visits.
More than one-third of older adult ED patients arrived by ambulance, using ambulance transport at more than double the rate of ED patients as
a whole (McCaig and Nawar, 2006). Despite older adults’ higher rates of
using emergency services, many EDs are not prepared to address the unique
needs of older patients (Hwang and Morrison, 2007; Wilber et al., 2006).
These EDs do not have the expertise, equipment, or policies to provide
optimal care for older patients.
Once they have been treated, older adults are more likely to have an
overnight hospital stay and also more likely to have multiple overnight
hospitalizations. In 2002 older adults accounted for more than 13 million inpatient discharges. The most common inpatient diagnoses included
coronary atherosclerosis (hardening of the heart arteries and other heart
disease), congestive heart failure, and pneumonia (Merrill and Elixhauser,
2005).
Forty-two percent of older adults receive some post-acute care services
after discharge from the hospital. Approximately 27 percent of older adults
are discharged to another institution, such as a skilled nursing facility
(SNF) or rehabilitation center; another 15 percent receive home health care
(AHRQ, 2007). Medicare covers up to 100 days (20 days of full coverage
and 80 days of partial coverage) in a SNF after a hospitalization of at least
three consecutive days (MedPAC, 2007b). The average length of SNF stays
covered by Medicare in 2005 was 26 days (MedPAC, 2007a). Overall,
almost 3 million Medicare beneficiaries received home health services in
2006, including skilled nursing, physical therapy, speech-language pathology services, aide service, and medical social work (MedPAC, 2007a).
Medicare provides home health care to homebound beneficiaries needing
part-time (fewer than 8 hours per day) or intermittent (temporary but not
indefinite) skilled care to treat their illness or injury. Personal care and other
non-skilled needs are not covered by Medicare.
Older adults are especially vulnerable as they transition between types
of care. A lack of coordination among providers in different settings can
lead to fragmentation of care, placing older adults at risk for absence or
duplication of needed services, conflicting treatments, and increased stress
(Parry et al., 2003). For example, medication changes, which are a common
cause of adverse drug events, are not unusual in the transition from hospital
to long-term care settings such as nursing homes and private home settings
(Boockvar et al., 2004; Foust et al., 2005; Levenson and Saffel, 2007).
Incomplete procedures during hospital discharge may also be linked to
unnecessary rehospitalizations (Halasyamani et al., 2006; Kripalani et al.,
2007). This type of fragmented care can also result from a lack of coordi-
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nation among providers who concurrently care for older adults in different
settings, exemplifying the failure of the health care system to meet the standards of quality (most notably safety, efficiency, and patient-centeredness)
as described in the IOM’s Crossing the Quality Chasm (IOM, 2001). Coordination of care and the use of interdisciplinary teams, is discussed in more
detail later in this report.
Long-term care services include health and personal services provided
to chronically disabled persons over an extended period of time. Estimating the total amount of long-term care services received by older adults is
difficult because utilization data are not often collected in a consistent manner across settings or care providers. Just over 60 percent of disabled older
adults living in the community obtain some long-term care services, most
commonly basic personal-care services and help with household chores,
averaging about 177 hours per month (Johnson and Wiener, 2006). Informal caregivers provide the vast majority of these services. Approximately
5.7 million older adults received some unpaid services in 2000 (Johnson et
al., 2007). Only about 18 percent of long-term care services provided to
disabled older adults in their homes are delivered by formal paid sources.
Medicaid accounts for about 41 percent of total long-term care expenditures (including non-elderly persons), while Medicare and out-of-pocket
costs each account for 22 percent of expenditures (Kaiser Commission on
Medicaid Facts, 2007).
As noted earlier, while approximately 1.45 million older adults live in
nursing homes, another 750,000 older adults live in alternative residential
care facilities, which provide housing and services outside nursing homes
for those unable to live independently (Spillman and Black, 2006). In
fact, assisted-living facilities have been the most rapidly expanding form
of residential care for older adults (Maas and Buckwalter, 2006). At the
same time, the percentage of older adults living in nursing homes declined
from 21 percent to 14 percent between 1985 and 2004, consistent with
the preferences of older adults to live in the community (Alecxih, 2006b).
While the Veterans Health Administration (VHA) allots 90 percent of its
long-term care resources toward nursing homes, about 56 percent of formal
long-term care service recipients receive community-based care (Kinosian
et al., 2007).
In 2005 about 870,000 Medicare beneficiaries received hospice care,
accounting for $7.92 billion in total Medicare payments (OIG, 2007).
Twenty-eight percent of these beneficiaries received some hospice care in a
nursing facility.
In addition to their increased needs for assisted housing and other
types of care, older adults account for a disproportionate share of prescription and over-the-counter medications (ACCP, 2005). They consume
34 percent of all prescriptions dispensed and account for about 40 percent
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of every dollar spent on prescriptions (Families USA, 2000). According to
physician office records and hospital outpatient records, the most common
medications used by older adults in 2004-2005 included anti-hypertensives
(133.3 drugs per every 100 older adults), cholesterol control drugs (128.1),
non-narcotic analgesics for pain relief (104.7), and diuretics for high blood
pressure and heart disease (95.4) (NCHS, 2007). In 2002, prior to the
implementation of Medicare Part D, the average Medicare enrollee aged
65 and older filled 32 prescriptions (including refills), but that number rose
dramatically for individuals with greater numbers of chronic conditions. On
average, enrollees with three or four chronic conditions filled an average of
44 prescriptions per year, and those with five or more filled 60 prescriptions
per year (Federal Interagency Forum on Aging Related Statistics, 2006).
Besides the traditional forms of health care discussed so far, surveys on
the use of complementary and alternative medicine (CAM) estimate that
anywhere from 30 percent to 88 percent of older adults use some form of
CAM. Studies often vary in terms of which forms of CAM are examined.
According to data from the National Health Interview Survey, prayer for
health is among the most common forms of CAM practiced among older
adults (Barnes et al., 2004). Data from the Health and Retirement Study,
which did not examine prayer, found that the most common forms of CAM
used by older adults included dietary supplements (65 percent) and chiropractic services (46 percent), though personal practice (breathing exercises
and meditation), massage therapy, and herbal supplements were also commonly used (Ness et al., 2005).
There are also a number of different types of providers, such as nurse
practitioners, social workers, psychologists, dentists, and pharmacists, for
which utilization data have not been discussed in this section. Visits to these
providers are typically not captured by national surveys of older adults, but
the numbers are likely to be considerable.
DIFFERENCES BY DEMOGRAPHIC CHARACTERISTICS
The data presented above mask important differences in the health
status of and the health care service use by older adults in various demographic categories, including sex, race, and socioeconomic status. For example, women and men face different challenges in maintaining their health
and have different patterns of service utilization. Men have higher rates of
heart disease, cancer, diabetes, and emphysema and have more inpatient
hospital stays than women (Robinson, 2007). On the other hand, women
have higher rates of osteoporosis, arthritis, asthma, chronic bronchitis, and
hypertension, and women are more likely to report depressive symptoms
(Federal Interagency Forum on Aging Related Statistics, 2006). Because
women have longer life expectancy than men and greater age-adjusted dis-
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ability rates (NCHS, 2007), women are more likely to live alone, and they
use more post-acute care services and long-term care services than men.
Much research has been conducted on the disparities in health status
between non-Hispanic whites and others. According to an analysis by
Hayward and Heron that studied adults of all ages, Native Americans
between the ages of 30 and 34 have a disability rate of 12 percent, but the
disability rate does not become that high among blacks until around age 37,
not until ages 50 to 54 for whites and Hispanics, and not until age 60 for
Asian Americans (Hayward and Heron, 1999). Their data for both sexes
combined indicate that Asian Americans exhibit the lowest rates of disability, the longest life expectancy, and the fewest years lived in poor health;
black populations have the shortest life expectancy, and a high proportion
of those years are lived with a chronic health problem. Black populations
have higher prevalence rates of stroke, diabetes, and hypertension than
white populations (IOM, 2004). Whites, however, are more likely to report
cases of cancer and chronic lung disease.
To examine these issues among older populations, the committee commissioned a paper to explore the topic. That paper reported many examples
of disparities among older adults of differing ethnic backgrounds. For
the most part, illness and poor health were more common among minority groups (those not classified as non-Hispanic white) than among nonHispanic whites. The 2000 Census found, for example, that approximately
49 percent of Hispanic older adults and 53 percent of non-Hispanic black
older adults reported a limitation or disability, versus 40 percent of nonHispanic white respondents (Freedman et al., 2004b). Older non-Hispanic
white adults (40 percent) and Asians (35 percent) are more likely to report
being in excellent or good health than are older Hispanics (29 percent),
American Indians/Alaskan Natives (28 percent) or African Americans (25
percent) (AOA, 2006).
Although minorities tend to be in poorer health than non-minorities,
they also tend to use health services less frequently (AHRQ, 2006; DamronRodriguez et al., 1994). A review by Gornick found that African American
beneficiaries used fewer preventive and health-promotion services (e.g.,
influenza and pneumococcal vaccines) than white beneficiaries, used fewer
diagnostic tests (e.g., colonoscopy), and underwent more surgical procedures associated with poor management of chronic disease (e.g., lower
limb amputations) (Gornick, 2003). Despite their less frequent use of many
acute-care services, African Americans tend to use nursing homes at higher
rates than white older adults, reversing a historical trend (NCHS, 2007).
They are also more likely to experience preventable adverse events or complications of care from hospitalization (AHRQ, 2005).
Some of the disparities in health status and utilization by race and
ethnicity may be attributable to differences in income. An inverse relation-
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51
ship exists between mortality and income (McDonough et al., 1997), and
older adults living below the poverty level are more likely to have multiple chronic conditions than those at higher income levels (NCHS, 2007).
Among older adults who require medical attention, wealthier individuals
are more likely to use health care services than are lower-income individuals (Chen and Escarce, 2004). And while today’s older adults are wealthier
than previous generations, their increased life expectancy may lead to less
economic self-sufficiency in their later years than previous generations,
leading to worse health status for the oldest of adults.
Socioeconomic factors may play an even larger role than race and ethnicity with regard to differences in the use of preventive services (Leatherman
and McCarthy, 2005). For example, low-income older adults are less likely
to receive a mammogram, colonoscopy, or influenza vaccination than are
high-income older adults. Similarly, the use of preventive services is more
common among those with supplemental coverage than among dually eligible older adults. Still, the vast literature detailing the relationship between
cultural background and health shows that cultural disparities in health
status and utilization persist after controlling for other factors, such as
income level (AHRQ, 2005; IOM, 2002). All of these differences demand
examination of whether the health care system for older Americans is
equitable according to the standards set by the IOM report Crossing the
Quality Chasm (IOM, 2001).
Income, gender, and race and ethnicity are but a few of the demographic characteristics that influence health status and health utilization.
Research has also identified differences based on marital status, level of
education, geographic location, and other factors (Freedman et al., 2004b;
Johnson and Wiener, 2006; Martin et al., 2007; Schoeni et al., 2005). For
example, Medicare beneficiaries with limited English proficiency are less
likely to have access to a consistent source of care and less likely to receive
important preventive care than Medicare beneficiaries who speak English
fluently. Married older adults are less likely to report a limitation or disability than those who are widowed, divorced, or never married, and rates
of limitations and disabilities decline with years of education. Studies have
also found differences in health status and utilization based on geography.
Older adults living in rural areas are more likely to rate their health as
“fair” or “poor” than are those in urban areas, and those in rural areas
have higher rates of chronic illness, disability, and mortality (Brand, 2007).
The geographic distribution of older adults also affects workforce needs
because different regions have differing needs for geriatric services. In 2006
older adults accounted for 12.5 percent of the total U.S. population, but
this percentage ranged from 6.8 percent of the population in Alaska to 16.8
percent of the population in Florida. (See Chapter 4 for more on the effect
of geographic distribution on the professional health care workforce.)
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Finally, certain subgroups of older adults may have particular health
needs. For example, veterans are twice as likely to commit suicide as the
general population (Kaplan et al., 2007). Posttraumatic stress disorder and
traumatic brain injury are sources of high morbidity for veterans returning
from the present-day conflicts in Iraq and Aghanistan as well as for Persian
Gulf War-era veterans (Rosenheck and Fontana, 2007; Warden, 2006). As
these veterans age, they will likely have persistent and unique health care
needs.
PROJECTIONS
This section begins with a brief review of population projections,
perspectives on future technology and preferences for care, and simple
projections of health status and utilization. Next is an examination of
three relatively complex models that were developed by RAND, the Lewin
Group, and the Urban Institute to simulate future health status and health
care utilization. Many of the projections discussed in the following sections focus on future dates other than the 2030 target date chosen by the
committee, but the projections still serve the overall purpose of presenting
a picture of the expected need for services and expected utilization rates if
patterns of care for older adults continue on the current trajectory.
The Elderly Population
Between 2005 and 2030 the population of older adults is expected to
almost double, from almost 37 million to 70 million (U.S. Census Bureau,
2000), although the need for health services may not rise in direct proportion. During that time, a number of factors are likely to alter the future
health status and patterns of utilization among older adults, making projections of health status and utilization uncertain. As discussed previously,
health status and utilization patterns vary according to certain demographic
characteristics, and the future older adult population will look somewhat
different from today’s older adults (Box 2-2).
It has been estimated that minority groups will make up a much larger
proportion of older adults in the future. The current population aged
65 and older is less diverse than the population currently aged 40 to 64
(Table 2-4), implying that older adults in 2030 will be a more diverse group
than older adults today. One projection has the percentage of minorities in
the oldest-old population increasing from 14 percent in 2000 to nearly 50
percent by 2100 (Wolf, 2001). As the proportion of minority populations
increases over time, especially those minorities with higher prevalences of
certain chronic diseases, the growing diversity among the older population
is bound to influence the types of services demanded and the subsequent
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BOX 2-2
A Profile of the Future Medicare Population
The Medicare Payment Advisory Committee (MedPAC), recognizing that future
Medicare beneficiaries will likely have different characteristics than today’s beneficiaries, conducted a project to develop a profile of these future Medicare beneficiaries. With input from an expert panel and a literature review, MedPAC staff
identified several important changes in beneficiaries’ characteristics that can be
expected to occur in the coming decades: increases in the proportions of obese
beneficiaries, of beneficiaries with chronic conditions, and of beneficiaries who
are racial or ethnic minorities; a decline in the proportion of beneficiaries with disabilities; a decline in the proportion with employer-sponsored insurance to supplement Medicare; fluctuations in the proportion of beneficiaries age 85 and older
(increasing through 2010, decreasing through 2030, and increasing thereafter); an
increase in the level of beneficiaries’ formal education; and a decreased reliance
on adult children as a source of care. MedPAC also noted that Medicare beneficiaries’ incomes have grown more slowly than health costs and that disparities in
incomes across beneficiaries have increased. These changes are likely to affect
future beneficiaries’ demand for care and to influence the types of services most
appropriate for future beneficiaries.
As a result, MedPAC staff identified several changes to the program that could be
put into place in order to better serve future beneficiaries. Those changes included
facilitation of care coordination, expanding the use of information technology and
comparative effectiveness analysis, greater promotion of healthy lifestyles, and
modifying cost sharing to have a single deductible for Medicare parts A and B and
to stop loss protection.
SOURCE: Zabinski, 2007.
rates of utilization. (See Chapter 4 for more on the effects of diversity on
the workforce.)
Additionally, the educational attainment of older adults is increasing.
Better-educated older adults tend to have lower levels of disability, and they
may be more likely to make beneficial changes in their lifestyles, to have
better access to care, and to comply with physicians’ instructions (Freedman
and Martin, 1998). However, this may not fully reflect the capacity of
older adults to navigate today’s complex health care system. Age itself also
plays an important role. The oldest older adults (ages 85 and older) have
the highest per capita utilization of health services, and that population is
expected to increase from 5 million to 9 million between 2005 and 2030.
Other demographic characteristics, such as net worth, family structure, and
geographic distribution, may similarly affect health status and the utilization of services.
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TABLE 2-4 Diversity Among the U.S. Resident Population Ages 40+, 2006
Ages 40-64
Total population
White alone
Black alone
Asian alone
Hispanic or Latino
origin
Ages 65+
Numbers
(in Thousands)
Percentage of
All Residents
Aged 40-64
Numbers
(in Thousands)
Percentage of
All Residents
Aged
65 and Older
97,346
80,130
11,172
4,151
10,184
100%
82.3%
11.5%
4.3%
10.5%
37,261
32,444
3,169
1,178
2,400
100%
87.1%
8.5%
3.2%
6.4%
NOTE: The total population includes races in addition to white, black, and Asian, so these
three groups do not total 100 percent. Hispanic or Latino origin was determined separately
from race, and so the categories are not mutually exclusive.
SOURCE: U.S. Census Bureau, 2008.
Demographic trends also have implications for the sites where care is
needed. A growing percentage of older adults prefer to receive long-term
care services in home and community-based settings, increasing the demand
for care in these alternative settings. The delivery of long-term care will
become especially complex as varying options for housing for older adults
develop leading to demands for services in multiple sites.
In addition, sites of care for special populations will be affected by
the aging trend. For example, in 2006, 3.7 percent of inmates in state
and federal prisons and local jails were over age 55. By 2030 one-third of
prisoners will be over the age of 55 (Enders et al., 2005). Also, in the next
decade the number of veterans over the age of 85 enrolled in the VHA is
expected to increase by 700 percent, and the utilization of long-term care
services is expected to increase by 20 to 25 percent, with special need for
community-based services (Kinosian et al., 2007). As Persian Gulf War-era
veterans and veterans currently returning from Iraq and Afghanistan get
older, their mental and physical impairments may persist, increasing the
need for the care of older adults within the VHA system. The VHA has a
remarkable history regarding the availability of a variety of geriatric care
programs, including nursing home care, home care, palliative care, and
acute care services for older adults; however, an influx of older veterans
will surely strain this well-developed system.
Finally, members of the future older adult population may bring a different stock of health capital to their older years than the current cohort
of older adults has done. Disability rates among older adults have been
declining in recent decades (Freedman et al., 2002; Manton et al., 1997,
2006), in part due to the educational gains among older adults discussed
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previously (Freedman and Martin, 1999). Educational gains are expected
to continue, although at a slower rate. On the other hand, the recent trend
of increases in disability at younger ages, although small and starting from
a very low level, may have negative implications for the future elderly
population (Lakdawalla et al., 2004). Some studies suggest that the gains in
mortality from reductions in smoking and better control of blood pressure
might be reversed in the coming years by high rates of obesity (Cutler et al.,
2007; Olshansky et al., 2005). Another study found that baby boomers on
the verge of retirement are in poorer health than pre-retirees 12 years ago
(Soldo et al., 2006). Trends in illness and disability will influence the need
for health services among the future older adult population, though the
direction and magnitude of their effects are not entirely clear. Still, even if
disability rates among older adults continue to decline, the size of the future
older adult population is so large that, overall, the total need for services
can be expected to increase (Johnson et al., 2007).
Health Status
Many efforts to project the future incidence or prevalence of disease
assume that the health status of individuals in a given age-sex category will
remain constant, and, therefore, the projections depend only on changes
in the age and sex composition of the population (Goldman et al., 2004).
This assumption may prove incorrect in the future. Nonetheless, for many
health conditions this type of projection offers the best available estimates.
Examples of such projections include the following:
•
•
•
The proportion of older adults with self-reported, doctor-diagnosed
arthritis will rise from 34 percent in 2005 to 48 percent in 2050
(Fontaine et al., 2007).
The prevalence of diabetes among older adults will rise from 5 million in 2005 to 10.6 million in 2025 and to 16.8 million in 2050
(Boyle et al., 2001).
7.7 million people will have Alzheimer’s disease in 2030, up from
4.9 million in 2007 (Alzheimer’s Association, 2007).
Assuming no change in current prevalence rates for disability, 26 million of the 75 million older adults alive in 2040 will have limitations in at
least one IADL, 16 million will have at least one ADL limitation, and 3
million will be institutionalized (Waidmann and Liu, 2000).
The Health Care Marketplace
Changes in the health marketplace will likely influence the demand
for services as well. A number of medical advances and technologies may
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be introduced in the coming decades (e.g., intraventricular cardioverter
defibrillators, continuous blood sugar monitors, pacemakers to control
atrial fibrillation, treatment of acute stroke, and cancer vaccines) that could
extend or improve life for older patients and, depending on the technology, increase or decrease the total demand for health services (AHA, 2007;
Goldman et al., 2004). More care may be provided remotely, and older
adults may be better able to monitor their conditions and to communicate
with health care providers from home. Additionally, more or different options for care may offer better matches to patient preferences. For example,
an increase in the availability of assisted-living options may result in fewer
older adults living in nursing homes (Stone, 2000).
Furthermore, in the future older adults may have different preferences
for care than older adults have had up to this point. Some data indicate
that the physician visit rates for the baby boom generation are higher than
for previous generations (AAMC, 2007). Baby boomers may have greater
expectations about care or may treat their illnesses more aggressively than
did their parents. Market research suggests that most baby boomers expect
to be healthier in their retirement than their parents were, and one-quarter
of them believe that a cure for cancer will be found before they retire (Del
Webb Corporation, 2003).
Finally, future changes in coverage, cost sharing, and reimbursement
policies could have a significant effect on access to care for older adults,
but it is not possible to predict exactly what these changes might be. For
example, the projected rise in Medicare and Medicaid spending may lead
policymakers to consider new ways to improve efficiency in the programs,
such as the use of health care rationing (Aaron et al., 2005). Researchers from Dartmouth estimated that nearly 20 percent of total Medicare
expenditures provide no benefit in terms of patient survival or quality of
life (Skinner et al., 2001); these expenditures might be cut to improve efficiency. Or, if all regions of the country could lower their spending levels
to be commensurate with the lowest-spending regions, Medicare could
potentially save 30 percent per year (Fisher et al., 2003). Policy makers are
currently exploring the expanded use of comparative effectiveness research
(Jacobson, 2007). Many of the new services provided to older adults today have little or no evidence showing that they are more effective than
established treatments, and it is difficult for patients and providers to make
informed decisions (MedPAC, 2007b). Policy makers may also explore the
potential of alternative payment mechanisms, such as bundled payments, to
provide incentives for providers to deliver care more efficiently.
Health Services Utilization
A number of projections have been developed to estimate the future
demand for care from certain types of health care providers using age-, sex-,
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and race-specific utilization patterns. However, these projections forecast
demand from all patients, not just older adults, and in most cases they assume that current utilization patterns will continue in the future, though
some efforts also include projections under alternative scenarios in which
practice or utilization patterns shift. For example, projections include the
following:
•
•
•
The need for critical care services will rise, increasing the need for
intensivists1 from 1,880 in 2000 to 2,600 by 2020 if current patterns of care continue. If utilization of critical-care physicians rises
by one-third (which is, some suggest, a more appropriate level of
use), approximately 4,300 intensivists would be required by 2020
(HRSA, 2006a).
Visits to oncologists for cancer are projected to increase from about
40 million to almost 60 million between 2005 and 2020 if current
patterns of care continue. A 2 percent increase in the percentage of
patients who see an oncologist and a 2 percent increase in the average visit-rates in the first 12 months post-diagnosis would result in
70 million visits in 2020 (AAMC, 2007).
If trends in emergency department visits among patients between
the ages of 65 and 74 continue at current rates, the number of visits
by these individuals would almost double from 6.4 million to 11.7
million by 2013 (Roberts et al., 2008).
Perhaps the most sophisticated models that project demand for health
services from health professionals are those maintained by the National
Center for Health Workforce Analysis at the Health Resources and Services
Administration (HRSA). The Physician Aggregate Requirements Model
(PARM) and Nursing Demand Model (NDM) project demand for services
and providers based on current and forecasted patterns of health care
use, staffing patterns, and insurance coverage. They consider provider-topopulation ratios for population segments defined by age, sex, metropolitan/
non-metropolitan location, and type of insurance. An assumption for the
baseline scenario is that these ratios are fixed (i.e., there is a constant insurance probability for each population group defined by age and sex). These
ratios are then applied to population projections to estimate future demand
(HRSA, 2003, 2006b).
Under a baseline scenario in which there is no change in per capita
health care utilization patterns, provider productivity, or provider staffing
patterns, changes in population characteristics would drive a 30 percent
increase in hospital inpatient days, a 20 percent increase in outpatient visits,
1 HRSA
defines intensivists as “physicians certified in critical care who primarily deliver care
to patients in an intensive care unit” (HRSA, 2006a).
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and a 17 percent increase in emergency department visits between 2000 and
2020. During that same period, nursing home residents would increase by
40 percent, home health visits by 36 percent, and visits to physicians’ offices
by 23 percent. This rise in demand would result in a 33 percent increase
in the requirements for physicians and similarly large increases in demand
for other health professions: 28 percent for nurses, 18 percent for physical
therapists, 20 percent for optometrists, 28 percent for podiatrists, 30 percent for licensed practical nurses, and 33 percent for nurse aides (HRSA,
2003). The PARM and NDM can be adjusted to produce estimates under
different scenarios, such as an increase in the productivity of health care
providers in the future.
These projections represent the aggregate rise in demand from all patients, not just older adults. However, the changes are largely driven by the
growth of the elderly population, particularly since the non-elderly population is growing at a much slower rate. The committee identified only a
few efforts that provide projections of the future health status and health
services utilization specifically for older adults. Three of those efforts are
highlighted in the next section: RAND’s Future Elderly Model is designed
to develop projections of disability and chronic disease and the use of acute
care services; the Lewin Group’s Long-Term Care Financing Model projects the use of long-term care and expenditures; and the Urban Institute’s
DYNASIM3, coupled with data from the Health and Retirement Study,
produces projections for disability and paid and unpaid long-term care.
RAND’s Future Elderly Model
The Centers for Medicare and Medicaid Services (CMS) contracted
with RAND to develop a model that would incorporate demographic
characteristics in generating estimates of the future health care needs of
Medicare beneficiaries as well as the expenditures on these beneficiaries.
Every year the Office of the Actuary in CMS issues a report containing an
overview and projections of current and future Medicare spending (Federal
HI and SMI Trust Funds Board of Trustees, 2007). These projections incorporate long-term trends in age-specific mortality rates (Goldman et al.,
2004), but they do not attempt to make any other assumptions about future
health trends (Singer and Manton, 1998). CMS has successfully predicted
the number of future Medicare beneficiaries, but it has encountered more
difficulty predicting program expenditures; thus the impetus for the RAND
project.
RAND’s Future Elderly Model (FEM) takes a comprehensive look at
the health status and utilization patterns of participating older adults and
allows for alternative projections based on various assumptions (Girosi,
2007). The FEM is a microsimulation model that tracks Medicare-eligible
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individuals over time. The model begins with a sample of beneficiaries,
ages 65 and older, from the 1998 Medicare Current Beneficiary Survey.
The model ages that cohort year by year, simulating health and functional
outcomes over time. These simulations require information on the risk
of developing a new health condition (e.g., hypertension or diabetes) and
entering a new functional state (ADL limitation, nursing home entrance,
death) based on such risk factors as age, sex, race, education, obesity, and
smoking. As the initial sample ages (rendering the model less representative
of the entire older population), the sample is “replenished” each year with a
new cohort of 65-year-olds using data from the National Health Interview
Survey, which provides information on the health status of those individuals
(Goldman et al., 2004, 2005).2
Baseline projections assume improvement in the mortality rate of 1.2
percent per year3 and a 2 percent increase in obesity from 2004 to 2028,
with a 0.5 percent increase thereafter. Results indicate a rise in the prevalence of many chronic conditions (e.g., high blood pressure, heart disease, diabetes, cancer, stroke) and ADL limitations by 2050, although the
prevalence of lung cancer decreases slightly. The projections change as the
assumptions are modified. Figure 2-1 shows the percentage change in prevalence for various conditions between 2004 and 2050 under the baseline
scenario. All conditions, with the exception of lung cancer, are projected
to increase. However, under an alternative scenario in which obesity is reduced (half of those who are obese are made overweight and half of those
who are overweight are changed to a healthy weight), the prevalence of
diabetes and lung cancer are reduced and the rates of increase for the other
conditions and limitations (excluding stroke) are decreased in comparison
to the baseline scenario. Under a scenario in which all older smokers quit,
the rates of increase for most health conditions are also smaller than in the
baseline scenario (except for cancer, which rises faster), and the prevalence
of lung cancer falls.
The FEM also makes projections that take into account variations
in utilization rates by age, health status, and socioeconomic class in the
future elderly population. The baseline projections suggest increases in
office visits, hospital days, and hospital stays of 155 percent, 170 percent,
and 165 percent, respectively, between 2004 and 2050 (Table 2-5). The
researchers further apportioned the change in utilization into two parts: the
demographic effect, or changes in utilization related to a change in the demographic composition of the population; and the health effect, or changes
2 See
Goldman et al., 2004, for a thorough explanation of the methods and assumptions
for the projections.
3 During the 20th century mortality among older adults declined approximately 1 percent
per year (Crimmins, 2004).
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Obesity Reduction
Baseline
Smoking Cessation
82 ADL3+
78
71
65 Diabetes
53
ADL12
30
28 HBP
Heart
25
18
13
10
15
10
Stroke
Cancer
37
23
19
13
10
5
0
-5 Lung
-8
-17
FIGURE 2-1 Percentage change in prevalence for various conditions projected for
2004-2050 under three scenarios: baseline, assuming obesity reductions, and assuming smoking cessation.
SOURCE: Girosi, 2007.
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TABLE 2-5 Utilization Projections and Decomposition, Baseline
Projections
Office visits
Hospital days
Hospital stays
Total expenditures
Percent Change (%)
Demographic Effect on
Percent Change (%)
Health Effect on
Percent Change (%)
155
170
165
180
85
80
85
75
15
20
15
25
SOURCE: Girosi, 2007.
in per capital utilization due to changes in health. Demographic changes
account for the vast majority of the increase in utilization.
Even under the alternative scenarios of obesity reduction and smoking
cessation, utilization still rises considerably overall between 2004 and 2050
(Table 2-6). Still, reductions in obesity would save resources and reduce the
overall increase in utilization compared to the baseline projection. Efforts
to persuade Medicare beneficiaries to quit smoking would improve health
but would also increase utilization because beneficiaries would live longer
(Girosi, 2007).
The Lewin Group’s Long-Term Care Financing Model
The Lewin Group developed a microsimulation model to estimate disability, use of long-term care (LTC) services, and LTC spending through the
year 2050 for older adults. The model uses data from a number of sources
including the Current Population Survey, Panel Study of Income Dynamics,
the Employee Benefits Survey, and the Health and Retirement Survey to
develop information on the individuals within the model, then uses prob-
TABLE 2-6 Utilization Projections and Decomposition Under Alternative
Scenarios
Office visits
Hospital days
Hospital stays
Total
expenditures
Obesity Reduction Scenario (%)
Quit Smoking Scenario (%)
Percent
Change
Demographic
Effect
Health
Effect
Percent
Change
Demographic
Effect
Health
Effect
155
155
155
170
95
100
100
90
5
0
0
10
160
170
170
180
85
90
90
80
15
10
10
20
SOURCE: Girosi, 2007.
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abilities to simulate events and transitions year by year, including family
status, work history, retirement income and assets, disability and mortality,
use of LTC services, and financing of LTC. Although the model is focused
on individuals ages 65 and older, it uses data on younger groups to project
characteristics of future cohorts of older adults (Kemper et al., 2005).
The model assumes, with some exceptions, that both individual behavior and current health policy (e.g., Medicaid benefits and eligibility requirements) will remain the same in the coming decades (Kemper et al., 2005).
Based on current trends, the model projections assume that age-specific
disability rates will continue to decline, that the use of assisted living will
grow relative to nursing home use, that the cost of LTC services will rise
faster than inflation, and that more workers will be offered LTC insurance
by their employers.4 Perhaps not surprising, the number of older adults
with disability is projected to rise steadily through 2050, so that the number
of older adults with any disability (IADL or ADL limitation) will rise from
about 7 million in 2005 to more than 15 million by 2050. The projections
for LTC spending are particularly striking, rising from $140 billion in 2005
to $570 billion by 2045 (Alecxih, 2006a).
Urban Institute Model
The Urban Institute and RTI International developed projections of the
number of older adults with disabilities and of their use of long-term care
services. First, the size and demographic characteristics of the older population were obtained from the Urban Institute’s microsimulation model,
DYNASIM3, which, like the Future Elderly Model, begins with a sample of
individuals and families and “ages” those observations year by year, simulating such demographic events as births and deaths, immigration, marriage
and remarriage, changes in living arrangements, and changes in disability. It
also simulates economic events, such as retirement. Second, data from the
Health and Retirement Study were used to develop models for the provision of paid and unpaid long-term care services as a function of disability,
financial resources, children’s availability, and other factors. Finally, three
different disability projection scenarios are used to project future long-term
care services. The model assumes that families weigh relative costs and
benefits when making long-term care arrangements and that they would
use less unpaid help from children and more paid help when the costs to
children of providing informal care are high (Johnson et al., 2007).5
4 See
Kemper at al., 2005, for a thorough explanation of the methods and assumptions for
the projections.
5 See Johnson et al., 2007, for a thorough explanation of the methods and assumptions for
the projections.
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Table 2-7 shows the results, detailing the percentage and number of
older adults with disabilities in 2000 and in 2040 under the three different
disability scenarios. Disability is defined as having any ADL or IADL limitation. The intermediate scenario, or the researchers’ “best guess,” assumes
no particular future trend in disability rates; the variations in rates are small
and depend on changing mortality rates and changes in the demographic
characteristics of the population. The high scenario assumes that the older
adult disability rate would increase by 0.6 percent per year from 2000 to
2014 and remain constant thereafter, similar to the rate of increase used in
RAND’s future elderly model. The low scenario assumes that older adult
disability rates will decline 1 percent per year indefinitely, which is consistent with assumptions for earlier projections made by the Congressional
Budget Office (Johnson et al., 2007).
Although disabled older adults are expected to decrease as a percentage
of all older adults in both the low and intermediate disability scenarios,
they are projected to increase in numbers under all scenarios because of
the rapidly increasing size of the older adult population. In the intermediate scenario, for example, the number of disabled older adults more than
doubles between 2000 and 2040. This increase would fuel the use of both
paid and unpaid long-term care services. Under the intermediate scenario,
an additional 5.5 million older adults would receive unpaid services and
3.1 million more would receive paid services in 2040 (Table 2-8). Even
under the optimistic low scenario, several million more older adults would
receive unpaid help and over a million more would receive paid care in
2040 than in 2000.
Despite the considerable growth in the absolute numbers of older
adults receiving services, the percentage of the population receiving services
TABLE 2-7 Size of the Population with Disabilities, by Disability
Scenario, 2000 and 2040
Year
2000
Percentage of Adults Ages 65+
Any disability
1-2 ADL limitations
3+ ADL limitations
Number of Adults Ages 65+ (Millions)
Any disability
1-2 ADL limitations
3+ ADL limitations
Year 2040
Low
Intermediate
High
30.3%
21.2%
9.1%
20.3%
14.2%
6.1%
28.0%
19.6%
8.5%
33.0%
23.1%
9.9%
10.0
7.0
3.0
15.1
10.6
4.5
20.9
14.6
6.3
24.6
17.2
7.4
SOURCE: Johnson et al., 2007.
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TABLE 2-8 Number of Older Adults Receiving Long-Term Care Services,
by Disability Scenario, 2000 and 2040 (in Millions)
Year 2040
Year
2000
Any unpaid help
Unpaid help from children
Unpaid help from other sources
Paid home care
Nursing home care
5.7
2.8
3.9
2.2
1.2
Low
Intermediate
High
8.2
3.7
5.7
3.9
2.0
11.2
5.0
7.9
5.3
2.7
13.1
5.8
9.3
6.2
3.1
SOURCE: Johnson et al., 2007.
is projected to remain steady or to decline (Figure 2-2). Nevertheless, in the
intermediate scenario, the average number of paid help hours per month
is projected to increase from 163 to 221 over the 40-year time period. The
average number of hours of unpaid at-home care received from children
would remain relatively constant, and the number of hours of unpaid help
received from others would decline slightly (Johnson et al., 2007).
Limitations of Projections
The projections presented above are helpful in providing a general idea
of the possible future health needs and health services utilization of older
70
60
57.2
53.8
Percent
50
39.1
40
2000
37.9
2040
27.8
30
23.9
22.2
25.5
20
12.3 12.9
10
0
Any unpaid
help
Unpaid
help from
children
Unpaid
help from
other
sources
Paid home
care
Nursing
home care
FIGURE 2-2 Percentage of older adults with disability receiving long-term care
services, intermediate disability scenario, 2000 and 2040.
2-4.eps
SOURCE: Johnson et al., 2007.
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HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION
65
adults, but they do not describe a complete picture. Most of the projections
rely heavily on data collected from large national surveys that ask about
a limited number of illnesses and types of health services used. Although
the Health Retirement Survey, the National Long-Term Care Survey, the
Current Medicare Beneficiary Survey, and the National Health Interview
Survey provide some limited data on geriatric syndromes, the simulation
models often do not examine that data. Also, national surveys and datasets
provide comprehensive information on physician visits and hospital stays
but not on visits to other types of providers who deliver significant amounts
of care services.
What all of the projections described above have in common is that
they extrapolate data from the past in order to predict the future. Although
it may be the best approach available in many cases, it is not without its
limitations and certainly not without controversy (Olshansky, 2005). For
example, one limitation of these projections is that they cannot predict
changes in utilization patterns that result from changing patient demands.
The models will project sizable increases in nursing-home use because of
the growing number of older adults, even though the use rates have been
falling.
Demographers and health service researchers regularly debate whether
assumptions about future rates of disability or illness are inappropriately
high or low; regardless of the precise assumptions used, however, the
qualitative interpretations of the findings are clear and consistent. Even
among the most optimistic projections in which the future cohort of older
adults is healthier than today’s, the growth in the absolute number of
older Americans will result in a greater total volume of illness and disability and a greater collective need for services from the health care system.
Estimates of the magnitude may vary, but again, even the most optimistic
scenarios indicate that the change will be considerable—and, in particular,
that it will be one that warrants a high level of attention and action today
so that the system is better prepared by 2030.
IMPLICATIONS FOR FINANCIAL RESOURCES
Although an examination of health expenditures is beyond the scope
of the committee’s charge, a consideration of the tremendous growth expected in the use of health services would not be complete without turning
some attention to its cost. In 1999 per capita health care spending for the
population under age 65 was $2,793; for the older adult population it was
$11,089, and for nursing home residents it was $44,520. The vast majority
of health care costs for older adults was borne by Medicare (52 percent)
and Medicaid (12 percent) (ASPE, 2005). In 2006 Medicare paid $406 billion in benefits (Federal HI and SMI Trust Funds Board of Trustees, 2007).
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66
RETOOLING FOR AN AGING AMERICA
In 2003 Medicaid paid $263 billion in benefits, including $105 billion for
dually eligible beneficiaries, the vast majority of whom are older adults, and
$68 billion for other aged and disabled Medicaid beneficiaries (Holahan
and Ghosh, 2005).
The 2007 report of the Federal Hospital Insurance and Supplemental
Medical Insurance Board of Trustees contained a Medicare funding warning: The projected growth rates are not sustainable under current financing
arrangements. The hospital insurance trust fund, which funds Medicare
Part A, is projected to be exhausted by 2019 (Federal HI and SMI Trust
Funds Board of Trustees, 2007). The financial outlook for Medicaid is
hardly better. Medicaid is the second largest program in state budgets,
growing faster than other state programs. Medicaid spending grew 9.5
percent in 2004, compared to a 3.4 percent growth in state revenue. States
have implemented a number of measures designed to slow the rate of spending, including reductions in eligibility and benefits (Smith et al., 2004). The
budgetary situation of these two programs is dismal, and policy changes
will likely occur prior to 2030 in order to address them.
Although the committee did not consider policy options for addressing
the financial viability of the two programs, committee members were mindful of the financial realities during the course of their deliberations. Insufficient funding for Medicare and Medicaid will place strains on the ability
of health care professionals to provide quality health care services. It will
also exacerbate issues of recruitment and retention—a particular concern
in the case of providers qualified in geriatrics, whose presence in the field
is already dreadfully low.
The financing of care is only part of the problem, however, and simply
allocating more funding or resources will not fully address the deficiencies
in the care of older adults.
CONCLUSION
Older Americans today have longer life expectancies than did previous
generations of older adults. As the population ages, however, the actual
numbers of older adults living with disability or illness are rapidly increasing. Many older adults live their extra years with higher rates of chronic
health conditions that require vigilant care on the part of their health providers. As a result, older adults account for a disproportionate amount of
the health care services delivered in the United States. Furthermore, because
of the variety of physical and mental illnesses seen among older adults and
the variety of care sites in which they receive services, the care of today’s
older adults is especially complex.
Future generations of older Americans may have different health care
needs because of changes in the distribution of many demographic charac-
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HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION
67
teristics, including race, socioeconomic status, and geographic location, and
also because of changes in personal preferences about how they care for
their health and where they receive their health care services. It is difficult
to make exact projections of these needs because of uncertainties regarding
the effects of changes in demographics, lifestyle, and disease prevalence.
Utilization patterns may also change markedly because of these effects and
also because of changes in the health care marketplace and innovations
in medical diagnostic and treatment modalities. While projections are difficult, one conclusion is certain—that the absolute growth in the number
of older Americans will strain the current health care system if patterns of
care remain the same.
If the health care workforce—already too low in numbers and competence levels to provide adequate care to the current population of older
adults—is to be prepared for the coming spike in demand for services,
serious reforms need to be considered. This will include redesign in the
way that health care teams deliver their services. New models of care have
been developed to improve the financing and organization of health care
services for older adults. These models have a variety of implications for
the workforce with respect to individual roles and responsibilities, scopes
of practice, and payment rates. Chapter 3 examines a number of these new
models as well as strategies to support their further development.
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for the future. Journals of Gerontology B: Psychological Sciences and Social Sciences
55(5):S298-S307.
Warden, D. 2006. Military TBI during the Iraq and Afghanistan wars. Journal of Head
Trauma Rehabilitation 21(5):398-402.
Wilber, S. T., L. W. Gerson, K. M. Terrell, C. R. Carpenter, M. N. Shah, K. Heard, and
U. Hwang. 2006. Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee on the Future of Emergency Care in the U.S. Health System.
Academic Emergency Medicine 13(12):1345-1351.
Wolf, D. A. 2001. Population change: Friend or foe of the chronic care system? Health Affairs 20(6):28-42.
Wolff, J. L., B. Starfield, and G. Anderson. 2002. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of Internal Medicine
162(20):2269-2276.
Zabinski, D. 2007. Medicare in the 21st century: Changing beneficiary profile. Presentation at
Meeting of the Committee on the Future Health Care Workforce for Older Americans,
Washington, D.C. March 27, 2007.
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New Models of Care
CHAPTER SUMMARY
This chapter presents the committee’s vision for the care of older adults
in the future and describes a number of new models of care delivery that
show promise for achieving this vision. Widespread implementation of
new models of care will require changes in traditional staffing patterns
and provider roles. Despite the evidence that patient care can be improved
through the implementation of new models of care, diffusion of those
models has been limited, in part due to external constraints such as insufficient funding. The committee recommends improved dissemination of
models that have been shown to be effective as well as increased support
for research and demonstration programs that promote the development
of new models of care.
The nation faces major challenges as it prepares for the growing number of older adults. There is a pressing need to develop a health care workforce that is sufficient in size and ability to meet the needs of this group.
Projections indicate that there will be significant workforce shortfalls in the
coming years, but simply increasing the numbers of geriatric-trained workers will not be sufficient, as it will do nothing to fix the deficiencies in the
way care is delivered to older adults or to address the inefficiencies in the
current system. The care that is currently provided to older adults often falls
short of acceptable levels of quality. Providers’ performance in the delivery
of recommended care to older adults varies greatly (RAND, 2004), and
there is limited coordination of care among providers. Expanding the capacity of the current system to meet the future needs of older adults would
75
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be a wasted opportunity. Instead, the current care delivery system requires
significant reform in order to improve the care of this population.
This chapter begins with the committee’s vision of how best to deliver
health services to older adults in the future. The vision represents a major
departure from the current system, and its implementation will require
shifts in the way that services are organized, financed, and delivered. After
this vision has been detailed, the chapter continues with a discussion of
models of health care delivery that hold promise for moving closer toward
the committee’s vision. The chapter examines the evidence on several models as well as the challenges that will likely be encountered in disseminating
these models. Although better models can lead to better care, dissemination
of improved models has generally proved to be limited, in part due to financial disincentives to implementing these better models. Thus the committee
offers its recommendation for how to foster dissemination of new models.
Finally, the chapter discusses shifts in the workforce that may be required
to support these new models, such as new roles for providers, increased
delegation of responsibilities, greater use of interdisciplinary teams, and
increased involvement of patients and their families.
A VISION FOR CARE IN THE FUTURE
The committee identified three key principles that need to form the
basis of an improved system of care delivery for older Americans (Box 3-1).
These principles are in alignment with the six aims of quality defined in
Crossing the Quality Chasm (IOM, 2001).
First and foremost, the health needs of the older population need to
be comprehensively addressed, and care needs to be patient-centered. For
most older adults care needs to include preventive services (including lifestyle modification) and coordinated treatment of chronic and acute health
conditions. For frail older adults social services may also be needed in order
to maintain or improve health. These social services need to be integrated
with health care services in their delivery and financing. Furthermore, ef-
BOX 3-1
Principles of Care
•
•
•
The health needs of the older population need to be addressed comprehensively.
Services need to be provided efficiently.
Older persons need to be active partners in their own care.
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forts need to be made to reduce the wide variation in practice protocols
among providers, which should further enhance the quality of care for
older adults.
The principle of comprehensive care also includes taking into account
the increasing socio-demographic diversity of older adults. The number and
percent of ethnic minorities in the older population is increasing dramatically, and even within ethnic groups there is tremendous cultural diversity.
Health care providers need to be sensitive to the wide variety of languages,
cultures, and health beliefs among older adults. Other segments of the older
population face additional challenges. For example, older adults in rural
areas often face isolation and barriers to access for some services.
The second principle underlying the vision of care in the future is that
services need to be provided efficiently. Providers will need to be trained to
work in interdisciplinary teams, and financing and delivery systems need to
support this interdisciplinary approach. Care needs to be seamless across
various care delivery sites, and all clinicians need to have access to patients’
health information, as well as population data, when needed. Health information technology, such as interoperable electronic health records and remote monitoring, needs to be used to support the health care workforce by
improving communication among providers and their patients, building a
record of population data, promoting interdisciplinary patient care and care
coordination, facilitating patient transitions, and improving quality and
safety overall. Giving providers immediate access to patient information,
especially for patients who are cognitively impaired and unable to provide
their own clinical history, may reduce the likelihood of errors, lower costs,
and increase efficiency in care delivery.
Efficiency can be further improved by ensuring that health care personnel are used in a way that makes the most of their capabilities. Expanding
the scope of practice or responsibility for providers has the potential to
increase the overall productivity of the workforce and at the same time
promote retention by providing greater opportunities for specialization
(e.g., through career lattices) and professional advancement. Specifically,
this would involve a cascading of responsibilities, giving additional duties
to personnel with more limited training in order to increase the amount of
time that more highly trained personnel have to carry out the work that they
alone are able to perform. While the necessary regulatory changes would
likely be controversial in some cases, the projected shortfall in workforce
supply requires an urgent response. This response will most likely have to
involve expansions in the scope of practice at all levels, while at the same
time ensuring that these changes are consistent with high-quality care.
The third principle is that older persons need to be active partners in
their own care, except when they are too frail, mentally or physically, to
do so. Such partnerships need to include the adoption of healthy lifestyles,
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self-management of chronic conditions, and increased participation by the
patient in decision making. By becoming participants in their own care, patients can improve their health, reduce unnecessary treatments, and reduce
the need for reliance on formal or informal caregivers.
Putting this vision into effect will require changes in policy and a restructuring of the health care financing and delivery systems. The purposes
of this chapter are to highlight those models of care delivery that hold
promise for providing high-quality and cost-effective care for older adults
and for promoting the committee’s vision for the future of care delivery; to
discuss the dissemination of new models of care; and to explore the changes
to the workforce that would best support those models.
NEW MODELS OF CARE DELIVERY
A number of new models of care have been developed with the aim of
improving quality and patient outcomes, promoting cost savings, or both.
The proliferation of these new models indicates not only a recognition that
services for older adults need to be improved but also a willingness among
providers, private foundations, and federal and state policy makers to commit resources to learning about better ways to finance and deliver care.
Nonetheless, while it is widely accepted that the current way of caring for older adults can be improved, there is little guidance available to
provider organizations about which interventions are most effective. Obtaining information on the effectiveness of various models is challenging
for two reasons. First, a general information gap exists. Many promising
approaches have not yet generated reliable or complete findings, and some
may never undergo rigorous evaluation because the resources required to
systematically collect data on a program can be prohibitive. Second, evaluations often come up with conflicting results. Many models have elements
in common (e.g., interdisciplinary teams, care coordination, disease management), and some evaluations of particular elements may indicate success
while others find no effect. It can be difficult to explain such discrepancies
because evaluations rarely provide information about key inputs, such as
staffing and training, or about the effects that these inputs have on program
outcomes.
In order to obtain a better understanding of the models that hold the
most promise, the committee commissioned a paper to identify those approaches to comprehensive health care delivery for older adults that have
the strongest evidence base. The review focused on frail older persons and
was limited to models that have been shown, in high-quality controlled
trials, to produce significant improvements in quality or efficiency (i.e., utilization and cost). The threshold for inclusion was the existence of one metaanalysis or at least three randomized controlled trials or quasi-experimental
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studies showing positive results. Undoubtedly these constraints led to the
exclusion of a number of approaches that may actually show promise in
the future, but a full analysis of every approach ever devised is beyond the
scope of this report.
The scope of the review was limited to articles published between
January 1987 and May 2007 on care models that were staffed primarily
by health care professionals and that in some way involved comprehensive
care (that is, were related to treatment for several chronic conditions, to
treatment for several aspects of one condition, or to treatment from multiple providers).
Altogether, the authors of the commissioned paper reviewed 128 articles reporting positive results. Because the number of new models of care
that have been developed is so large, it is not possible to discuss each one.
The models of care described here offer a few examples of the innovative
ways in which care is being provided to older adults at several points along
the care continuum and in a variety of settings. Notably, many of the models strive to provide care in a manner that is consistent with the committee’s
vision—in a more comprehensive way (e.g., by providing services beyond
those normally available), more efficiently (e.g., through the coordination
of medical and social services and the shifting of traditional provider responsibilities), and with encouragement for older adults to take on more
active roles in their own care.
Private-Sector Models
Improving Mood: Promoting Access to Collaborative Treatment for Late
Life Depression (IMPACT)
Depression in older adults is common, particularly among individuals with chronic illness (Katon, 2003). Because of the importance of this
disease to the older adult population, the John A. Hartford Foundation assembled a panel of national experts to design a program to treat depression
in the primary care setting. The result was the IMPACT program, a care
model that builds upon evidence-based treatment for depression and that
incorporates approaches used in managing other chronic diseases, such as
diabetes. Those approaches include collaboration among patients, primary
care providers, and specialists (including the use of targeted consultations);
development of a personalized treatment plan; proactive follow-up and
monitoring; and protocols for stepped care (Unutzer et al., 2002).
Patients participating in IMPACT receive educational materials about
late-life depression and visit a depression-care manager at a primary care
clinic. The care managers (typically nurses, psychologists, and social workers) are trained as depression clinical specialists and work with the patient’s
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regular primary care provider to establish a treatment plan. These care managers are supervised by a team psychiatrist and a primary care physician.
Under the IMPACT program, the care managers monitor patients in
person or by telephone and have contact with each patient at least once
every other week. They encourage patients to engage in social events, and
they refer them for additional health or social services as necessary. If a patient recovers from depression, a relapse-prevention plan is developed, and
the care manager continues to follow up with the patient. If a patient does
not respond to treatment, the patient’s case is discussed by the IMPACT
team, the patient receives a consultation with a psychiatrist at the primary
care clinic, and the patient’s medications may be altered.
The IMPACT program has reported successes according to a variety of measures. Participants had higher rates of depression treatment,
for example, and greater reductions in depressive symptoms compared to
nonparticipants (Unutzer et al., 2002). Participants were also more satisfied with their care and reported less functional impairment and greater
quality of life. They experienced an average of 107 more depression-free
days over a 2-year period than did patients receiving usual care (Katon et
al., 2005). Positive results also held over time. One year after IMPACT
activities ended, participants maintained improvements with respect to
antidepressant treatment, depressive symptoms, remission of depression,
physical functioning, quality of life, self efficacy, and satisfaction with care
as compared with a control group (Hunkeler et al., 2006).
Results from the model indicate that evidence-based care for major
depression can be successfully delivered by specially trained nurses, psychologists, and social workers in primary care settings. Total outpatient
costs were $295 higher for participants during the course of the program,
or an average of $2.76 for each additional depression-free day. Another
evaluation of IMPACT, limited to older adults with depression and diabetes, found that the incremental outpatient cost for each depression-free
day was 25 cents (Katon et al., 2006). It is difficult to know, however, the
degree of cost savings that may have been realized through the prevention
of unnecessary hospitalizations or other treatments associated with unmanaged depression.
Geriatric Resources for Assessment and Care of Elders (GRACE)
Providing health care for low-income older adults is challenging for a
number of reasons, including their high incidence of chronic illness, limited
access to care, low health literacy, and socioeconomic stressors (Counsell
et al., 2007). To improve the care provided to these patients, the GRACE
model was developed by researchers from the Indiana University School
of Medicine, the Indiana University Center for Aging Research, and the
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Regenstrief Institute. The GRACE intervention provides home-based, integrated geriatric care by a team consisting of a nurse practitioner and a
social worker that visits patients at their homes for an initial assessment
and then follows up with the patients at least once a month, either by
phone or face to face. The team also visits the patients at home after any
emergency-department or hospital visit. This two-person team is supported
by a larger interdisciplinary team which is led by a geriatrician and which
also includes a pharmacist, physical therapist, mental health social worker,
and community-based services liaison. This group, using input from the
patient’s primary care physician, establishes a care plan for the patient
which incorporates protocols that have been developed for the treatment of
12 targeted geriatric conditions. The GRACE interdisciplinary team meets
weekly to discuss the patient’s progress with the smaller team. The team’s
efforts are also supported by an electronic medical record and web-based
tracking system.
In a controlled clinical trial, Counsell and colleagues found that the
GRACE program resulted in improved quality of care and reduced acutecare utilization among a group of high-risk, low-income seniors. However,
improvements in health-related quality of life were mixed, and physical
functional outcomes did not differ from the control group (Counsell et al.,
2007). These somewhat mixed results may be explained by several factors,
including the difficulty of quantifying the comprehensiveness, coordination,
and patient-centeredness of the care. Furthermore, the study duration may
have been too short to allow a complete assessment of the intervention
(Reuben, 2007).
The Green House Model
Historically, residents’ quality of life in nursing homes has received
insufficient attention (Bowers, 2006). For example, nursing home residents
often have little choice in their schedules or daily activities. Over the past
decade, however, a small but growing movement has developed whose
goal is to change the culture of traditional nursing-home care both to improve workers’ job satisfaction and to improve the residents’ quality of life
through transformed environments, greater choice, and more empowerment
of the direct-care staff. Several new models of nursing-home care have been
developed that move away from a medical model of care toward a more
patient-centered approach.
One such model is the Green House (GH), which is designed to make
residents feel at home (March, 2007). The GH model emphasizes residents
living their lives under normal, rather than therapeutic, circumstances. The
model was based on the principles of the Eden Alternative, a movement to
foster culture change within nursing homes by creating a home-like culture
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with plants, pets, and visits by children (Hamilton and Tesh, 2002). The
Eden Alternative also decentralizes the organizational structure of nursing
homes to empower certified nursing assistants (CNAs) to develop their
own schedules and daily assignments and to provide companionship to
the residents. GHs take the concept one step further by creating a more
residential social setting.
The initial development and implementation of the GH model was supported by grants from private foundations. The model involves three key
elements. First, the environment is composed of a small, technologically
sophisticated house that functions as a home for eight to ten residents. Each
resident has a private room and bathroom, and the residents’ individual
rooms are clustered around a central area with a shared kitchen, dining
room, and living room. GHs serve as real homes in appearance and function and, as such, do not have nurses’ stations, medication carts, or public
address systems (Kane et al., 2007).
Second, the frontline caregivers have broad roles that include personal
care, cooking, housekeeping, and assuring that residents spend time according to their preferences. These direct-care workers, referred to as shahbazim,
receive 120 hours of training above those required to be a CNA. This level
of training is significantly beyond federal and state requirements and reflects
the CNAs’ expanded role in a GH. In addition, there are “sages,” older
adults who serve as coaches or mentors to the shahbazim, and “guides,”
who are supervisors and serve as liaisons between the shahbazim and other
staff. This system of support is the basis of the care team.
Third, professional healthcare providers (e.g., nurses, physicians, social
workers, and pharmacists) form visiting clinical support teams that provide
specialized assessments for residents. Licensed nurses are available and
responsible for the clinical care in the GH. A nurse is available to shahbazim whenever needed, 24 hours a day, by emergency pager (NCB Capital
Impact, 2007).
While information on the effectiveness of GHs is preliminary, a recent
evaluation of the model showed that GH residents reported better quality
of life on several measures, higher satisfaction with their place of residence,
and better emotional health than a comparison group (Kane et al., 2007).
No difference in self-reported health was noted. Quality of care was at least
as good in the GH group as in the control group. The GH group also had
a lower prevalence of residents on bed rest, fewer residents with limited
activity, and a lower prevalence of depression compared with residents of
traditional nursing homes.
In addition to its potential to promote patient-centered care, the GH
model also holds promise for improved recruitment of direct-care workers.
The first GH site received only two responses to advertisements for a CNA
but received more than 70 when the ad was for a shahbaz (Angelelli, 2006).
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Shahbazim are paid approximately 10 percent more than CNAs for their
additional responsibilities and training hours (NCB Capital Impact, 2007).
The additional pay is made possible through stabilization of the direct-care
workforce (i.e., lower costs due to decreased turnover rates), operational
efficiencies, and diminished need for middle-management positions. However, GHs do require providers to adapt to new roles. For example, attending physicians and medical directors provide care in disaggregated homes
where shahbazim are central to the care of residents and are responsible
for monitoring their status based on the direction of physicians (Kane et
al., 2007). This is different from the situation in the typical nursing home
setting, where physicians have traditionally had little communication with
direct-care staff.
The Advanced Illness Management (AIM) Program
Numerous studies have shown deficiencies in the quality of care at the
end of life. Many older adults die with inadequate palliative care (Zerzan
et al., 2000), and often patient preferences are not assessed, communicated,
or followed (Haidet et al., 1998; Hofmann et al., 1997). Most patients
prefer to die at home, yet most deaths occur in the hospital (Brumley et al.,
2007; Grande et al., 1999). And although hospice care can lead to higher
patient and family satisfaction at a lower cost (Brumley et al., 2007), many
individuals do not receive hospice care (NHPCO, 2005), and those who
do receive it rarely use the full Medicare hospice benefits (Ciemins et al.,
2006).
In an effort to bridge the gap between curative care and hospice care,
Sutter Visiting Nurse Association and Hospice created the Advanced Illness
Management (AIM) program, which provides both disease-modifying care
and comfort care in the home setting to those with advanced illnesses who
are eligible for home care but not yet eligible for hospice care (Ciemins et
al., 2006). Patients are included regardless of Medicare eligibility or insurance coverage. The program coordinates hospital services, home health
care, and, when needed, hospice services. The goals of the program are to
provide seriously ill patients with an array of home-based services, to ease
their transition from home health care to hospice care, and to avoid unnecessary hospitalizations.
The program uses a combination of home care and hospice staff. Nurse
case managers (known as AIM nurses) are the primary providers for AIM
patients. They educate patients on disease process and prognosis, treatment alternatives, advance care planning, avoidance of unnecessary hospitalization, management of pain and symptoms, and hospice enrollment.
Additionally, AIM nurses receive training classes that cover such topics as
palliative care definition and philosophy, insurance coverage, home care
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and hospice regulations, and facilitating difficult conversations. They also
attend biweekly patient-centered conferences.
An early evaluation of the program found that AIM program patients
had higher rates of hospice utilization (Ciemins et al., 2006). Notably, the
program was successful in increasing hospice utilization by African Americans, a group that has traditionally had very low rates of hospice use.
Medicare Research and Demonstration Projects
In addition to private-sector initiatives, a number of models have been
tested by the Centers for Medicare and Medicaid Services (CMS). These
demonstration projects have examined mechanisms to restructure the Medicare and Medicaid programs in ways that support more efficient and more
effective care delivery for older adults. For example, older adults with
long-term health care needs often face fragmentation in their care because
the Medicare program finances acute care at the national level while stateadministered Medicaid programs are the predominant payers for long-term
care services (Kaiser Family Foundation, 2006). Discontinuities between the
two programs can translate into discontinuities in care as well as into higher
costs, as the two programs often seek to shift costs to each other (National
Commission for Quality Long Term Care, 2006). CMS demonstration
projects have tested a number of ways to improve quality in Medicare (and
often Medicaid as well). Several of these projects are described below.
Programs of All-Inclusive Care for the Elderly (PACE)
PACE is a managed-care program that was developed to address the
spectrum of needs for adults aged 55 and older with disability levels that
make them eligible for nursing-home care (Tritz, 2005). The program is
based on the belief that the well-being of older adults can be improved by
serving them in the community (Mukamel et al., 2007). PACE was modeled
after an innovative initiative in San Francisco, On Lok, that was designed
to help the Asian American community care for older adults in their homes
(Greenwood, 2001).
Start-up funds for PACE were provided by private foundations, and its
implementation was supported by congressional authorization of Medicare
and Medicaid waivers (Gross et al., 2004). The PACE model funds a comprehensive set of services by combining federal Medicare dollars, state and
federal Medicaid funds, and the individuals’ own contributions (National
PACE Association, 2007). The PACE service package includes all Medicare
and Medicaid covered services plus additional services, including adult
day care, nutritional counseling, recreational therapy, transportation, and
personal-care services, such as meals at home (CMS, 2005). PACE also pays
for nursing-home care, if appropriate.
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PACE services are provided by an interdisciplinary team composed of at
least the following members: a primary care physician, a registered nurse, a
social worker, a physical therapist, a pharmacist, an occupational therapist,
a recreational therapist, a dietician, a PACE center manager, a home-care
coordinator, personal-care attendants, and drivers (Mukamel et al., 2007).
The team approach in PACE is innovative in its inclusion of both professionals and direct-care workers as part of the care team. Each member of
the team performs an initial assessment of each patient, and then the group
works together to create a single care plan that takes the different assessments into account. The team holds weekly care-planning meetings during
which the care plans are reassessed.
The services, which are provided primarily at an adult day-care center,
are also highly coordinated (Cooper and Fishman, 2003; Mukamel et al.,
2006). The center includes a health clinic and at least one common room
for social and recreational activities. PACE enrollees attend the day center
approximately three days per week, enabling team members to identify
subtle changes in health status or mood and to address them quickly. Team
members regularly reassess the medical, functional and psychosocial conditions of patients and document any changes in the medical record.
An evaluation of the PACE demonstration program found that enrollment was associated with higher patient satisfaction, improved health status
and physical functioning, an increased number of days in the community,
improved quality of life, and lower mortality (Chatterji et al., 1998). The
benefits of PACE were even greater for the frailest older adults, whose enrollment was associated with lower rates of service utilization in hospitals
and nursing homes and higher rates of ambulatory care services.
An analysis showed that capitated payments under PACE were about
10 percent higher than the payments that would have been likely under
the fee-for-service (FFS) program. The analysis found savings for Medicare but higher costs for Medicaid. Capitated Medicare payments were
42 percent lower than projected Medicare FFS expenditures, but capitated
Medicaid payments were 86 percent higher than projected FFS expenditures
(Grabowski, 2006; White et al., 2000).
It is also notable that PACE programs have achieved some success in
the recruitment of direct-care workers (Hansen, 2007). The program has
a 12 percent annual turnover rate among aides, well below rates reported
nationally. Aides at PACE sites are given opportunities for career advancement, and PACE provides financial support to direct-care workers seeking
additional training.
Evercare
The Evercare program, originally developed by United Health Care
Corporation, assigns nursing-home residents to a risk-bearing health main-
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tenance organization (HMO) (Inglis et al., 2004) that coordinates Medicare
acute-care services and nursing-home services under Medicaid (Hansen,
2007). Under the program, nurse practitioners provide more intensive
primary care services than is typical for nursing-homes residents, and they
coordinate enrollees’ care with the nursing-home staff (Stone, 2000). The
nurse practitioners have relatively small caseloads and visit each of the
nursing homes every second or third day. They are engaged in clinical work,
spending about one-third of their days on direct patient care, and they also
serve in a coordinating role, communicating information to various parties, including nursing-home staff, families, and patients’ physicians. The
nurse practitioners work with nursing-home staff to monitor treatment and
to identify changes in patient status. The Evercare program also educates
nursing-home staff through formal in-service training as well as through
less formal on-the-job training.
An evaluation of the Evercare program showed that it succeeded in
reducing hospital admissions and in providing high-quality coordinated
care to patients, with a number of caveats (Kane et al., 2002). The analysis
showed that, on average, the use of nurse practitioners saved approximately
$88,000 per year per nurse practitioner in reduced hospital usage. In large
part this reduction in hospital usage resulted from Evercare’s use of intensive service days, through which nursing homes were paid an extra fee to
take on cases that might otherwise be handled in the hospital. The evaluation concluded that providing more intensive primary care to nursing-home
residents produced more efficient crisis care, but it typically did not prevent the crises themselves. In addition, the capitated payments resulted in
overpayment to the plan and no Medicare cost savings (Kane et al., 2002).
Nonetheless, the Medicare Modernization Act (MMA) of 20031 made the
Evercare program a permanent option.
Social HMO Demonstrations
The Social HMO (SHMO) demonstrations focused on new approaches
for providing care on a capitated basis to patients with complex medical needs, specifically frail patients at risk for nursing-home placement
(Vladeck, 1996). The Deficit Reduction Act of 19842 called for a demonstration of the SHMO concept (SHMO I), which sought to integrate health
care services and long-term care services. A second demonstration model
(SHMO II) was authorized in the Omnibus Budget Reconciliation Act of
1 Medicare
2 Deficit
Modernization Act of 2003. Public Law 108-173. 108th Congress. (2003).
Reduction Act of 1984. Public Law 98-369. 98th Congress. (1984).
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1990.3 Four sites became operational under SHMO I, and only one plan
participated in SHMO II (Thompson, 2002).
Enrollees of the SHMOs received coordinated acute-care and communitycare benefits, including personal care, homemaking services, adult day care,
personal emergency response service, transportation, respite, durable medical
equipment, and short-term institutional care for convalescent and respite
stays (Leutz and Capitman, 2005). Integration of acute care and long-term
care involved operational linkages, including referral systems, as well as
sharing of assessments and clinical data, management of transitions across
settings, and benefit coordination. The project did not generally involve
such strategies as changing the practice patterns of primary care physicians
to include geriatric principles or the hiring of a variety of geriatric practitioners. The SHMO II model incorporated a more team-oriented geriatric
approach to care than did the first demonstration, and it brought together
primary care physicians, geriatricians, specialists, pharmacists, dieticians,
and nurse case managers (Thompson, 2002).
Project evaluations for SHMO I generally found the effects of the program to be limited in terms of cost and enrollee outcomes, although the
methodologies employed by these analyses have been criticized (Atkinson,
2001; Manton et al., 1993). A study by Manton and colleagues found that
SHMOs produced better outcomes for healthy and acutely ill enrollees than
for impaired persons or for acutely ill persons with chronic impairments
(Manton et al., 1993). The same report found that neither the long-term
care services provided by the SHMOs nor their integration with acute care
appeared to be effective. An evaluation conducted for CMS in 2002 found
that payments to SHMOs were 15 percent to 30 percent higher than standard HMOs would have received for the same enrollees (Thompson, 2002).
Another study, however, found that the termination of the Minneapolis
SHMO project in 1994 was associated with a 40 percent increase in longterm institutional placement, indicating that the program had been effective
in its primary objective of keeping older adults in community-based settings
(Fischer et al., 2003).
Other Medicare Demonstrations
In addition to the demonstration projects described above, the Medicare program has developed and implemented a number of other demonstration projects that have tested new ways of delivering care to older
adults. CMS’s demonstration authority allows the agency to waive certain
rules concerning which services are covered and how they are reimbursed in
3 Omnibus
Budget Reconciliation Act of 1990. Public Law 101-508. 101st Congress.
(1990).
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order for the agency to be able to test and measure the effects of potential
program changes (Thompson, 2002).
Table 3-1 offers details on several of the demonstration projects. These
demonstrations were designed to encourage coordinated care for chronically ill beneficiaries and to address some of the structural impediments to
providing appropriate care for these beneficiaries. The designs of many of
the projects were based on disease-management programs developed in the
private sector (CMS, 2007b). The hope was that the demonstration projects
would point to ways to improve treatment plans, reduce avoidable admissions, and promote improved patient outcomes without increasing cost.
Unfortunately, the majority of these demonstration projects had little effect
on patient outcomes and produced no cost savings. In fact, in a number of
cases Medicare expenditures increased as a result of the project, in part because of expansion of services and in part because the specific savings that
had been projected were not realized. As discussed previously, the mixture
of results makes it difficult to pinpoint which elements of these models are
most likely to lead to successful improvements in patient care.
The evaluations revealed that the demonstration projects encountered
a number of difficulties, including problems enrolling patients in the demonstrations, low levels of enthusiasm for the program by patients and
physicians, inexperienced or inadequately trained staff, and hardware and
software problems with patient-monitoring equipment (Guterman, 2007).
Still, considering the evidence that the Medicare program often falls short
on various dimensions of quality and efficiency, the need to research and
develop alternative approaches to care delivery remains paramount.
Despite this need, however, relatively little investment has been made
in the research and development of innovative models of care that could
improve outcomes or lower costs, particularly as compared with how much
is spent each year on the health care of older adults. In fiscal year 2007,
for example, the total budget for Medicare operations was more than $2
billion; less than 2 percent of this was spent on research, demonstration,
and evaluation (Table 3-2). In fact, in recent years Medicare has spent a
decreasing proportion of its operations budget on research, demonstration,
and evaluation. This low investment is even more startling when compared
to the hundreds of billions of dollars spent on Medicare benefits. In order
to improve the way that care is delivered, more investments will be needed
to explore newer and more efficient models of care.
Medicaid Demonstration Projects
Many state Medicaid programs have developed innovative models of
care to integrate services, to improve care coordination, and most notably,
to allow individuals a larger role in shaping the services that they receive. In
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NEW MODELS OF CARE
TABLE 3-1 Findings from Select Medicare Demonstration Projects
Project (Start Year)
Purpose
Outcomes
Care Management
for High Cost
Beneficiaries (2005)
To study various caremanagement models for
high-cost beneficiaries in the
traditional Medicare fee-forservice program who have
one or more chronic diseases
(e.g., Texas Senior Trails;
Health Buddy).
Ongoing. Will review 3-year pilot
programs implemented by six Care
Management Organizations (CMOs).
Community
Nursing
Organization
Demonstration
(2003)
Tested the use of nurse case
managers to coordinate care
and provide enrollees with
a more flexible array of
services, such as prevention
and health promotion, under
a capitated arrangement.
Enrollment did not affect health status
or utilization of services covered
under the traditional Medicare benefit
package. Total expenditures for
treatment groups were significantly
greater than the control group.
Medicare Disease
Management
Demonstration
(2003)
To evaluate the effect of
disease-management services,
coupled with a prescription
drug benefit, for those with
advanced-stage congestive
heart failure, diabetes, or
coronary disease.
The three demonstration sites
encountered difficulties identifying and
enrolling beneficiaries, and, given the
magnitude of the risk they faced, the
project was discontinued prior to the
intended conclusion date.
Medicare
Coordinated Care
Demonstration
(2001)
To test whether providing
coordinated-care services to
Medicare beneficiaries with
complex chronic conditions
can yield better patient
outcomes without increasing
program costs.
Interim evaluation found increases in
beneficiary education but no effect on
satisfaction, patient adherence, self
care, or Medicare expenditures. There
was a small but statistically significant
reduction in the proportion of patients
hospitalized during the year after
enrollment.
Informatics for
Diabetes Education
and Telemedicine
(IDEAtel) (2000)
To test the use of
telemedicine networks
to improve primary and
preventive care for Medicare
beneficiaries with diabetes
who live in underserved
inner-city and rural areas of
New York.
Interim evaluation shows the project
had favorable effects on diabetes
control and care, use of recommended
medications, and communication
with health care providers about diet
and care. The demonstration did not
generate savings to the Medicare
program and was costly to implement
($8,200 to $8,900 per enrollee per
year).
Medicare Case
Management (Early
Coordinated Care)
Demonstrations
(1995)
To provide case-management
services to beneficiaries with
catastrophic illnesses and
high medical costs.
Despite high levels of satisfaction
among the beneficiaries who
participated, there was no
improvement in self care or health.
Medicare spending was not reduced.
SOURCE: CMS, 2008a.
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TABLE 3-2 Appropriations History of Medicare Research,
Demonstration, and Evaluation as Compared to Medicare Operations
Fiscal
Year
Research,
Demonstration, and
Evaluation (in Millions)
Total Medicare
Operations
(in Millions)
Research, Demonstration,
and Evaluation as Percent
of Medicare Operations
2003
2004
2005
2006
2007
2008d
$73.7
$77.8
$77.5
$69.4a
$41.5
$33.7
$1,666.7
$1,701.0
$1,730.9
$2,200.8b
$2,210.6c
$2,303.6
4.42%
4.57%
4.48%
3.15%
1.88%
1.46%
aIncludes
bIncludes
Deficit Reduction Act funding.
Deficit Reduction Act and the Secretary’s Section 202 Transfer Authority
funding.
cIncludes Tax Relief and Health Care Act of 2006 funding.
d2008 reflects the President’s FY 2008 budget.
SOURCE: DHHS, 2007.
Maine, for example, Medicaid beneficiaries are referred to a consumer-run
independent living center, which assesses their preferences and their ability
to self-direct care, trains them with regard to hiring and managing their
own services, and provides a list of available workers (Benjamin, 2001).
Oregon’s Medicaid program allows individuals, with guidance from case
managers, to hire and fire workers as they choose. An evaluation of these
models found that patients had greater satisfaction with services, increased
feelings of empowerment, and better perceived quality of life (Stone, 2000).
There is limited evidence, however, that focuses specifically on older adults
and the effect that these programs have on them. Four of these programs
are described below.
Arizona Long-Term Care System (Arizona)
The Arizona Long-Term Care System (ALTCS) was developed in 1989
to provide care to Medicaid-eligible individuals who are at risk of institutionalization in a long-term care setting, typically older adults and disabled
persons. ALTCS is a capitated, mandatory long-term care system in which
services are integrated by a managed care organization into a single delivery package. For those beneficiaries also eligible for Medicare, providers
must bill those services to Medicare and are paid through the FFS system.
Services offered under ALTCS include acute medical care, behavioral health
services, and case management. Services are also covered for care delivered
in nursing homes, in the home setting, and in assisted-living facilities.
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91
ALTCS pays for part of the costs for room and board, medical and hospital
care, and prescription drugs.
An evaluation of ALTCS showed that, compared to New Mexico Medicaid (a traditional Medicaid program), ALTCS provided quality care at
lower costs (McCall, 1997). Program savings averaged 18 percent annually,
totaling $290 million in savings for medical services alone. ALTCS beneficiaries had more medical visits but fewer hospital days than beneficiaries of
New Mexico Medicaid. During the first 13 years of the program, however,
the quality of care was found to be higher in the traditional Medicaid program. This program is still active in Arizona.
Senior Health Options (Minnesota)
The Minnesota Senior Health Options (SHO) program was adopted
with support from the Robert Wood Johnson Foundation. SHO offers enrollees a package of acute and long-term care services through a choice of
managed care plans. The state is essentially treated like a health plan that
contracts with CMS to provide services; the state then subcontracts with
health plans that combine services from Medicare and Medicaid into one
integrated benefit package for enrollees (CMS, 2004; Malone et al., 2004).
At the center of the initiative is coordination of care for dually eligible
beneficiaries who live in institutions or who live in the community but
meet institutional placement criteria. Evaluations indicate that enrollees in
the program had fewer hospitalizations and emergency room visits (Kane
et al., 2004) and were more likely to receive preventive services (Kane and
Homyak, 2003); however, capitation rates were higher than they would
be under fee-for-service. The program, which began in 1997, continues to
operate and became a statewide option in 2005 (Tritz, 2006).
Family Care (Wisconsin)
The goals of Wisconsin’s Family Care program are to improve patient
choices regarding type of residence and service supports that enrollees
receive, improve access to services and quality of care, and achieve cost efficiencies (Justice, 2003). The program has two significant design features:
a single entry point for patients (an Aging and Disability Resource Center)
and patient-centered services. The center provides patients with advice and
access to long-term support options, screening to determine eligibility for
publicly financed services, and pre-admission consultations for those entering nursing homes or residential care facilities. The centers are staffed by
social workers and nurses who are supported by direct-care workers and
volunteers. Together these workers conduct a comprehensive assessment of
patients’ needs, preferences, and values.
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Care-management organizations (CMOs) manage the Family Care
benefits, providing services in community, residential, and institutional
settings (Justice, 2003). Funding from multiple programs (e.g., home- and
community-based waiver services, state general-revenue-funded programs,
and Medicare long-term care services) are consolidated into the single
Family Care program, and CMOs are paid a capitated rate. This creates
an incentive for the CMOs to provide support to enrollees in their homes
rather than in institutions. The program also allows enrollees to have a high
level of self-direction, organizing services around enrollees’ unique needs
and preferences rather than strictly by allowable services or designated
providers.
Through its focus on social outcomes, the program has succeeded in
increasing choice and access and improving quality, but early results found
no effect on claims-based measures, such as utilization, and it was not
possible to determine the cost-effectiveness of the program (Alecxih et al.,
2003). Regardless, enrollees did not experience a decline in service levels at
the start of the program, and the demand for services from the centers has
been much stronger than anticipated (Medstat, 2003).
Cash and Counseling
Under the national cash and counseling demonstration project conducted in three states, individuals received a monthly allowance (in the form
of direct cash payments) to purchase disability-related goods and services.
Enrollees were provided with counseling and financial assistance to help
them plan and manage their choices. An evaluation found that the program
improved satisfaction and the quality of life for enrollees and caregivers, reduced most unmet needs among enrollees without adversely affecting health
or safety, and resulted in a reduction in nursing-home and other long-term
care costs (Foster et al., 2003; RWJF, 2006). Costs were somewhat higher
for enrollees because they were receiving more of the care that they were
authorized to receive. Similar programs are now being adopted in 12 more
states, and federal waiver authority is no longer required for states to implement cash and counseling programs.
One unusual aspect of these efforts is that they often allow patients to
hire informal caregivers as their workers. Critics suggest that this allowance presents an opportunity for fraud and abuse and worry that costs will
soar if informal caregivers currently providing unpaid care start to demand
payment for their services (Stone, 2000). Others contend that the allowance
will expand the pool of available caregivers and that the services provided
may be more in line with patients’ preferences (Benjamin, 2001). Evidence
of the effect of hiring relatives is not clear. One study found that about one
in five paid informal caregivers had not been providing care prior to the
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formal hiring. The study also found that beneficiaries had a greater sense
of security and choice in hiring a family member. Overall, the results of the
cash and counseling demonstration, which allowed enrollees to hire family,
indicate that the project did not result in misuse of Medicaid funding.
Features of Innovative Models
The committee did not attempt to rank the models described above
or to recommend one model of care over another. In fact, little evidence
exists that one might use to rate the relative effectiveness of these different
approaches. Typically, evaluations focus on whether a single model proved
to be successful rather than identifying which of several models produced
the strongest results. The committee concluded that no single one of the
models described above would be sufficient to meet the needs of all older
adults. Instead, a variety of models will need to be employed to meet the
targeted needs of older adults. For example, preventive home visits may be
too costly to expand to all older persons, the majority of whom may not
even require that level of care. Similarly, caregiver-support programs may
not be sufficient for older adults with more intensive needs. The health care
needs of the older population are diverse, and addressing those needs will
require varying models of care. Fortunately, the models described above
have generally been successful in enrolling mainly those older adults who
would best benefit from the expanded services.
After reviewing the evidence on a number of different models of care,
the committee concluded that some of the models with the strongest evidence of success in improving care quality, health-related outcomes, or
efficiency have common features which may contribute to their success
(Table 3-3).
The model components described in Table 3-3 have shown positive
outcomes, at least in some circumstances, but these findings need to be
interpreted with caution. First, the list is derived from an examination of
only those interventions that have been rigorously evaluated and published
in the peer-reviewed literature; many others have not yet been thoroughly
evaluated. Furthermore, because the models have proved successful in only
certain settings, one cannot be certain that they will experience the same
success if they are adopted more widely. Adoption of a model in rural areas
or at community hospitals, for instance, may not yield the same results as
when the initiatives were undertaken at urban academic medical centers.
Similarly, there is limited information on the scalability of the models, that
is, on whether they could be successfully applied to a much larger population of patients. Finally, the literature review commissioned by the committee focused on identifying interventions that have produced successful
results. In some cases, alternative evaluations of the same model may show
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TABLE 3-3 Features of New Models (Select Research Findings Showing
Positive Results)
Description
Findings in Support of the Intervention
Interdisciplinary team care. Providers from
different disciplines collaboratively manage the
care of a patient. These providers may include
primary care physicians, registered nurses,
social workers, physical therapists, pharmacists,
occupational therapists, recreational therapists,
dieticians, home-care providers, personal-care
attendants, and drivers. The members of the
team communicate regularly with each other
about their patients.
Some studies demonstrated improved
survival and quality of life (QOL)
(improved well-being, less anxiety, and
dyspnea), quality of care, health outcome
scores, and patient satisfaction.
Care management. In most forms a nurse or
social worker provides patients (and sometimes
families) a combination of health assessment,
planning, education, behavioral counseling,
and coordination. Their communication with
primary care providers varies from frequent
to rare, depending on the care-management
program.
Studies examining care management for
patients with heart failure demonstrated
improved satisfaction, use of appropriate
medications, QOL, and survival, as well
as fewer hospital admissions and days.
Chronic disease self-management
programs. Self-management programs are
structured, time-limited interventions designed
to provide health information and to empower
patients to assume an active role in managing
their chronic conditions. Some are led by health
professionals and focus on the management
of specific conditions, such as stroke, while
others are led by trained laypersons and address
chronic conditions more generally.
Improved QOL (psychosocial function,
control of symptoms, pain, stiffness),
functional autonomy (e.g., mobility,
fewer bed days, walking capacity), and
satisfaction.
Pharmaceutical management. Advice about
medications is provided by pharmacists to
patients, either directly or through the actions of
interdisciplinary teams. Recommendations are
intended to encourage the safe, effective use of
prescribed and over-the-counter medications.
Improved quality of care (adherence
to medication guidelines), QOL (fewer
symptoms), control of blood pressure,
and survival.
Preventive home visits. Home visits are
provided to older persons by nurses or other
visitors to monitor health and functional status
and to encourage self-care and appropriate use
of health care services. These visitors usually
visit their clients quarterly and communicate
regularly with their patients’ primary care
providers.
Improved QOL, survival, functional
autonomy.
Some also showed lower total costs,
fewer hospital admissions, physician
visits, emergency department visits, and
x-rays.
Fewer hospital admissions and days,
lower coronary artery disease inpatient
costs.
Insufficient evidence to indicate efficiency
improvements.
Fewer nursing-home and hospital
admissions.
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TABLE 3-3 Continued
Description
Findings in Support of the Intervention
Proactive rehabilitation. As a supplement to
primary care, rehabilitation therapists provide
outpatient assessments and interventions
designed to help disabled older persons to
maximize their functional autonomy, home
safety, and quality of life. Most of the few
existing experimental programs operate in
concert with patients’ primary care physicians.
Improved QOL (less pain, fewer
symptoms, decreased fear of falling,
improved self efficacy), functional
autonomy (improved activities of daily
living [ADLs] and instrumental activities
of daily living [IADLs], functional
independence, chance of remaining at
home), and survival.
Insufficient evidence to indicate efficiency
improvements.
Caregiver education and support. These
programs are designed to help the informal
caregivers of older persons with chronic
conditions such as dementia and stroke. Led by
psychologists, social workers, or rehabilitation
therapists, these programs provide varying
combinations of health information, training,
access to professional and community resources,
emotional support, counseling, and coping
strategies. They communicate with primary care
providers primarily through their clients.
Improved QOL (e.g., mood) and physical
functioning of care recipients.
Transitional care. Typically a nurse or an
advanced-practice nurse prepares and coaches
the patient and informal caregiver for the
transition from hospital to home. The nurse
visits the patient at home to ensure that all
needed medication, equipment, and supplies
are available and that the patient and caregiver
know how to use them, how to self-monitor,
and whom to call if problems arise. The nurse
continues to monitor the situation for several
weeks until the patient has returned to preadmission status, contacting the primary care
physician as needed.
Improved QOL and survival.
Lower total cost of care, delayed and
fewer nursing home admissions.
Lower total costs, fewer hospital
readmissions.
SOURCE: Boult et al., 2007.
no improvement in quality, outcomes, or efficiency. Still, the results from
these evaluations give reason to be cautiously optimistic that the diffusion
of models with these features could result in improved care for older adults
and perhaps introduce greater efficiencies into the Medicare and Medicaid
programs.
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PAYING FOR NEW MODELS OF CARE
The models of care with the strongest evidence base often expand the
range of services provided to older patients, for example, with the addition
of social services, caregiver education and support, and preventive home
visits. Yet, Medicare typically does not cover these additional services, even
if evaluations indicate that they reduce costly hospitalizations or nursinghome use in the long run. This lack of coverage contributes to the failure of
many models to gain widespread traction. This section reviews the way in
which Medicare services are currently paid for and presents several alternatives that could be used to foster the development and implementation of
new models of care.
Fee-for-Service Medicare
One major problem is that brief visits are a poor way of managing
chronic conditions even though care for chronic conditions is the most common reason that Medicare patients seek physician care (Hing et al., 2006;
McGlynn et al., 2003; Scherger, 2005). Furthermore, under the FFS system,
more visits lead to higher physician and hospital revenues regardless of the
quality or efficacy of the services being delivered (MedPAC, 2006). Payment
is directed to individual physicians and emphasizes treatment for in-person
care, which serves as a barrier to care coordination. This disincentive is
particularly significant since most Medicare patients seek care from multiple
providers (MedPAC, 2006). Furthermore, such a payment mechanism provides no financial incentive for health care providers to deliver services that
extend beyond the typical office visit, such as ongoing patient education to
teach older adults how to better manage their chronic conditions between
visits (Brown et al., 2007).
Medicare is required by statute to apply its rules uniformly to all
providers, limiting its ability to reward exemplary performance (Berenson
and Horvath, 2003). CMS cannot provide additional payment or greater
flexibility to organizations that offer additional services to patients, even if
they are targeting frail older adults or some other particularly needy group
of older adults. Overall, the traditional FFS system limits innovation in
care delivery.
Shifting the focus of care delivery away from acute care is difficult in
part because of the rather complicated process that CMS must follow in
order to add coverage for newer services, such as preventive home visits or
care coordination. CMS must determine that the service fits into a statutorily established benefit category and that it is “reasonable and necessary”
in order to diagnose or treat an illness, and then it must assign the service
an appropriate payment code. Many services that are critical components
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of new models of care would have difficulty fitting into these criteria. For
example, neither patient education to promote self-management nor interdisciplinary team meetings to discuss patients’ health status fit easily into a
statutorily established benefit category (Berenson and Horvath, 2003). Furthermore, many geriatric care models require the services of care managers,
typically nurses or social workers, but these workers often do not qualify
for Medicare reimbursement. Statutory changes will be needed to make it
possible to pay for these services.
Medicare Advantage
Nineteen percent of Medicare beneficiaries are enrolled in Medicare
Advantage (MA), Medicare’s managed care program. MA’s capitated payment system puts health plans at financial risk, which gives them an incentive to identify high-risk enrollees and assist them in averting medical
complications and also to promote continued good health among older
beneficiaries who are not chronically ill. The goal of this approach is to
encourage health plans to promote appropriate, cost-effective care across
settings (Berenson and Horvath, 2003).
Capitated payments allow for greater innovation in care delivery and
can promote the adoption of new models of care. For example, Kaiser
Permanente’s Medicare HMO has been able to hire greater numbers of
geriatricians and increase payments for their services. In addition, MA plans
offer benefits beyond those that are available in the traditional FFS system,
including preventive dental services. Care coordination, which is generally
not available to beneficiaries under FFS, is routinely offered by MA plans
and is administratively easier to perform under capitation because of the
plans’ provider networks. Plans are required to use any cost savings they realize to provide benefits beyond those required by the Medicare program.
Studies indicate that older adults who choose to enroll in MA are generally healthier and have lower medical costs than FFS beneficiaries, and
at least one study suggests that the incentive for MA plans to maintain this
member composition may persist despite the implementation of risk adjustment (MedPAC, 2007a). CMS began phasing in risk-adjustment payments
in 2004, and by 2007 payments were based entirely on risk-adjusted rates
(Berenson and Horvath, 2003). At the same time, CMS also included a
hold-harmless adjustment so that plan payments would not decline due to
risk adjustment. In fact, payments to MA plans are about 12 percent higher
than the average FFS costs in the same area (Kaiser Family Foundation,
2007). That difference is expected to decrease as the hold-harmless adjustment is phased out through 2011 (MedPAC, 2007b).
Although capitation appears to be a reasonable means to incorporate cost-effective new models of care into practice, this promise has not
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been fully realized. Based on recent experience, health plans have typically
contracted with all available physicians and hospitals rather than developing tighter networks, and the quality of care for individuals with chronic
disease in FFS and managed care has ended up being roughly equivalent
(Norwalk, 2007). However, a review of studies conducted by Miller and
Luft found that enrollees in Medicare HMOs reported worse results on
measures of access to care and patient satisfaction (Miller and Luft, 2002).
In short, considerable debate still exists about whether the added funds
provided to MA plans have been worth the investment.
New Financing Mechanisms
Given the challenges associated with traditional FFS Medicare and MA,
a new model of payment is needed to support effective models of care and
the integration across various settings of service that are necessary to prevent or delay declines in functional and health status for older adults (Biles
et al., 2006; Guterman and Serber, 2007). Even with start-up funding from
a foundation, insurer, or provider organization, the long-term sustainability
of such services is limited in the absence of appropriate reimbursement from
Medicare and other payers.
It is beyond the scope of this report to recommend a specific method
of reimbursement to support new models of care, but the committee did
identify several promising methods. In general, it is important to note that
during the research and demonstration phase of a new model CMS typically
sets up financial arrangements that differ significantly from the traditional
FFS arrangement. In order to move from the demonstration stage to widespread adoption, the general financing system will also need to be altered,
likely requiring that some sort of capitated arrangement be put in place.
Special Needs Plans
As a result of the Medicare Modernization Act (MMA) of 2003,4
special needs plans (SNPs) were created within the MA program. SNPs
can target their enrollment to high-needs patients such as institutionalized
beneficiaries, dually eligible beneficiaries, or beneficiaries with severe or disabling conditions (CMS, 2007c). Targeted enrollment allows plans to design
clinical programs that can accommodate those with distinct health needs,
which can potentially result in reduced hospitalization and institutionalization (CMS, 2007a). SNPs are paid under the same system (risk-adjusted
capitation) and regulated in the same manner as other MA plans.
The number of SNPs has been growing rapidly, increasing from 276
4 Medicare
Modernization Act of 2003. Public Law 108-173. 108th Congress. (2003).
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in 2006 to 775 in 2008. As of November 2007, SNPs had enrolled more
than 1 million Medicare beneficiaries (Harrison and Podulka, 2007). SNPs
were reauthorized through the end of 2009,5 including a 1-year moratorium
for new SNPs. To evaluate the effect of using SNPs, CMS contracted with
the National Committee for Quality Assurance (NCQA) to develop SNPspecific measures based on those used for the Healthcare Effectiveness Data
and Information Set (HEDIS). Measures specific to the care of older adults
include glaucoma screening, osteoporosis management, and use of high-risk
medication (NCQA, 2008). SNPs were required to report on these measures
by June 30, 2008; data regarding the results of this evaluation were not
available at the time this report was prepared.
MedPAC Approaches
A number of additional proposals to support new models of care have
been developed. MedPAC proposed two approaches for enhancing care coordination in Medicare FFS (Stone, 2000). Under the first approach, group
practices or integrated delivery systems would furnish care-coordination
services to high-risk patients (e.g., a nurse care manager would share space
with the physicians). These group practices would be responsible for investing in information technology and in a nurse-manager infrastructure in order to better manage care. Under the second approach, solo or small group
practices would refer high-risk patients to an affiliated care-management
organization that would employ the care-manager nurses and have information systems to assess patient severity levels and target interventions.
Medicare would pay the care-coordination entity (either the group practice
or the care-management organization) for services, and that payment would
be tied to cost savings and quality goals. Payment would be either shared
savings or an at-risk care managed fee. Medicare would also provide an
incentive payment to physicians to encourage them to collaborate with the
care managers.
Addition of Medicare Benefits
Another way to support new models of care would be for Congress to
create additional Medicare benefits. For example, one proposal calls for
the creation of a modified home visit benefit for beneficiaries in need of
extended home-nursing and personal-care services (Berenson and Horvath,
2003). The new, lower-level home health benefit would not be as intensive
as the current home health benefit, but it could allow instead for physicians
5 Medicare,
Medicaid, and SCHIP Extension Act of 2007. Public Law 110-173. 110th
Congress. (2007).
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to authorize their nurses or physician assistants to periodically conduct
home visits for patients unable to come into the office. It would cover
such services as medical assessment, medical monitoring, and medication
management. Delivery of such services would allow the physician to receive
more direct knowledge than could be obtained if similar services were provided through a separate home health agency. This approach of legislating
additional benefits could potentially be applied to other types of services,
such as chronic-disease self-management training and caregiver education
and support.
Advanced Medical Homes
Finally, a more radical departure from the current FFS system is a
proposal that calls for the creation of advanced medical homes through
comprehensive payment for primary care (Goroll et al., 2007). In this
system physicians would be paid a risk-adjusted, per-member, per-month
fee that would cover care coordination and medical services provided to
the patient (Berenson, 2007). Payment would be considerably higher than
current FFS or MA payments, allowing practices a greater opportunity to
support different models of care. Participating practices would be required
to undergo structural and organizational changes (e.g., the adoption of
interoperable electronic health records with decision support and the use
of interdisciplinary teams) that follow established standards. A portion of
the payment would then be based on performance.
Risk adjustment would make it less likely that physicians would avoid
high-risk or psychosocially disadvantaged patients and would also influence the pay-for-performance goals (Goroll et al., 2007). Several validated
diagnosis-based models of risk adjustment exist and have been modified for
payments to health plans (Ash et al., 2000; Kronick et al., 2000; Newhouse
et al., 1997). Those models would need to be further modified for the practice level and need to include the spectrum of risk determinants, including
patient behaviors. Although costs would initially be high, proponents of
this revised payment system believe that long-term costs would be tempered
by reductions in administrative costs, inefficiencies, and overutilization.
This proposal differs from some capitated payment systems in that
physicians would not be at risk for hospital, specialist, and ancillary service
costs. Appropriate utilization of services would be achieved through the use
of evidence-based guidelines and decision-support systems, and the pay-forperformance bonuses would be based both on outcomes and efficiency. If
responsibility for a patient is transferred to a specialist—for example, in
the case of a patient with cancer—the specialist may receive some or all of
the per-member, per-month payment.
Additional payments to practices under this proposal provide the means
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to offer new services or deliver care in a new manner (e.g., preventive home
visits and use of interdisciplinary teams).
It should be noted that CMS is implementing a new Medical Home
demonstration program in 2008 that is similar in many ways to the advanced medical home concept. According to the statutory language, physicians will be required to (1) provide ongoing support, oversight, and
guidance to implement an integrated, coherent, cross-discipline plan for
ongoing medical care, which will be developed in partnership with the
patient and all other physicians, medical personnel, and agencies (e.g.,
home health agencies) providing care to the patient; (2) use evidence-based
medicine and clinical decision support tools to guide decision making; (3)
use health information technology (e.g., remote monitoring and patient
registries) to monitor and track the health status of patients and to provide
them with enhanced and convenient access to services; and (4) encourage
patients to engage in the management of their own health through education and support systems (CMS, 2008b). Participating physicians will be
reimbursed under the traditional Medicare Physician Fee Schedule but will
also be eligible for a care-management fee for each participating beneficiary
under their care and a bonus based on the achievement of savings and quality goals (ACP, 2006). However, while the concept of an advanced medical
home was intended to be applicable to all individuals, the demonstration
project will be limited to those with multiple chronic illnesses.
DISSEMINATION OF NEW MODELS OF CARE
Identifying successful models of care is just the first challenge in improving the delivery of services to older adults. Successful models need
to be replicated and incorporated widely into practice in order to reach a
large patient population, and, in general, the adoption of best practices has
occurred very slowly in the health care sector as well as other industries
(Berwick, 2003). Indeed, evidence shows that innovations that have been
demonstrated to improve the quality of patient care can take more than 17
years to become common practice (Balas and Boren, 2000). Little is known
about the best way to promote the exchange of information concerning
how to improve the quality of care (IOM, 2006a). Rogers’ diffusion of
innovations theory defined five categories related to the adopters of new
practices:
•
•
•
Innovators, who embrace new ideas
Early adopters, who are the opinion leaders of a community
Early majority, who are convinced by the early adopters to adopt
the innovation
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•
•
Late majority, who adopt the innovation mostly due to peer
pressure
Laggards, who are skeptical and resistant to change
This theory suggests that the adoption of new ideas by a select few
will lead to a process of natural diffusion through which ideas spread
throughout a community. Rogers also described how perceptions of the
innovations can contribute to the adoption of a new practice. These perceptions include
•
•
•
•
•
relative advantage (comparison of the innovation to current
practice);
compatibility (how the innovation fits with the adopter’s values,
needs, etc.);
complexity (difficulty of adopting the innovation);
triability (if the innovation can be tested before full investment);
and
observability (whether others have successfully adopted the innovation) (Rogers, 2003).
Aside from these characteristics, a variety of other factors affect the
adoption of new ideas, including both external factors (e.g., financial incentives and politics) and internal factors (e.g., competing priorities and
resources) (IOM, 2006a). Finally, successful adoption of innovations demands commitment and a readiness for change as well as the support of
organizational leadership in the adopting institution.
In the case of new models of care, dissemination has traditionally been
slow and many models have been proved to be unsustainable (Leipzig et
al., 2002; Reuben, 2002; Wolff and Boult, 2005). According to Rogers’s
theory, a number of factors, if present, can be expected to improve the
perception and potential appeal of new models of care for older patients.
They include
•
•
•
•
•
the model having an intuitive appeal;
the existence of a strong evidence base demonstrating benefits for
patients;
potential cost savings;
patient dissatisfaction with existing care; and
secular trends, such as the aging of the population, recognition of
the importance of managing chronic disease, and the move toward
community-based care (Leff, 2007; Rogers, 2003).
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A number of factors can also diminish the potential appeal of new
models. They include
•
•
•
•
•
•
•
information gaps in the literature that leave potential adopters with
insufficient detail about the model, including a lack of information
about such things as the optimal target population, staffing requirements, and the training and supervision necessary for staff;
an evidence base that focuses on patient-related outcomes but not
on other outcomes relevant to adopting organizations;
the existence of few or no financial incentives or even of significant short-term financial disincentives, such as substantial startup
costs;
lack of awareness by patients and families of the potential personal
value of these models;
reliance on teams of providers, which makes the models complex
and difficult to implement;
riskiness caused by the model having been implemented and observed in only a few other locations; and
poor alignment with the circumstances of a potential adopter’s local health system (Frank et al., 2003).
Experiences with Individual Models of Care
While the published literature on the dissemination challenges associated with the adoption of specific models of care for older adults is generally
limited, some information is available on the dissemination experiences of
the IMPACT and PACE models (described above) as well as on the Hospital
Elder Life Program (HELP), a model of care designed to prevent delirium
and functional decline in hospitalized older adults (Inouye et al., 2006).
Experience from the IMPACT Model
The IMPACT model for depression treatment was originally implemented between 1999 and 2001 in 18 clinics nationwide; by 2007, 67
individuals or organizations had implemented or were pursuing IMPACT or
key components of the program (IMPACT Implementation Center, 2007).
The spread of the IMPACT model, though somewhat limited, has been
aided by the IMPACT Implementation Center, which is funded by private
foundations and provides resources and technical assistance to organizations seeking to adopt the IMPACT model.
Although it has not been widely adopted, IMPACT has served as a
foundation for the creation of other models, such as the Prevention of
Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), spon-
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sored by the National Institute of Mental Health (Bruce et al., 2004). Like
IMPACT, PROSPECT provides depression-care management to older patients in primary-care settings in an effort to reduce the burden of depressive
symptoms, remove suicidal ideation, and improve health-related quality of
life. Twenty practices in New York, Philadelphia, and Pittsburgh provided
a total of 598 participants with either treatment as usual or depression
care management similar to that employed in IMPACT. An evaluation of
PROSPECT in a 53-month follow up found that the program resulted in
significantly better response and remission rates for major depression, faster
resolution of suicidal ideation, and reduced mortality.
Despite the effectiveness of models that provide depression treatment in
primary care settings, financial and organizational barriers have made the
interventions difficult to sustain in clinical practice (Barry and Frank, 2006;
Frank et al., 2003; Pincus et al., 2003). The cost of providing IMPACT care
for one individual is approximately $580 per year (Bachman et al., 2006),
but capitated payment creates an incentive for primary care physicians to
deliver fewer services, not more. Further, additional payment (under FFS or
capitation) is not available for the use of depression-care managers in the
primary care setting. Behavioral health carve-outs also serve to reinforce
the disincentives to treat depression in the primary care setting. Carve-outs
allow primary care physicians to refer patients for specialized care without
penalty, and they preclude the physician from billing for mental health
procedures. The higher co-payments charged to patients receiving mental
health care services also discourage utilization. These factors all serve as
barriers to the adoption of models such as IMPACT or PROSPECT, even
if care in the primary care setting is cost-effective or most appropriate for
patients.
Furthermore, physician education and training does not always promote or encourage depression care in the primary care setting (Pincus et
al., 2003). Behavioral health training is limited and highly variable in both
family medicine and general internal medicine, and it is not made clear
during physician training whether primary care providers are responsible
for providing behavioral health services. Primary care providers may view
diagnostic systems as too complex to implement (Pincus et al., 2003) and
may feel little pressure to implement depression care models in the absence
of demand from patients or payers. Eliminating the current disparities in
mental health copayments would be one way to increase patient demand.
Experience of the PACE Model
The initial success of the PACE approach led Congress in 1997 to
designate PACE as a permanent Medicare provider and to give state Medicaid agencies the option to include PACE as a Medicaid benefit (Degruy,
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1996). By 2004 Congress had authorized 180 PACE programs, but while
approximately 3 million older adults were eligible for PACE in that year,
only about 10,000 were being served by a PACE program. Currently 42
PACE programs are operating in 22 states (National PACE Association,
2007). Overall, the growth of PACE has not met expectations.
The initial PACE programs received significant start-up funding from
private foundations, allowing the development of many independent, freestanding programs (Gross et al., 2004). But once grant funds became
unavailable, only large health care organizations, such as hospitals, health
care systems, and long-term care systems, had the funds to make the initial
investment. Securing facilities and staffing for the programs requires significant capital expenditures (Gross et al., 2004). Organizations attempting to
set up a PACE program may also have difficulty in collecting an adequate
patient base because of geography (i.e., sparse populations in rural areas)
or because of an insufficient number of adults in a community who qualify
for the program.
A further hurdle has been local labor shortages, particularly in nursing
and therapies, which have made it difficult to fill open positions even when
funding is available. On the other hand, the environment and regular hours
offered by PACE programs have generally made it easier than it otherwise
would have been to attract and retain staff. Marketing the programs has
also been difficult in some cases. Many PACE programs operate in competitive, service-rich environments which offer a number of other service
options for older adults. Moreover, PACE centers receive a combined capitated rate of approximately $4,900 per member per month from Medicare
and Medicaid. For older adults who are not eligible for Medicaid, this cost
is often prohibitively high (Hansen, 2007).
The National PACE Association, largely funded by private foundations,
offers a number of resources and technical assistance to organizations that
wish to establish PACE programs. The association also awards grants to
states to expand their capacity to administer PACE programs. In addition,
Congress has appropriated funding to the Health Resources and Services
Administration (HRSA) to support technical assistance and assess the staffing and training needs of rural providers in developing PACE programs.
Experience of the Hospital Elder Life Program (HELP)
As noted above, the HELP is a model of care designed to prevent delirium in hospitalized older adults. Delirium is defined as an acute decline in
cognitive functioning and attention, and it is the most frequent complication
of hospitalization in older persons, being estimated to occur in 14 percent
to 56 percent of older hospitalized adults (Leslie et al., 2005). Delirium is
also associated with increased morbidity, mortality, and health care costs.
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The HELP interdisciplinary team consists of a geriatric nurse-specialist,
a specially trained “Elder Life Nurse Specialist,” a geriatrician, and trained
volunteers. The Elder Life Nurse Specialist is the program and volunteer
coordinator and is responsible for screening and enrolling patients, and
keeping track of the program’s adherence to the HELP guidelines. The Elder
Life Nurse Specialist has specialized training in geriatrics and carries out
nursing-related assessments and intervention protocols targeted toward six
delirium risk factors (cognitive impairment, sleep deprivation, immobility,
visual impairment, hearing impairment, and dehydration) (Inouye et al.,
2006). Evaluations of HELP indicate that it is effective in preventing delirium and functional decline, and that it is cost effective in hospitals and
long-term care settings (Inouye et al., 2006).
In 2000, a HELP Dissemination Program was established with funding
from private foundations. A dissemination team (a full-time nurse practitioner, 10 percent time for the geriatrician who developed the program,
and 25 percent time for a dissemination project director) provided training
materials, offered ongoing support for HELP hospital staff implementing
HELP, and held an annual conference for HELP sites. Additionally, a HELP
website was created to make resources on HELP readily available to interested organizations.
Like IMPACT and PACE, dissemination of HELP has been modest.
The dissemination team assisted 17 sites with the implementation of HELP,
and several more sites have since adopted HELP. Through interviews with
HELP staff at nine sites, researchers identified six challenges associated with
implementation of the program: (1) gaining internal support for the program despite differing requirements and goals of administration and clinical
staff, (2) ensuring effective clinician leadership, (3) integrating with existing
geriatric programs, (4) balancing program fidelity with hospital-specific
circumstances, (5) documenting positive outcomes of the program despite
limited resources for data collection and analysis, and (6) maintaining the
momentum of implementation in the face of unrealistic time frames and
limited resources (Bradley et al., 2004a). A second study was conducted
to identify key elements that make it easier to sustain the program. The
researchers identified three factors: the presence of clinical leadership, the
ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term
resources and funding for HELP (Bradley et al., 2005).
Like many other models, HELP requires the delivery of additional
clinical services that are not typically reimbursed under Medicare, and the
diffusion of HELP has largely depended upon staff funded specifically to
disseminate the program (Bradley et al., 2004b).
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Fostering the Dissemination of New Models of Care
One of the major challenges to the adoption of a new model is that it
can require collaboration among a variety of stakeholders, including public
and private insurers, health systems and hospitals, health care regulators,
and practicing professionals. Much of the research on the dissemination of
innovations has focused on physicians, with little consideration for the role
of other workers. The Medicare payment system itself presents many barriers, including the focus on provider-specific reimbursement, the limitations
on who can bill for services, and the complex regulatory environment that
makes legislative changes difficult. Additionally, the health care workforce
may lack sufficient numbers of providers to fully staff these models.
Contextual factors, such as the challenges in changing the cultures of
health care organizations and gaining internal support for adoption from
the organization’s leadership, are also critical to dissemination, but such
factors are not well understood. Creating culture change in health care
settings requires that organizations and individuals consider better ways to
deliver care, including changing the ways that health care personnel function (Shields, 2005). Additionally, when implementing new models, health
care organizations need to become effective learning organizations. That is,
they need to be able to learn from their experiences and change course as a
result of that learning. In 1990 Senge defined the characteristics of successful learning organizations (Senge, 1990). They include
•
•
•
•
•
systems thinking (determination of how individual parts of the
system interact);
personal mastery (recognition by the individual of his or her role
in the system);
mental models (examination of individual perceptions and willingness to change);
shared vision (development of a common goal); and
team learning (enhancement of individual capabilities to achieve
the shared vision).
These learning organizations need strong leaders who are committed
to changing the system, ongoing dialogue among all members of the system, and a commitment to continuous quality improvement, including the
ability to learn from mistakes (IOM, 2007). In addition to dealing with
institutional resistance to culture change, health care organizations that
are attempting to change their vision of how care is delivered needs to take
into account public perceptions of the use of alternative models and also
the types of workers they need to carry out that vision.
While some models are difficult to diffuse because of their inherent
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design, others may be hard to diffuse because of administrative or financial
barriers.
The committee concluded that innovative models of care for older patients generally fall into the latter category—models that are difficult to
diffuse because of administrative or financial barriers—and that these
administrative and financial barriers should be addressed.
Recommendation 3-1: Payers should promote and reward the dissemination of those models of care for older adults that have been shown
to be effective and efficient.
Incentives to adopt new models of care should include enhanced payments for services under these models; provision of capital for infrastructure,
such as health information technology; the streamlining of administrative
and regulatory requirements; and the elimination of existing impediments
to the use of innovative models by older patients, such as Medicare’s copayment disparity for mental health and other services.
DEVELOPMENT OF FUTURE MODELS AND FURTHER RESEARCH
The committee’s commissioned review of models of care revealed several types of models that hold promise for providing high-quality and costeffective care for older adults at several points along the care continuum.
The committee supports the continued development of models in these
areas. Still, as discussed previously, the evidence base on models of care
for older adults remains somewhat limited, and the information regarding
which models are most suitable for dissemination needs to be improved.
Considering the current relative lack of investment in research and demonstration programs for new models of care, especially in comparison to
annual spending on health care services, much more funding is needed to
develop this evidence base. In particular, efforts should target those areas
of care that demonstration programs have traditionally overlooked and
should look for the most efficient ways to use the workforce in staffing
new models of care.
Recommendation 3-2: Congress and foundations should significantly
increase support for research and demonstration programs that
• promote the development of new models of care for older adults
in areas where few models are currently being tested, such as
prevention, long-term care, and palliative care; and
• promote the effective use of the workforce to care for older
adults.
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Relatively few models of care focus on improving the rates of utilization of preventive clinical services among older adults or address behavioral
health risks, such as exercise, smoking, and weight management. This may
be due in part to a misconception that older adults are too old to benefit
from prevention efforts (Hansen, 2007; The John A. Hartford Foundation,
2000). In reality, however, about one-fifth of older adults have no chronic
illness and are generally in very good health; models should be explored
that can promote the continuation of good health for this group.
Models of long-term care appropriate for middle-class older adults
should also be explored further. Many of the models tested to date have
focused on dually eligible older adults and have relied upon the integration of Medicare and Medicaid financing. The median household income
of older adults is approximately $28,000 per year, however, which is well
above the eligibility threshold for Medicaid (Fleming, 2002).
Models of palliative care offer another example of where more research
is needed. About half of families report concerns about the care provided
at the end of life, particularly about the patient not receiving enough emotional support (DeNavas-Walt et al., 2007). End-of-life care varies considerably by race and ethnicity and by where a patient receives the care (Teno
et al., 2004). More information is needed on the best way to improve the
access to and the quality of palliative and end-of-life care.
It is important to note, however, that these three areas—preventive services, long-term care for middle-class older adults, and palliative care—are
meant only as examples of the types of models that warrant development
and are not meant as an exhaustive list. There are other areas where few
models are currently being tested that also deserve attention.
Any such new models of care need to be tested for their appropriateness and effectiveness for special populations, such as low-income groups,
racial and ethnic minorities, rural populations, and gay, lesbian, bisexual,
and transgender groups. Older adults are a diverse group, with differences
in language proficiencies, risks for diseases, education, acculturation, income, and family systems (e.g., dependency on adult children), all of which
may affect their health and access to appropriate care. Models need to be
developed that benefit diverse groups of patients.
Not only is more information needed on efficient and effective models
of care, but more research is needed to determine how best to create an
effective workforce. Best practices need to be developed for increasing the
size of the health care workforce (e.g., through improved recruitment and
retention) and expanding its capabilities (e.g., through advanced education
and training). More information is needed on how the size and capabilities of the health care workforce affect patient care in terms of quality and
outcomes. If care continues to be provided in the same way, there will
simply not be enough providers in the coming years to deliver the care that
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is needed. Therefore, new research and demonstration projects should be
developed to test alternative approaches that advance the use of the health
care workforce, including
•
•
•
programs to retain direct-care workers in nursing-home and homecare settings;
models of recruiting older volunteers to help care for older persons;
and
financial incentives to increase the availability of informal
caregivers.
The challenges associated with caring for an aging society are not
unique to the United States. Most other countries around the world are
also experiencing increased demand for health care and social services due
to increases in elderly and disabled populations (WHO, 2003). Many have
been struggling with same issues of how to improve quality, organization,
and resources for such care (Kodner, 2004). While some have successfully
managed to address these issues, it is difficult to draw from the experiences
of other countries given the very different nature of each health system’s
organizational and financial structures.
As the United States goes forward in developing new models of care,
however, some lessons may be drawn from international efforts. Countries
that have successfully addressed these challenges have several common attributes associated with their efforts. Among them are administrative consolidation (the reorganization of key functions, such as client assessment,
care planning, service coordination, quality management and financial
oversight, into a single agency at the level closest to the target population),
co-location of services (reducing service fragmentation by locating multiple
elder care agencies in single service centers), and service-enriched housing
(providing housing situations or physical environments that accommodate
each patient’s individual health needs or preferences, allowing greater freedom in choice of care settings).
One specific lesson, for example, is the value of job delegation, which
has been used successfully around the globe in various professions or
populations, although not necessarily in situations related to the care of
older adults. For instance, countries in Africa expanded their traditional
workforce models in response to the HIV epidemic (Samb et al., 2007). In
countries such as Malawi, where persons living with HIV/AIDS outnumber
doctors 7,435 to 1 and nurses 286 to 1, the delegation of tasks has been
essential to meeting care needs. Another example of job delegation is the
way that countries such as Canada, New Zealand, Finland, and the United
Kingdom developed auxiliary dental professions (e.g., an advanced dental
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hygienist or dental aide therapist) to solve overwhelming oral-health workforce shortages (Kravitz and Treasure, 2007).
IMPLICATIONS FOR THE WORKFORCE
As discussed previously, changing the way that health care services
are delivered to older Americans will require an overall culture change
by all segments of the workforce and delivery organizations, including
changes in ideas about who needs to provide specific services and how
those individuals need to interact with each other. Adopting new models
of care will require the care teams to be flexible so that the workforce will
be sufficient in both size and skill to meet the needs of older adults. While
it is not possible to discuss in detail the implications of each individual
model for the health care workforce for older adults, the committee determined that the models have certain common themes that demonstrate
the need for the different segments of the health care workforce to adapt
to changes in the way that care is delivered to older adults.
The models that have the strongest bases of evidence typically require
providers of different disciplines to work together to improve the coordination of care. In addition, several of the models require providers to take
on new roles and assume greater levels of responsibility. As more models
depend on patients and informal caregivers being part of the health care
team, these individuals will need to be given more education and training
so that they can be more effective members of the team. Finally, as is true
for the health care workforce as a whole, the development and use of new
technologies will have implications for the health care workforce for older
adults; the implications will arise not only from the need to train individuals
in the use of these new technologies but also from their potential ability to
assist existing health care workers in performing tasks and their potential
for reducing the number of workers needed. These types of adaptations are
discussed in general terms below and then in greater detail in subsequent
chapters where their implications for different parts of the health care
workforce are considered.
New Roles and Responsibilities
Many of the new models of care require the workforce to change its
practices in various ways. For example, as discussed previously, the shahbazim from the Green House model take on far more responsibility and are
more involved in residents’ lives than are traditional CNAs. They interact
regularly with the residents’ health care providers and alert them to changes
in residents’ status. Under the IMPACT program, depression-care managers
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RETOOLING FOR AN AGING AMERICA
are responsible for the majority of patient care and monitoring (Sibbald
and Roland, 1998).
Many of these new roles and responsibilities require additional training, although the training in some cases can be provided by the hiring
organization and may not require a higher educational degree. IMPACT’s
depression-care managers, for example, underwent a 2-day orientation
session and 2-day training meetings (Wagner et al., 2001). Some models of
care also require the professional providers to serve as the instructors to
patients or informal caregivers.
Overall, new models of care often require all members of the care
team—whether they are health care professionals, formal direct-care workers, informal caregivers, or patients—to take on added responsibilities.
Cascading various patient-care responsibilities—shifting them from one
type of worker to another—will be an essential tool in efforts to alleviate
the projected shortages in the numbers of providers available to meet the
care needs of an aging society. In some cases, the assumption of these new
responsibilities will require regulatory changes, most often through the
expansion of state-based definitions of scopes of work.
Recommendation 3-3: Health care disciplines, state regulators, and
employers should look to expand the roles of individuals who care for
older adults with complex clinical needs at different levels of the health
care system beyond the traditional scope of practice. Critical elements
of this include
• development of an evidence base that informs the establishment
of new provider designations reflecting rising levels of responsibility and improved efficiency;
• measurement of additional competence to attain these designations; and
• greater professional recognition and salary commensurate with
these responsibilities.
These new roles and responsibilities have implications for the workforce beyond the need for more training. First, as new and expanded roles
are delineated, more will need to be done to assure the competence of those
providing increased levels of care. Second, as more responsibilities are
delegated by professionals to other members of the health care workforce,
these professionals will have increased responsibility for management and
supervision but will need to be taught the skills required for these roles.
Finally, the assumption of increased responsibility, especially for direct-care
workers, has been associated with greater job satisfaction, and ultimately,
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NEW MODELS OF CARE
higher retention and potential improvement in patient outcomes. Specific
examples of changing roles, delegation of responsibilities, and expanded
scopes of work are discussed later in this report as they relate to each segment of the workforce.
Patients and Informal Caregivers
Some models of care introduce new and expanded roles for patients and
informal caregivers and integrate those individuals into the care team. An
important element of the chronic-care model is engaging patients in their
health and providing them with the education and tools to make decisions
about their own care and to manage it (Arehart-Treichel, 2006; Unutzer et
al., 2001). As more services are delivered in home- and community-based
settings, patients and informal caregivers will become even more important
to the delivery of care. And, as models of care recognize the contributions
needed by these individuals to improve care, more will need to be done to
educate and train them in principles of self-management, proper methods
of service provision (e.g., wound care and medication administration), and
use of new technologies. (See Chapter 6 for more on patients and informal
caregivers.)
Interdisciplinary Care
The introduction of interdisciplinary teams into care delivery will pose
a number of challenges. Although in the long run the use of such teams
has the potential to reduce the use of intensive health services such as
hospitalization, these teams are not adequately reimbursed at this time.
Furthermore, since team care requires greater effort with respect to primary
care and patient monitoring, the introduction of interdisciplinary teams to
manage patients may strain the existing capacity of primary care providers
even further. An additional challenge is that team training is not a focus of
the curriculum for many providers, so that they may be unfamiliar with this
practice style (see Chapter 4). Finally, effective teams also require a certain
level of respect, comfort, and trust among members, which in some cases
may not be present (Boult et al., 2001; Sommers et al., 2000).
Care Coordination
As discussed in Chapter 2, the coordination of care among providers and across settings, especially during transitions, can greatly influence
patient outcomes. Older adults often see multiple providers—on average,
Medicare beneficiaries are treated by five physicians annually, and beneficia-
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RETOOLING FOR AN AGING AMERICA
ries with chronic conditions (e.g., heart failure, coronary artery disease, or
diabetes) see an average of 13 physicians annually (IOM, 2007). As a result,
the care that these beneficiaries receive from physicians and other health
care providers is often fragmented and not well coordinated. The lack of
coordination stems from a variety of factors, including poor definitions
of accountability, misaligned financial incentives (including the inability
to reimburse for care coordination under FFS), lack of connection among
information systems, and minimal training of providers in cross-site collaboration (Coleman, 2003; Coleman and Berenson, 2004; IOM, 2006b).
In the 2007 IOM report Rewarding Provider Performance, the committee
recommended that Medicare, in order to reduce fragmentation of services,
encourage beneficiaries to identify a primary accountable source of care
to act as that patient’s care coordinator and guide the patient through the
health care (IOM, 2007).
Many new models of care strive to improve care coordination, and
these efforts can affect the use and development of the health care workforce. Some models, for example, require a geriatric care manager who
helps patients navigate the health care system (see Chapter 4). Additionally, many efforts to improve care coordination call for enhancing communication among providers; this enhancement of communication among
providers—and also between caregivers and patients—will require providers to change their practice patterns in a variety of ways. Furthermore, as
patients and their families assume more responsibility in care delivery, it
will be essential to involve these individuals in the coordination of care,
which in turn will make it necessary to recognize the barriers to effective communication that some older adults experience, including hearing
and vision deficiencies. (See next section for more on self-management.)
Finally, one of the easiest ways to improve the coordination of care will
be to enhance the use of those information technologies that help to share
important patient information.
Health Technology
Many models of care require an increased use of health information
technology (HIT), such as electronic health records and personal health
records, to facilitate the sharing of information among providers and to
improve their ability to coordinate the complex care of older patients.
Health information technologies may also be used to build databases on the
health of older populations which may be very useful to practitioners and
researchers in aging. Other technologies used in new models may reduce the
need for certain types of workers. For example, remote-monitoring technologies can extend the reach of health care professionals into the home.
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As a result, many members of the health care workforce will need to be
trained in the proper use of all of these technologies.
Technologies that assist in performing activities of daily living may
reduce the demands placed on direct-care workers and informal caregivers, effectively shifting these responsibilities back to the patient’s level. The
interaction between developing technologies and the health care workforce
is discussed further in later chapters, and recommendations are offered for
encouraging the development and use of health technologies.
CONCLUSION
Simply expanding the size of the workforce qualified to provide the
needed health care services to older adults will not be sufficient to address
the challenge that will face this country over the next two decades. It will
be necessary to develop new models of financing and care delivery in order
to promote greater efficiencies in the use of the existing workforce while at
the same time promoting improvements in care quality. Although a number
of innovative models have already been developed, few have been widely
adopted, and in large part this is because no adequate financing mechanism
is in place to encourage the promotion of these models. Given that no single
model of care will be sufficient to meet the needs of all older adults in all
settings of care across the health care continuum, the committee recommends both an improved dissemination of models that have been shown
to be effective and the development of new models of care that address
specific settings or populations that have largely been overlooked and that
encourage more effective use of the health care workforce.
The adaptation of these new models of care will have important implications for the development of a better health care workforce for older
adults. Common features of new models include expanding the roles of
workers (including expansion of the involvement of patients and their
families), creating new provider roles, using interdisciplinary care teams,
and improving the coordination of care through improvements in communication. Today’s health care workforce is not properly prepared to perform
its work in the ways that these new models demand, so all segments of the
health care workforce will need to be educated and trained in the new care
principles that underlie these models. The remainder of this report discusses
the education, training, recruitment, and retention of the various segments
of the health care workforce, with a particular emphasis on how the roles
of health care providers will need to change in order to provide high-quality
and cost-effective care to older Americans.
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4
The Professional Health Care Workforce
CHAPTER SUMMARY
The need for health care professionals trained in geriatric principles is
escalating, but even though opportunities for geriatric specialization exist, few providers choose this career path. The education and training of
professionals in the area of geriatrics is hampered by a scarcity of faculty,
inadequate and variable academic curricula and clinical experiences, and
a lack of opportunities for advanced training. Furthermore, the education and training of geriatric health care professionals is often limited in
scope and needs to be expanded both to take into account the diversity of
health care needs among older populations and to prepare professionals
for the coming new models of care, many of which will require changed
or expanded roles. The committee recommends that more be done to ensure that all professionals have competence in geriatric principles. Finally,
the recruitment and retention of geriatric professionals are hampered by
several factors, including the persistent stereotypes of older populations,
the aging of the workforce itself, and significant financial disincentives.
The committee recommends that several types of financial incentives be
offered to promote the recruitment and retention of clinical and academic
geriatric specialists.
In the coming decades demand is expected to increase markedly for
all types of health care professionals in all settings of care for the elderly
population. This chapter examines issues related to the education, training,
recruitment, and retention of health care professionals in the care of older
adults. This chapter begins with a brief overview of the supply of and de123
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RETOOLING FOR AN AGING AMERICA
mand for professionals who care for older patients. The overall pattern here
is that older Americans account for a disproportionate share of professional
health care services but, in spite of this demand, the number of geriatric
specialists remains low. Next the chapter focuses on a few individual professions essential to the care of older adults. It goes on to examine overarching themes in geriatric education and training. While improvements in
the education and training of the health care workforce in geriatrics are
evident, these efforts have failed to ensure that all providers who treat older
adults have the necessary knowledge and skills to provide competent care.
The chapter then considers future trends in education and training. Not
only will there be a need for many more professionals working with older
adults, but health care workers of the future will need to take on new and
expanded roles. As discussed in Chapter 3, these changing responsibilities
will affect the entire workforce, including the direct-care workforce, informal caregivers, and patients themselves. (These populations are examined
in more detail in Chapters 5 and 6.) Finally, the chapter concludes with
strategies for recruiting and retaining professionals in geriatric specialties.
These strategies largely depend on overcoming financial disincentives, such
as relatively low salaries and the high cost of training.
SUPPLY AND DISTRIBUTION
The number of professional workers directly involved in the care of
older adults is difficult to quantify, for a number of reasons: changes in employment status, differing measures (e.g., licensed vs. active professionals),
and the presence of ill-defined and overlapping titles for many occupations.
Furthermore, many professionals treat older patients without being identified as geriatric providers either by title or certification. Health care-related
careers, including medical assistants, physician assistants, physical therapists, mental health counselors, pharmacy technicians, and dental hygienists, account for about half of the country’s 30 fastest-growing occupations
(BLS, 2007a). Despite the rapid growth, however, the supply of health care
workers does not satisfy current demands and will certainly fall short of
the increased demands expected in the future. In fact, the United States will
need an additional 3.5 million health care providers by 2030 just to maintain the current ratio of health care workers to population (Table 4-1).
While the general need for professionals who care for older patients
is high, the particular need for geriatric specialists is even greater. For example, geriatricians1 are the physicians who are specially trained in care
1 While a physician who has extensive experience with elderly patients may specialize in geriatrics, the term “geriatrician” refers to a physician who has been certified in the subspecialty
of geriatric medicine, or received a certificate of added qualifications in geriatric medicine.
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THE PROFESSIONAL HEALTH CARE WORKFORCE
TABLE 4-1 Number of Providers in 2005 and Projected Number
Needed in 2030 to Maintain Current Provider-to-Population Ratios (in
Thousands)
Total health providers
Registered nurses
Nursing aides
Physicians
Licensed practical and vocational nurses
Pharmacists
Dentists
Other providers
2005
2030
Difference
9,994
2,458
2,009
804
654
236
163
3,670
13,522
3,326
2,719
1,088
885
319
220
4,965
3,528
868
709
284
231
83
57
1,295
NOTE: Numbers are for overall health care workforce and not limited to geriatric
population.
SOURCE: Mather, 2007.
of the elderly population as a subspecialty of internal or family medicine.
These specialists account for only a very small portion of the total physician
workforce—just 7,128 physicians are certified geriatricians, or one geriatrician for every 2,546 older Americans (ADGAP, 2007b). By 2030, assuming
current rates of growth and attrition, one estimate shows that this number
will increase to only 7,750 (one for every 4,254 older Americans), far short
of the total predicted need of 36,000 (ADGAP, 2007b; Alliance for Aging
Research, 2002). In fact, some argue that there could be a net decrease in
geriatricians because of the decreasing number of physicians entering training programs as well as the decreasing number of geriatricians who choose
to recertify (Gawande, 2007). Geriatric psychiatry faces a similar shortage.
Only 1,596 physicians are currently certified in geriatric psychiatry, or one
for every 11,372 older Americans, and by 2030 that total is predicted to
rise to only 1,659, which would then be only one for every 20,195 older
Americans (ADGAP, 2007b).
Other professions have similarly low numbers of geriatric specialists.
For example, just 4 percent of social workers and less than 1 percent of
physician assistants identify themselves as specializing in geriatrics (AAPA,
2007; Center for Health Workforce Studies, 2006). Less than 1 percent of
registered nurses (Kovner et al., 2002) and pharmacists2 are certified in
geriatrics. In short, dramatic increases in the number of geriatric specialists are needed in all health professions. Even with tremendous effort, it is
2 Personal
communication, T. Scott, American Society of Consultant Pharmacists, November
6, 2007.
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RETOOLING FOR AN AGING AMERICA
unlikely that we can completely fulfill the projected needs, but, still, much
can be done to begin to close the gaps.
Aside from concerns about the total numbers of health care workers
with geriatric competencies, the composition and distribution of the health
care workforce for older Americans should also be considered. This includes racial and ethnic diversity as well as the geographic distribution of
professionals trained to provide care to older adults.
Racial and Ethnic Diversity
The committee commissioned a paper on the increasing diversity of
older populations (Yeo, 2007) and found that the diversity of the workforce is important for several reasons. First, minority patients often prefer
to be treated by health care professionals of the same ethnic background
(Acosta and Olsen, 2006; IOM, 2004; Mitchell and Lassiter, 2006; Tarn et
al., 2005). Second, a provider from a patient’s own background may have
better understanding of culturally appropriate demonstrations of respect
for older populations and may also be more likely to speak the same language (in the case of bilingual providers). Finally, providers from minority
populations often account for most of the services provided to underserved
populations (HRSA, 2006a). For example, while only 3.4 percent of dentists are black, they treat almost two-thirds (62 percent) of black patients
(Mitchell and Lassiter, 2006).
While older adults are more diverse than ever before, the younger generations training to care for them are even more diverse (see Chapter 2).
The pattern of this diversity, however, will not necessarily match up with
the pattern of diversity among older Americans. Table 4-2 demonstrates,
for example, that there is significant diversity among resident physicians in
geriatrics, but the percentage of white residents (39 percent) is much lower
than the percentage of whites in the elderly population, and the percentage
of Asian residents (42 percent) is much higher that the percentage of Asians
in the elderly population.
Geographic Distribution
The distribution of both professionals and older adults varies widely
across the country. Since both of these populations may be unevenly distributed across regions, states, and local communities, different areas may
have different workforce needs. The committee commissioned a paper on
state profiles of the U.S. health care workforce (Mather, 2007). This report
showed there is an average of 443 dentists per 100,000 population aged 65
and older in the United States, but this ratio varies widely among the states.
There are 759 dentists per 100,000 older adults in New Hampshire, but
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THE PROFESSIONAL HEALTH CARE WORKFORCE
TABLE 4-2 Race and Ethnic Origin of Residents in Geriatric Medicine
and Psychiatry, 2006
Black
Geriatrics
(Family
Medicine)
Geriatrics
(Internal
Medicine)
Geriatric
Psychiatry
Total
American
Indian/
Alaskan
Native
White
Asian
Native
Hawaiian/
Pacific
Other/
Islander
Unknown
Hispanic
Origina
Total
4
0
22
15
1
2
5
44
23
0
92
103
5
20
23
243
7
0
25
32
1
7
8
72
34
0
139
150
7
29
36
359
aHispanic
origin was determined separately from race, and so the categories are not mutually exclusive.
SOURCE: Brotherton and Etzel, 2007.
only 104 dentists per 100,000 older adults in Kansas. This variance must be
caused by a variety of factors, since these states do not have similar distributions in the numbers of other types of professionals. New Hampshire has
a lower-than-average number of pharmacists per population of older adults,
for example, while Kansas has a higher-than-average number of registered
nurses. The need for health care workers with geriatric skills can also vary
according to the distribution of older adults. For example, as discussed in
Chapter 2, older adults make up 16.8 percent of Florida’s total population,
while they account for only 6.8 percent of Alaska’s population (U.S. Census
Bureau, 2008). Differences by community are likely to also vary widely.
Therefore, the needed distribution of the health care workforce for older
American can vary by both the state and the individual profession.
The recruitment and retention of health care professionals in rural
areas is especially challenging (IOM, 2005), and this is an important factor when discussing the health care needs of the geriatric population, since
older adults are disproportionately over-represented in rural areas (Hawes
et al., 2005). Older adults that live in rural areas tend to be less healthy
than those in urban areas and to have a higher rate of difficulty with activities of daily living (ADLs) (Brand, 2007; Magilvy and Congdon, 2000),
while their access to health services is limited by the relatively small number of providers (especially specialists) that choose to work in rural areas.
Because of the relatively small number of specialists, physician assistants
and nurse practitioners play significant roles in providing health services
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RETOOLING FOR AN AGING AMERICA
to the rural aging population (Henry and Hooker, 2007). Among the challenges in recruiting any type of professional to rural areas are professional
isolation, heavy call schedules, and few job opportunities for the spouses
of the health care professionals. The best strategies for recruitment and
retention may be those that focus on the training of existing rural providers in geriatric skills via distance education in conjunction with the use of
remote technologies to increase the availability of outside geriatric experts
for rural elderly populations.
THE CURRENT STATE OF GERIATRIC
EDUCATION AND TRAINING
For more than 30 years the IOM (IOM, 1978, 1993) and others
(LaMascus et al., 2005; Olson et al., 2003) have called for improvements
in the geriatric education and training of virtually all types of health care
providers. While progress is evident, many formal training programs still do
not include robust coursework in geriatrics (Berman et al., 2005; Eleazer et
al., 2005; Linnebur et al., 2005; Scharlach et al., 2000). Among the barriers
to increased education and training in geriatrics for all professions are the
lack of faculty, lack of funding, lack of time in already-busy curricula, and
the lack of recognition of the importance of geriatric training (Bragg et al.,
2006; Hash et al., 2007; Hazzard, 2003; Rubin et al., 2003; Simon et al.,
2003; Thomas et al., 2003; Warshaw et al., 2006). Furthermore, very little
is known about the best methods to improve the knowledge and skills of
professionals in caring for older adults (Gill, 2005).
It is not possible to discuss every profession in detail, as virtually every professional cares for older patients to some degree. In the following
section, several professions instrumental to the care of older adults are examined. (See Table 4-3 for an overview.) Specifically, the status of geriatric
education and training within each profession is discussed. While some
professions are discussed more extensively than others, the committee does
not intend for this to imply any conclusion about their importance to the
care of older adults. Rather, this is a reflection of the amount of data available and the extensiveness of the existing education and training programs
in geriatrics. Overall, the breadth and depth of geriatric education and
training remains inadequate to prepare all professionals for the health care
needs of the future elderly population.
Physicians
Older Americans account for a disproportionate share of physician
services, but a 2002 survey of primary care physicians showed that only
half of these physicians believed that their colleagues could adequately treat
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THE PROFESSIONAL HEALTH CARE WORKFORCE
129
geriatric conditions (Moore et al., 2004). This section examines the education and training of all physicians in the care of older adults, with a focus
on the path for geriatricians.
Geriatric Content
The geriatric curricula in medical schools has had notable improvements. The percent of medical schools with requirements for “geriatric
exposure” has increased from 82 percent in 1985-1986 to 98 percent in
1996-1997 (Eleazer et al., 2005). Still, much of this exposure is inadequate
or occurs too late in the educational process to influence which specialities the students select. As noted above, several major public and private
initiatives support improvement in the geriatric education of physicians. In
May 2001 the Donald W. Reynolds Foundation awarded $19.8 million in
grants to 10 institutions in order to develop comprehensive training programs in geriatrics (Donald W. Reynolds Foundation, 2007). Because of
the success of this effort, the Donald W. Reynolds Foundation repeated the
grants in 2003 and 2005, distributing almost $20 million in each round,
and in October 2007 the Donald W. Reynolds Foundation issued a request
for proposals for a fourth series of grants. In addition to this effort, the
Donald W. Reynolds Foundation has established two departments of geriatric medicine.
The Health Resources and Services Administration (HRSA) distributes
grants to support Geriatric Education Centers (GECs), which educate and
train individuals in the care of older patients. These centers are often collaborative efforts among several health-profession schools or health care
facilities and have a special focus on interdisciplinary training.
In July 2007 the John A. Hartford Foundation and the Association of
American Medical Colleges (AAMC) hosted the National Consensus Conference on Geriatric Education. There the participants developed a set of
minimum standards for the knowledge, skills, and attitudes of graduating
medical students with respect to the care of older patients (Leipzig, 2007).
The standards covered a number of domains, including
•
•
•
•
•
•
•
•
cognitive and behavioral disorders;
medication management;
self-care capacity;
falls, balance, gait disorders;
atypical presentation of disease;
palliative care;
hospital care for older adults; and
health care planning and promotion.
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RETOOLING FOR AN AGING AMERICA
TABLE 4-3 Overview of the Education and Training of Professionals in
Geriatrics
Total jobs
held (2006)a,1
Nurses
Oral-Health Workers
Pharmacists
RNs: 2.5 millionb,2
LPNs: 749,000
Dentists: 161,000;
(General dentists:
136,000)
Dental hygienists:
167,000
243,000
Unknown
1,297 certified (less than
1%)4
Geriatric
Less than 1% of RNs
specialization
and about 2.6% of
or certification APRNs certified3,28
Academic
leadership
76% of baccalaureate 63% of dental schools
programs have at least have a geriatric
one full-time “expert,” director or chairman9
29% have a certified
faculty member8
43% have two full-time
faculty; most rely on
part-time faculty10
Exposure to
geriatrics in
schools
One-third of
baccalaureate
programs require
exposure; 94% of
fundamental courses
integrate geriatric
content8
100% of dental and
dental hygiene schools
have identifiable
content; 18.8%
of dental hygiene
schools have a discrete
course14
43% have a discrete
course; all schools
provide opportunity for
advanced training in
geriatrics or long-term
care10
Advanced
geriatric
training
programs
Less than 100
master’s and postmaster’s programs;
five programs in
geropsychiatric
nursing3
13 programs for
geriatric dental
academic training; no
residencies specific to
geriatric dentistry18
10 residency programs;
one fellowship
program19
Number of
advanced
geriatric
trainees
Approximately 300
geriatric APRNs
produced annually3
Unknown
13 resident slots; one
fellowship slot19
Explicit
testing on
non-geriatric
board
certification
exams?c
Yes21
No22
No general certification;
national licensure
exam organized by
approaches23
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THE PROFESSIONAL HEALTH CARE WORKFORCE
Physician Assistants
Physicians
Social Workers
66,000
633,000
595,000
Less than 1% specialize5
7,128 certified in geriatric
medicine; 1,596 certified in
geriatric psychiatry6
About 4% of social workers
specialize7
27% of program
directors surveyed had
some form of geriatric
training11
Less than 1% of faculty
specialize; all programs have
an identifiable leader in
geriatrics12
40% of schools have no faculty
knowledgeable in aging13
Accreditation requires
geriatric exposure,
including clinical
experience in long-term
care15
98% of schools require some
form of exposure16
80% of BSW students have no
coursework in aging17
None
Medicine:
139 fellowship programs
(468 1st-year positions)6
29% of MSW programs offer
aging certificate, specialization,
or concentration20
Psychiatry:
58 fellowship programs
(142 1st-year positions)6
DSW: unknown
Medicine: 253 in 1st year;
34 in 2nd year6
Unknown
Not Applicable
Psychiatry: 726
Yes24
Internal Medicine: 10% of
exam25
Family Medicine: optional
module26
Psychiatry: yes27
No general certification;
national licensure exam
organized by approaches28
continued
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RETOOLING FOR AN AGING AMERICA
TABLE 4-3 Continued
Geriatric
certification
body
Nurses
Oral-Health Workers
Pharmacists
American Nurse
Credentialing Center
(ANCC)
None
Commission for
Certification in Geriatric
Pharmacy (CCGP)
Fellowship status
offered by American
Society for Geriatric
Dentistry (ASGD)
and diplomate status
offered by American
Board of Special Care
Dentistry (ABSCD)
ABBREVIATIONS: Advanced Practice Registered Nurse (APRN); Bachelor of Social Work
(BSW); Doctor of Social Work (DSW); Licensed Practical Nurse (LPN); Master of Social Work
(MSW); Registered Nurse (RN).
aNumber of jobs may be greater than number of practicing professionals, since some professionals work in more than one position.
bAs of 2004, there were 240,260 jobs held by APRNs.
cRelies on description of exam content.
The group then developed a total of 36 competencies based on these
domains (AAMC/The John A. Hartford Foundation, 2007). The competencies included
•
•
•
•
•
•
identification of medications to be avoided or used with caution in
older adults;
ability to define and distinguish delirium, depression, and
dementia;
assessment of ADLs and IADLs;
identification of physiological changes due to aging;
identification of psychological, social, and spiritual needs of patients; and
performance of examination to assess skin pressure ulcer status.
While the coverage of geriatric issues at medical schools is increasing,
students still express significant reservations about their abilities to treat
older patients. The AAMC’s 2002 Medical School Graduate Questionnaire
found 55 percent of graduates perceived inadequate coverage of geriatric
issues in medical school; only 68 percent felt adequately prepared to care
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THE PROFESSIONAL HEALTH CARE WORKFORCE
Physician Assistants
Physicians
Social Workers
None
American Board of Internal
Medicine (ABIM), American
Board of Family Medicine
(ABFM), American Board of
Psychiatry and Neurology
(ABPN), American Osteopathic
Board of Family Practice
(AOBFP), American
Osteopathic Board of Internal
Medicine (AOBIM)
National Association of Social
Workers (NASW)
SOURCES: 1BLS, 2008; 2HRSA, 2006; 3Kovner et al., 2002; 4Personal communication, T. Scott,
American Society of Consultant Pharmacists, November 6, 2007; 5AAPA, 2007; 6ADGAP,
2007b; 7Center for Health Workforce Studies, 2006; 8Berman et al., 2005; 9Mohammad et
al., 2003; 10Odegard et al., 2007; 11Olson et al., 2003; 12LaMascus et al., 2005; Warshaw et
al., 2002; 13Scharlach et al., 2000; 14Mohammad et al., 2003; Tilliss et al., 1998; 15Brugna et
al., 2007; 16Eleazer et al., 2005; 17Lubben et al., 1992; 18HRSA, 2005; 19ACCP, 2007; ASHP,
2007; 20Cummings and DeCoster, 2003; 21NCSBN, 2007; 22ABGD, 2007; 23NABP, 2008;
24NCCPA, 2008; 25ABIM, 2007; 26ABFM, 2007; 27ABPN, 2007c; ASWB, 2007; 28HRSA,
2006b.
for older persons in acute-care settings, and only half felt prepared to care
for them in long-term care settings (Eleazer et al., 2005). In spite of this,
less than 3 percent of medical students take geriatric electives (Moore et
al., 2004).
Advanced Training
Postdoctoral training of physicians occurs during both residency and
fellowship programs. As of 2003, 27 types of medical residency programs
(accounting for 70 percent of trainees) included Accreditation Council for
Graduate Medical Education (ACGME) requirements for some form of geriatrics training, but the extent of such training is highly variable (Bragg and
Warshaw, 2005; Bragg et al., 2006; Simon et al., 2003). One survey showed
that only about half of graduating family-practice and internal-medicine
residents (48 percent and 52 percent, respectively) felt very prepared to care
for elderly patients (Blumenthal et al., 2001). Although a large majority
of graduating psychiatry residents felt very prepared to diagnose and treat
delirium (71 percent) and major depression (96 percent), only 56 percent
felt very prepared to diagnose and treat dementia.
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RETOOLING FOR AN AGING AMERICA
Several specialties that treat large numbers of older patients, including ophthalmology, general surgery, and dermatology, do not include any
requirements for geriatric training (Bragg and Warshaw, 2005). Since 1994
the John A. Hartford Foundation has funded the Geriatrics-for-Specialists
Initiative, which aims to improve geriatric knowledge of surgical specialists and related medical specialists. Their Geriatrics Education for Specialty
Residents Program encourages interaction between directors of specialty
residencies and the geriatricians within their facilities.
After completion of a residency in internal medicine, family medicine,
or general psychiatry, a physician can pursue a fellowship in geriatric
medicine or geriatric psychiatry, which may last one or more years. Fellows
may be graduates of allopathic or osteopathic schools of medicine, or they
may be international medical graduates (IMGs). This finding is notable in
that IMGs have become increasingly relied upon to provide primary care
services and care to underserved populations in the United States (Hart et
al., 2007).
About half of geriatric-medicine and geriatric-psychiatry fellows (58.2
percent and 44.4 percent, respectively) are female, and about two-thirds of
the two types of fellows (64.1 percent and 61.1 percent, respectively) are
IMGs (Brotherton and Etzel, 2007). By comparison, across all specialties
IMGs make up only 26.9 percent of the entire resident-physician population. As seen in Figures 4-1 and 4-2, while the number of positions available
in geriatric-medicine and geriatric-psychiatry fellowship programs has been
increasing, the percentage of positions filled has been decreasing. Very few
fellows continue past the first year, possibly because of the decrease in the
requirement for the length of training that is needed to pursue certification
(discussed later in this section).
The Veterans Administration (VA) plays an important role in the development of geriatric fellowships. In the 1970s, in anticipation of the wave of
aging World War II veterans, the VA established Geriatric Research, Education and Clinical Care Centers (GRECCs) to improve geriatric knowledge
(Goodwin and Morley, 1994; Warshaw and Bragg, 2003). These centers are
still in operation and often educate and train multiple disciplines in geriatric
care. At around the same time the VA first established fellowship programs
in geriatric medicine and geriatric psychiatry, often in conjunction with a
GRECC. Today, about 25 percent of geriatric-medicine fellowship positions
and almost 50 percent of geriatric-psychiatry fellowship positions are supported by the VA, and many other geriatric fellows will receive part of their
training in VA facilities (VA, 2007a). The VA also funds four fellowships in
geriatric neurology (VA, 2007b).
Other branches of the federal government also support the geriatric
education and training of physicians. HRSA administers the Title VII Geriatrics Health Professions Program. Although funding was eliminated for
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135
THE PROFESSIONAL HEALTH CARE WORKFORCE
500
sitions
ble
Availa
ear Po
First-Y
400
ar Positions
Filled First-Ye
300
200
100
07
06
20
20
20
05
04
20
03
20
02
20
01
20
00
20
99
19
98
19
19
97
0
Year
FIGURE 4-1 First-year geriatric medicine fellowship positions, available and
filled.
SOURCE: ADGAP, 2007b.
Figure 4-1
150
ns
io
t-Year Posit
Firs
Available
100
Filled First-Ye
ar Positions
50
20
07
20
06
05
20
4
20
0
03
20
2
20
0
01
20
00
20
9
19
9
98
19
19
97
0
Year
FIGURE 4-2 First-year geriatric psychiatry fellowship positions, available and
filled.
SOURCE: ADGAP, 2007b.
Figure 4-2
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RETOOLING FOR AN AGING AMERICA
fiscal year 2006, it was restored for fiscal year 2007, with $31.5 million for
the support of 48 GECs, 88 Geriatric Academic Career Awards (GACAs)
for individuals, and 11 Geriatric Training for Physicians, Dentists, and
Behavioral/Mental Health Professions Program awards given to institutions
to prepare faculty for these professions (ADGAP, 2007c). In 2007 Congress
approved a fiscal year 2008 Labor-Education-HHS appropriations bill3
that included continuation of the Title VII geriatrics programs at the same
funding level as for fiscal year 2007, but President Bush vetoed the bill on
November 13, 2007, and the House of Representatives failed to override
the veto on November 15, 2007.
Finally, CMS is the major financial supporter of the residency training
of all physicians. In fiscal year 2004 it paid $7.9 billion for graduate medical education (GME) (GAO, 2006). Medicare pays for a portion of the cost
of GME for physician residents and fellows through direct and indirect
medical-education payments. Direct medical education (DME) payments
support hospitals’ direct cost of operating a GME program, especially
salary support for residents; indirect medical education (IME) payments
cover a portion of the added patient care costs associated with teaching
hospital settings (MedPAC, 2003). Through GME, Medicare has specifically supported advanced training in geriatrics by counting geriatric fellows
as full-time equivalent (FTE) residents, while all other subspecialty fellows
count only as one-half of a full-time equivalent. Thus hospitals that train
geriatricians receive more GME funding than hospitals that train other
types of subspecialists (MedPAC, 2003). Furthermore, when GME updates
were frozen in the 1990s, geriatric programs were exempt.
Sites of Training
The training of medical students and residents tends to occur in discrete
episodes of care, within single disciplines, and usually only in the hospital
or ambulatory setting, which means that residents generally do not have
the opportunity to follow patients longitudinally over time and across settings of care. Thus many students and residents lack exposure to alternative
sites of care of importance to the geriatric patient—namely, home-care settings, nursing homes, and assisted-living facilities. Deterrents to increasing
student clinical experiences in these sites include the need for an on-site
supervisor of the same discipline, the need for collaboration with site staff,
a lack of student interest, and a lack of time in already crowded programs
(Leipzig et al., 2002; Warshaw et al., 2006).
In one national survey, only 27 percent of graduating family-practice
3 Departments
of Labor, Health and Human Services, and Education, and Related Agencies
Appropriations Act, 2008. HR 3043. 110th Congress. July 13, 2007.
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THE PROFESSIONAL HEALTH CARE WORKFORCE
137
residents and only 13 percent of graduating internal-medicine residents felt
very prepared to care for nursing-home patients (Blumenthal et al., 2001).
Still, clinical experiences in alternative sites of care have increased somewhat from past years (Cheeti and Schor, 2002; Matter et al., 2003). For
example, Weill Cornell Medical College implemented a clerkship in which
third- and fourth-year medical students accompanied a geriatrics team on
home visits to patients living with chronic illness; when interviewed about
the experience, 84 percent of recent graduates felt that it had had a positive
effect on their delivery of care (Yuen et al., 2006).
Among the obstacles to expanding training sites is a lack of funding to
cover the expenses of residents while in non-hospital settings. As described
above, Medicare distributes GME funds, primarily to hospitals, to support
the training of residents. However, the Balanced Budget Amendment of
1997 allows for other providers, including federally qualified health centers, rural health clinics, and managed care organizations to receive GME
funds directly (AAMC, 2007c). Furthermore, since 1987 hospitals have
been allowed to count the time that residents spend in settings outside the
hospital, such as nursing homes and physician offices, subject to certain
agreed-upon conditions between the hospital and the outside entity. Still,
this does not happen often enough. Since most care of older patients occurs
in non-hospital settings, more needs to be done to ensure that professionals
are fully trained in how to care for patients in these settings.
The committee concluded that comprehensive care of older patients
should include training in non-hospital settings.
Recommendation 4-1: The committee recommends that hospitals
should encourage the training of residents in all settings where older
adults receive care, including nursing homes, assisted-living facilities,
and patients’ homes.
Residency program directors need to ensure that their residents’ schedules include adequate time rotating through these alternative settings, and
the directors and hospital administrators need to be willing to collaborate with the outside entities to reach mutually agreeable conditions for
partnership.
Board Certification
Physicians may pursue voluntary national board certification in many
major specialties and then become certified in the subspecialties of geriatric
medicine or geriatric psychiatry. It was in 1988 that the American Board
of Family Medicine (ABFM) and the American Board of Internal Medicine
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RETOOLING FOR AN AGING AMERICA
(ABIM) first offered a 10-year certificate of added qualifications (CAQ) in
the subspecialty of geriatric medicine.4 Originally CAQs were available
only to physicians with at least 2 years of specialty geriatric training or to
those who had substantial clinical experience (the “practice pathway”). In
1994 the ABIM and ABFM phased out the practice-pathway option, and
in 1998 they lowered the training requirement to only 1 year, resulting in
a slight upward trend in the recruitment of geriatric fellows. As seen in
Figure 4-3, the number of physicians certified annually surged and then
sharply decreased when the practice-pathway option was eliminated; only
13.4 percent of all new certifications occurred after the practice-pathway
option ended.
Osteopathic physicians may pursue CAQs from the ABIM or ABFM and
also from the American Osteopathic Board of Family Physicians (AOBFP) or
the American Osteopathic Board of Internal Medicine (AOBIM), which have
offered certification since 1991. The AOBIM ended the practice-pathway
option in 1994, and the AOBFP ended it in 2002.
The American Board of Psychiatry and Neurology (ABPN) recognized
geriatric psychiatry as a subspecialty in 1989 and first awarded 10-year
CAQs in 1991 (ABPN, 2007a). In 1996 the ABPN phased out the practicepathway option and subsequently reduced post-graduate training requirements from 2 years to 1 year. Figure 4-4 shows a similar surge and then a
drop in certification related to these events.5 Only 13 percent of all geriatric
psychiatrists ever certified became certified after the practice pathway was
phased out.
As the geriatric certifications expire, many physicians do not pursue
recertification; most of these physicians were certified via the practice pathway. Reasons for not recertifying are multifactorial, including retirement,
the burden of the process, and the lack of perceived benefit. Table 4-4
shows that only about half of all physicians certified in geriatric medicine
or geriatric psychiatry before 1994 have been recertified (ADGAP, 2005).
By comparison, 89 percent of physicians who received specialty certificates
in other disciplines6 from the ABIM between 1990 and 1995 enrolled in
the maintenance of certification process; of those, 81 percent completed the
process (ABIM, 2005). The comparable rate of recertification in geriatrics
among other health professions is unknown.
4 In 2006, the ABIM recognized geriatric medicine as a subspecialty of internal medicine
instead of as a CAQ (ABIM, 2006).
5 The ABPN dropped the term “of added qualifications” in 1997 (ABPN, 2007b).
6 Excluding clinical cardiac electrophysiology, critical care medicine, and geriatric
medicine.
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THE PROFESSIONAL HEALTH CARE WORKFORCE
3000
Practice Pathway
Eliminated
2500
2000
1500
Training Requirement
Reduced to 1 Year
1000
500
2004
2003
2002
2001
2000
1999
1998
1996
1994
1992
1990
1988
0
Year
FIGURE 4-3 Numbers of physicians newly certified in geriatric medicine,
4-3.eps
1988-2004.
SOURCE: ADGAP, 2005.
800
Practice Pathway
Eliminated
700
600
500
400
Training Requirement
Reduced to 1 Year
300
200
100
0
1991
1992
1994
1995
1996
1998
2000
2002
2004
Year
FIGURE 4-4 Numbers of physicians newly certified in geriatric psychiatry,
1991-2004.
4-4.eps
SOURCE: ADGAP, 2005.
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RETOOLING FOR AN AGING AMERICA
TABLE 4-4 Number of Physicians Certified and Recertified in Geriatrics
Family Medicine
Internal Medicine
Psychiatry
Yeara
Certified
Recertified
Certified
Recertified
Certified
Recertified
1988
1990
1991
1992
1994
TOTAL
752
473
NA
597
771
2,593
477
313
NA
359
371
1,520
(58.6%)
1,654
1,204
NA
1,254
1,568
5,679
801
524
NA
605
585
2,515
(44.3%)
NA
NA
490
359
422
1,271
NA
NA
323
236
154
713
(56.1%)
NOTE: NA = not applicable.
aCertification examinations by each body were not available in every calendar year.
SOURCE: ADGAP, 2005.
Nurses
Professional nurses7 represent the largest sector of the health care
workforce responsible for patient care in most health care settings. The professional nurse workforce consists of registered nurses (RNs) and advanced
practice registered nurses (APRNs), who are RNs prepared in master’s
degree programs. With few exceptions, almost all professional nurses are
involved in the care of older adults. In addition to direct care, professional
nurses supervise licensed practical nurses (LPNs)8 and certified nurse aides
(CNAs) (discussed in Chapter 5). While the current and impending nursing
shortage has received much attention, there have been some improvements;
enrollment in baccalaureate programs increased by 5 percent from 2005 to
2006, and the number of graduates increased by 18 percent (AACN, 2006).
However, this upswing is tempered by the fact that more than 32,000
qualified applicants to nursing programs (baccalaureate level or higher)
were not accepted; about half the schools identified lack of faculty as the
main barrier to admitting more students (AACN, 2006; Anderson, 2007).
Additionally, men remain underrepresented in the nursing profession and
need to be considered for recruitment efforts to allay workforce shortages
(see Chapter 5).
Licensed Practical Nurses
LPNs have a more limited scope of practice than RNs, but this scope
can vary widely among states, especially in light of the nursing shortage.
7 In this report, “professional nurses” refers to nurses who have graduated from an approved
baccalaureate, associate degree, or diploma nursing program and who have passed a national
licensing examination, the NCLEX-RNs.
8 In some states, this level of nurse is referred to as a licensed vocational nurse (LVN).
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With about 26 percent of all LPNs working in nursing homes, LPNs are
especially important to the care of older adults in long-term care settings
(BLS, 2007b). LPNs often provide more hours of care per nursing home
resident per day than do RNs (Harrington et al., 2006). LPNs receive about
1 year of training through technical or vocational schools or through junior
or community colleges. With experience and training, LPNs may supervise
nurse aides. For example, the Institute for the Future of Aging Services is
developing a leadership training program to teach LVNs the necessary skills
and competencies to be more effective supervisors (IFAS, 2008). Some of
the elements of this training include communication, critical thinking, conflict resolution, and cultural competency. Little is known about the geriatric
training of LPNs.
Registered Nurses
As with other professions, nurses generally receive little or no preparation in the principles that underlie geriatric nursing in their basic nursing
education. In 2005, 31 percent of new RNs received baccalaureate degrees,
but only one-third of the baccalaureate programs required a course focused
on geriatrics. Almost all baccalaureate programs include some geriatric
content, but the extent of this content is unknown (Berman et al., 2005).
While 42 percent of RNs receive their initial education through associate
degree nursing programs (HRSA, 2006b), the degree of integration of geriatrics into these programs is also unknown. Given the paucity of geriatric
content in programs preparing nurses, it is appropriate to assume that most
practicing RNs have little formal preparation in geriatrics.
There exist a number of efforts aimed at ensuring nursing competency
in geriatric care. In 2000, for example, the American Association of Colleges of Nursing (AACN) developed guidelines for geriatric competencies
in baccalaureate programs. The National Council of State Boards of
Nursing (NCSBN) mapped those guidelines against the National Council
Licensure Examination (NCLEX), which is required for licensure of all
nurses, to ensure adequate testing on geriatric issues (Wendt, 2003). Still,
more needs to be done to analyze the depth of this content (Bednash et
al., 2003).
As with other professions, there exist various public and private efforts
aimed at increasing the geriatric content of nursing programs and developing geriatric nursing leaders. Since 1996 the John A. Hartford Foundation
has invested $60 million in the Hartford Geriatric Nursing Initiative, which
includes the Institute for Geriatric Nursing and the Centers of Geriatric
Nursing Excellence. These programs foster the development of academic
leaders and increase geriatric content in the education and training of
nurses. In 2002 the Atlantic Philanthropies funded a 5-year initiative to
improve nursing competence in treating older adults (Box 4-1). Under the
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RETOOLING FOR AN AGING AMERICA
BOX 4-1
Nurse Competence in Aging Initiative
“Nurse Competence in Aging (NCA) is an initiative to improve the quality of health
care older adults receive by enhancing the geriatric competence—the knowledge,
skills and attitudes—of the 400,000 nurses who are professionally identified as
members of approximately 57 specialty nursing associations. Nurse Competence
in Aging is committed to:
“Enhancing Geriatric Activities of National Specialty Nursing Associations Associations apply for grant funding and receive technical assistance to move forward
with geriatric best practice initiatives. Funded associations are designated ANASNAPGs, or American Nurses Association-Specialty Nursing Association Partners
in Geriatrics.
“Promoting Gerontological Nursing Certification to encourage specialty nurses to
obtain dual certification and validate their geriatric competence along with their
specialty expertise. Scholarships available!
“Providing a Web-based Comprehensive Geriatric Nursing Resource Center
GeroNurseOnline is a comprehensive website providing current best practice
information on care of older adults. We invite you to explore GeroNurseOnline
and become a Gero Smart Nurse!
“Nurse Competence in Aging was a 5-year initiative funded by The Atlantic Philanthropies (USA) Inc., awarded to the American Nurses Association (ANA) through
the American Nurses Foundation (ANF), and represented a strategic alliance
among ANA, the American Nurses Credentialing Center (ANCC) and the John A.
Hartford Foundation Institute for Geriatric Nursing, New York University.”
SOURCE: ANA, 2007.
Nurse Reinvestment Act,9 the Comprehensive Geriatric Education Program
provides funds for clinical training of nurses in geriatrics, the development
and dissemination of geriatric nursing curricula, and the preparation of
nursing faculty to teach geriatrics. Funding for this program has remained
at around $3.4 million annually since fiscal year 2004 (HRSA, 2007b). The
Nurse Education, Expansion, and Development Act of 200710 proposes to
9 Nurse
Reinvestment Act. Public Law 107-205. 107th Congress. August 1, 2002.
Education, Expansion, and Development Act of 2007. S 446. 110th Congress, 1st
session. January 31, 2007.
10 Nurse
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THE PROFESSIONAL HEALTH CARE WORKFORCE
143
offer grants to nursing schools to increase the integration of geriatrics into
their core curricula.
Similar initiatives have also been developed to support education and
training in geropsychiatric nursing. For example, in 2007 the John A.
Hartford Foundation awarded $1.2 million to establish the Geropsychiatric
Nursing Collaborative. This group will establish a core set of geropsychiatric competencies in order to develop basic curricula for all levels of nurse
training (The John A. Hartford Foundation, 2007).
Advanced Practice Registered Nurses
An RN may become an APRN by obtaining a master’s degree and
may become certified either through a national certifying examination or
through state certification mechanisms. An APRN functions as an independent health care provider, addressing the full range of a patient’s health
problems and needs within an area of specialization. There are a number of
different types of APRNs, including: nurse practitioners (NPs), who provide
primary care; clinical nurse specialists, who typically specialize in a medical
or surgical specialty; certified nurse anesthetists; and certified nurse midwives. The pipeline for producing APRNs with a specialization in geriatrics
is inadequate to meet the need. As with other types of nurses, the John A.
Hartford Foundation has been a key supporter in the development of the
geriatric APRN workforce. In particular, the Building Academic Geriatric
Nursing Capacity Scholars and Fellows Awards Program targets doctoral
and post-doctoral nurses and APRNs who want to redirect their careers
toward geriatrics (Fagin et al., 2006).
NPs represent a particularly important component of the workforce caring for older adults because of their ability to provide primary care as well as
care for patients prior to, during, and following an acute care hospitalization
and also to care for residents in institutional long-term care settings. NPs
treat a disproportionate number of older adults—23 percent of office visits
and 47 percent of hospital outpatient visits with NPs are made by people 65
and older (Center for Health Workforce Studies, 2005). Furthermore, NPs
care for a higher proportion of elderly poor adults than do physicians or
physician assistants (Cipher et al., 2006). Finally, NPs have been shown to
provide high-quality care and be cost-effective (Hooker et al., 2005; Melin
and Bygren, 1992; Mezey et al., 2005).
While APRNs care for large numbers of older adults in ambulatory
care, hospitals, and institutional long-term care settings, APRN education
programs lack specific geriatric requirements. The AACN publishes a set
of competencies called Nurse Practitioner and Clinical Nurse Specialist
Competencies for Older Adult Care (AACN, 2004), but it does not require
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RETOOLING FOR AN AGING AMERICA
that these competencies be incorporated into educational programs. Some
of these competencies include
•
•
•
•
•
•
ability to distinguish between illness and normal aging;
assessment of geriatric syndromes;
identification of changes in mental status;
education of patients and their families about prevention and endof-life care;
assessment of cultural and spiritual concerns; and
collaboration with other health care professionals.
Little is known about on-the-job opportunities for APRNs to gain
knowledge and skill in geriatric nursing care.
Oral-Health Care Workers
The oral health needs of older adults are significantly different from
the needs of younger people, and older adults face a variety of challenges
in meeting these needs. One of the barriers facing older adults who need
oral-health services is lack of access to care. This lack of access is often
due to the lack of coverage under Medicare for routine services, but it is
also the case that many oral-health professionals are reluctant to travel
to alternative sites of care (such as community-based settings) or to manage the complicated social and medical challenges associated with older
patients. Even though the delivery of basic oral-health services to nursing
home patients is supported by government regulation, less than 20 percent
of residents of government-certified institutions received dental services
in 1997 (MacEntee et al., 2005). In 1987 the National Institute on Aging
(NIA) predicted a need for 1,500 geriatric dental academicians and 7,500
dental practitioners with training in geriatric dentistry by the year 2000
(NIA, 1987). By the mid-1990s, however, only about 100 dentists in total
had completed advanced training in geriatrics (HRSA, 1995), and little has
changed since then.
The availability of geriatric training for dentists has improved over the
past few decades. In 1976, only 5 percent of dental schools offered courses
in geriatric dentistry and, at that time, more than half of the programs (52
percent) did not foresee geriatric dentistry as part of their future curricula
(Mohammad et al., 2003). However, by 1981 about half of all schools
had developed geriatric dentistry programs, and an additional 25 percent
planned to add geriatric curricula in the near future. As of 2001, all dental
schools reported having some curricula related to geriatric dentistry, and
almost one-third operated a geriatric clinic (Mohammad et al., 2003).
The geriatric content varies greatly among schools. A school may offer
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145
only a single elective course, for example, or material information may be
imparted via guest lecturers. Additionally, exposure to clinical experiences
is lagging behind the didactic requirements. Of the students graduating in
2001, almost 20 percent did not feel prepared to care for the elderly population, and 25 percent felt the geriatric dental curriculum was inadequate
(Mohammad et al., 2003).
The American Dental Association currently does not recognize geriatric
dentistry as a separate specialty, and none of the 509 residencies recognized
by the American Dental Education Association are specifically devoted to
the care of geriatric patients; in contrast, specialty recognition and 71 residencies exist for pediatric dentistry. In fiscal year 2005, HRSA supported
seven residency programs in pediatric or general dentistry; one program
specifically requested funds to improve clinical and didactic curriculum in
geriatric dentistry, but the residency is not focused on geriatrics (HRSA,
2005b). The VA’s Advanced Fellowship in Geriatrics program allows dentists (and other health care professionals) to pursue advanced research in
geriatrics at one of 16 GRECCs (VA, 2007a). Previous VA fellowships in
geriatric dentistry are no longer available. As mentioned previously, HRSA
administers the Title VII Geriatrics Health Professions Program, which
includes awards to institutions to prepare geriatrics faculty in dentistry,
medicine, and behavioral/mental health.
The American Board of General Dentistry (ABGD) offers board certification in general dentistry following completion of a post-graduate
residency; exam content does not explicitly require questions on geriatric
care or on special-care dentistry, but it does explicitly require knowledge of
pediatric dentistry (ABGD, 2007). Also, while the ABGD’s general dentistry
certification process has minimum requirements for continuing dental education in several areas (e.g., periodontics, orthodontics, and pediatric dentistry), it has no minimum requirements for “special patient care,” although
it is a listed category. The American Society for Geriatric Dentistry (ASGD),
part of the Special Care Dentistry Association, offers fellowship status to
ASGD members who meet requirements for post-graduate and continuing
education and who pass an oral examination. The American Board of Special Care Dentistry further offers diplomate status to ASGD fellows based
on time in practice and membership in the SCDA. The American Dental
Association, however, does not recognize this specialty board.
Less is known about the geriatric education and training of dental hygienists, although dental hygienists are increasingly important in providing
care to special populations, especially those in rural areas and long-term
care settings. Dental hygienists usually earn associate degrees, but some
programs grant up to a master’s level degree. Dental hygienists are licensed
by individual states, must pass written and clinical examinations, and have
variable requirements for continuing education. While all schools have in-
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RETOOLING FOR AN AGING AMERICA
tegrated geriatric content, about half (49.5 percent) consider their geriatric
curricula to be inadequate (Tilliss et al., 1998).
Pharmacists
There is currently a significant national shortage of pharmacists in the
United States, which is due to a number of factors, including increased use
of prescription medications, increased workloads, changing sites of service,
demographic changes in the workforce, and expanding scopes of work
(HRSA, 2000). While the absolute number of pharmacists has grown, supply has not kept up with demand, and wide variations in the numbers of
pharmacists per capita exist from state to state (Walton et al., 2007). The
current shortage causes problems for older adults, who tend to be heavy
users of prescription drugs and to rely on pharmacists for counseling on
the proper use of medications and on the monitoring of medication-related
problems, such as interactions, duplications, adverse events, and adherence
irregularities (Cooksey et al., 2002).
The role of pharmacists in the interdisciplinary care of older patients
was reinforced in 1974 when Medicare first mandated drug regimen reviews (now called a Medication Regimen Review) in nursing homes by
consultant pharmacists (Levenson and Saffel, 2007). In this setting, the role
of the consultant pharmacist includes the provision information and recommendations to physicians regarding medications, identification of improper
use of medications or the prescription of incompatible medications, and
collaboration with the medical director and other staff to develop proper
protocols for response to adverse events. This role has increased importance
with the escalation of the number of medications given to the most frail
and chronically ill patients. Additionally, with the advent of Medicare Part
D, pharmacists potentially have a role in the education of older adults on
their plan options and associated implications.
The doctor of pharmacy (PharmD) degree requires 4 years of pharmacy
education. The Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree,
adopted in 2006, implies that geriatrics should be a part of the pharmacy
curriculum but does not explicitly require its inclusion. However, the science foundation of programs must consider populations that have altered
pharmacological needs because of physiology or other reasons; this may
include geriatric patients. Some of the competencies needed for the care of
older patients include knowledge of the influence of aging on drug therapy,
provision of medication and wellness counseling, and knowledge of geriatric syndromes (Odegard et al., 2007).
The American Society of Health-System Pharmacists (ASHP) accredits
1-year residencies in pharmacy, community pharmacy, or managed care
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pharmacy, which are referred to as PGY-1, for Post Graduate Year 1. Pharmacists may pursue a second year of residency training (PGY-2) in a focused
area, including geriatric pharmacy. The ASHP currently accredits (or preaccredits) 351 PGY-2 programs (ASHP, 2007). There are eight accredited
programs in geriatric pharmacy, and two other programs are pre-candidates
for accreditation. The American College of Clinical Pharmacy offers one
fellowship position in geriatrics to prepare pharmacists for academia and
independent research; this 2-year fellowship focuses on Alzheimer’s Disease (ACCP, 2007). Viability of these programs has been hindered by
inconsistent funding; with the exception of GECs, there are few federal or
private-foundation-funded programs or initiatives that support pharmacist
education and research training in geriatrics.
Pharmacist licensure, which is performed by individual states and jurisdictions, depends on passing a national examination, and 46 jurisdictions require an additional examination on federal law and state-specific
regulations (CCP, 2006). Some states also require laboratory and oral
examinations. Re-licensure requires a minimum of continuing education
credits. Currently, neither continuing education in geriatrics nor demonstrated geriatric competency is required for pharmacist re-licensure in any
state. However, a 2005 survey of state pharmacy laws found that one state
requires all pharmacists to participate in 2 hours of continuing education
in end-of-life care every 2 years, and two states require all pharmacists
working as long-term care consultants to have at least a portion of their
continuing education activities focused on the care of older adults (Linnebur et al., 2005).
Physician Assistants
Physician assistants (PAs) represent an important part of the workforce for the elderly population (Olshansky et al., 2005). PAs work under
the supervision of a physician, but they can often work apart from the
physician’s direct presence and can prescribe medications and bill for health
care services. Unlike some of the other professions described above, the PA
workforce tends to be younger and is growing rapidly. About half of PAs
work in family medicine or general medicine (Brugna et al., 2007; Hooker
and Berlin, 2002). The 65-and-older population accounts for about 32 percent of office visits to PAs (Hachmuth and Hootman, 2001), and 78 percent
of PAs report treating at least some patients over the age of 85 (Center for
Health Workforce Studies, 2005).
PAs are an especially important source of care in underserved areas,
where they often act as the principal care provider in clinics, with physicians attending on an intermittent basis. In this vein, they are a potential
source of care to meet the increased need that is projected for long-term
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care settings. Their use may be a particularly attractive strategy since, as
with NPs, the use of PAs has been shown to be cost-effective (Ackermann
and Kemle, 1998; Brugna et al., 2007). On the other hand, according to a
survey of more than 23,000 PAs, only 5 percent of respondents reported
spending any time in a nursing home or other long-term care facility, and
less than 1 percent identified their primary practice as geriatrics (AAPA,
2007). Of those respondents who specialize in geriatrics, 67 percent reported working primarily in a nursing home or long-term care facility, and
75 percent reported spending at least some time in those settings. Almost
18 percent of PAs who specialize in geriatrics spend some time caring for
patients at home, compared to 1.3 percent of all other types of PAs. And
almost 22 percent of PAs specializing in geriatrics are employed by the
government, primarily by the VA, while only 9 percent of all other types of
PAs work for the government.
The overwhelming majority of the 136 accredited PA programs are
located within universities and colleges, but a few exist within hospitals, community colleges, and military institutions (BLS, 2007c). Most of
these programs offer a master’s level degree, while others offer bachelor’s
and associate-level degrees. Virtually all students in these programs—99
percent—pursue primary-care tracks. Most programs follow traditional
curricula of medical schools (Hooker and Berlin, 2002), and while some
PAs receive advanced training, the bulk of the advanced programs focus
on surgical and emergency care (APPAP, 2008). Accreditation standards
require training in geriatrics but do not specify a minimum workload (BLS,
2007c). As is the case with other professions, there have been many calls for
increased education and training of PAs in geriatrics (Brugna et al., 2007;
Olson et al., 2003; Segal-Gidan, 2002; Woolsey, 2005). Unfortunately, very
little has been done to examine the quality and quantity of current geriatric
education and training among PA programs. In one survey, PA program administrators who were asked which areas of the curricula needed increased
emphasis said that geriatric issues related to pharmacology and mental
health deserved the highest priority (Olson et al., 2003).
Social Workers
The need for geriatric social workers has been recognized for decades
(NIA, 1987; Saltz, 1997). In 1987 the NIA estimated that there would be
a need for 70,000 social workers prepared in geriatrics by 2020, or a 43
percent increase over the needs at that point in time. In spite of this urgency,
the number of social workers trained in geriatrics has not kept pace with
the need. While 73 percent of social workers report that they work with
adults aged 55 and over, and between 7.6 and 9.4 percent of social work-
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ers are employed in long-term care settings, only about 4 percent actually
specialize in geriatrics (ASPE, 2006; Center for Health Workforce Studies,
2006). Between 1996 and 2001 the number of students specializing in aging
decreased by 15.8 percent (ASPE, 2006). On the other hand, many social
workers begin to specialize in the care of older persons after graduation
and do so without formal training in geriatrics (Cummings and DeCoster,
2003).
Social workers receive training through either bachelors-level (BSW) or
masters-level (MSW) programs, which may be accredited by the Council on
Social Work Education. As of 2006, the Council accredited 458 BSW programs and 181 MSW programs; there were also 74 doctoral programs in
social work (DSW or PhD) at the time (BLS, 2007d). Combined, BSW and
MSW programs graduate about 31,000 students annually (ASPE, 2006).
Social workers with BSW degrees are more likely to work in long-term
care settings than those with MSW degrees. A 1995 survey showed that
11.5 percent of BSW social workers worked in nursing homes or hospices,
compared to 1 percent of MSW holders, and 16.5 percent identified aging
services as their primary practice, compared to 3.7 percent of MSW holders
(ASPE, 2006).
In spite of the long-recognized need for social workers trained in aging
issues, most social work programs contain little or no geriatric content in
their curricula. In fact, the proportion of programs offering specialization
in aging is decreasing. In the early 1980s almost half of MSW programs
offered an aging specialization; by the early 1990s this had dropped to
about one-third of programs, and as of 2003 only about 29 percent of
MSW programs offered an aging concentration, specialization, or certificate
program (Cummings and DeCoster, 2003; Scharlach et al., 2000). Existing
aging curricula often have limited content, rarely offering more than one or
two elective courses. In 1988 the vast majority of BSW programs—about
80 percent—did not offer specific instruction on aging issues (Lubben et al.,
1992). The inadequacy of curricula is compounded by the fact that socialwork students show low levels of interest in taking courses on aging and
have persistent negative attitudes about working with older people (Hash
et al., 2007; Lubben et al., 1992).
In 2000 the Council on Social Work Education, in conjunction
with Strengthening Aging and Gerontology Education for Social Work
(SAGE-SW), surveyed social workers about the competencies that geriatric
social workers and other types of social workers need in order to care for
older patients effectively (Rosen et al., 2000). Sixty-five competencies were
identified, of which 35 were described by the respondents as being needed
by all types of social workers. These competencies included
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•
•
•
•
•
•
knowledge of the physical, social, and psychological changes of
aging;
knowledge of the diversity of attitudes about aging;
use of case management skills to get access to needed resources;
collaboration with other health professionals;
identification of one’s own biases toward aging; and
respect of diverse cultural and ethnic needs.
Several initiatives aim to promote education and training in geriatric
social work:
•
•
•
•
The Social Work Leadership Institute at the New York Academy
of Medicine, funded by the Atlantic Philanthropies and the John
A. Hartford Foundation, coordinates the Practicum Partnership
Program, an innovative educational model to train masters level
social workers in their field work (Box 4-2).
The Atlantic Philanthropies established the Institute for Geriatric
Social Work, which, in partnership with the American Society on
Aging and other groups, promotes the training of practicing social
workers in issues related to the elderly population (IGSW, 2007).
In 2000-2004 the John A. Hartford Foundation supported the
Geriatric Enrichment Program (GeroRich) to increase geriatric content in basic social work courses at both the BSW and MSW levels
(Hash et al., 2007).
The John A. Hartford Foundation also supports the Council on
Social Work Education Gero-Ed Center, which serves as a resource
for both faculty and students to become competent in geriatric
issues.
Very few social-work trainees do advanced training or field work in
aging, and of those who do, most are students in MSW programs. This
lack of training is primarily due to a lack of funding for program support
or stipends (ASPE, 2006; Scharlach et al., 2000). In partnership with the
Social Work Leadership Institute, the John A. Hartford Foundation supports 60 MSW programs in an effort to increase the quality and content of
field experiences in aging. The effort aims to increase the numbers of MSW
students who go on to specialize in geriatrics.
In 1998 the National Association of Social Workers (NASW), the voluntary professional organization of social workers, created a new specialty
section on aging. Recently the NASW has developed three specialty certifications in gerontology available to its members (NASW, 2007).
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BOX 4-2
The Practicum Partnership Program
“The Practicum Partnership Program sponsored by the New York Academy of
Medicine and the Hartford Foundation is in its eighth year. It has trained more
than 1,000 social workers to work with older adults using a specialized field education model for students at masters-level social work programs. PPPs across the
country form a strong educational foundation to grow the ranks of leaders with
aging specializations.
“The PPP differs from traditional MSW field education models. Based on innovative partnerships between universities and community-based agencies, the PPP
provides students with wide-ranging, hands-on experience in older adult care.
Over the course of either one or two years, students rotate through multiple field
settings, gaining exposure to different care systems and a broad spectrum of life
phases.
“Evaluations of the program have already demonstrated promising results: in our
pilot study, 80 percent of PPP graduates have gone on to pursue careers in the
field of aging. Since 1999, with support from the John A. Hartford Foundation, 45
PPPs have been established at colleges and universities nationwide.”
SOURCE: SWLI, 2007.
Allied Health and Other Professions and Occupations
Many other professionals also provide essential health services to older
Americans. These professionals are pressed to meet the needs of the growing older population because of shortages of supply, increases in demand,
and deficiencies in geriatric education and training that are similar to those
already discussed. For example,
•
•
HRSA’s 1995 report on the status of geriatric education showed
only 17 percent to 19 percent of physical therapy programs had
at least 75 percent of their students complete a geriatric internship
even though 39 percent of the physical therapy patients were over
65 (HRSA, 1995).
The Emergency Medical Technician—Basic: National Standard
Curriculum, developed by the National Highway Traffic Safety Administration, includes modules dedicated to the care of obstetrics
and pediatric patients, but none are dedicated to the older adult
patient (NHTSA, 1994).
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•
•
•
•
While 84 percent of optometry schools and colleges reported
a required geriatrics course, the content of these courses was
variable.
Only one of the eight schools of podiatric medicine has a discrete course devoted to the care of geriatric patients, while six list
courses specific to the care of pediatric patients (AACPM, 2007).
In a 2004 survey of dietetics and nutrition programs, 22 percent of
the undergraduate programs and 44 percent of the graduate programs offered courses in aging (Rhee et al., 2004). In comparison,
maternal and child health courses were offered in 31 and 51 percent of the programs, respectively. Thirty-seven percent of graduate
programs had no faculty in geriatrics.
None of the following specialties with high volumes of older patients has a subspecialty certificate available in geriatrics: dermatology, emergency medicine, physical medicine and rehabilitation,
or surgery. By contrast, all have certification in pediatrics (ABMS,
2007).
Of particular importance are the many occupations that fall under the
broad category of “allied health care workers.” This term is ill-defined,
and the many definitions that have been developed are often contradictory
(Lecca et al., 2003). In general, allied health care workers represent nearly
200 different occupations, including various types of technologists, technicians, therapists, and health-information professionals. Many of the allied
health occupations are currently experiencing shortages and are projected
to be among the fastest-growing occupations in the United States (BLS,
2007a). These groups face significant increases in need for their services
in all care settings (Chapman et al., 2004). The geriatric education and
training of the allied health care workforce is highly variable and is usually
structured according to the standards of the appropriate accrediting body.
Other Issues in Geriatric Education and Training
In addition to the particular professional concerns discussed in the previous section, there are a number of other overarching issues that all professions face in the geriatric education and training of their practitioners.
First, the education and training of all types of professionals depends on
the availability of qualified faculty. Second, practitioners should be aware
of the unique health care needs of several special elderly populations; these
populations include various racial and ethnic groups as well as the growing
number of lesbian, gay, and bisexual older adults.11 Third, all practitioners
11 There
are insufficient data on transgendered older adults to include in this section.
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who care for older adults should be educated and trained in the full spectrum of health care needs, from health promotion to palliative care. Finally,
as discussed in Chapter 3, interdisciplinary care of older adults shows
promise, so students in all professions should be trained on how to be an
effective member of an interdisciplinary team.
Leadership
A well-recognized barrier to geriatric education and training of all
health care providers is the inadequate number of available and qualified
academic faculty (Berkman et al., 2000; Berman et al., 2005; Cavalieri et
al., 1999; Graber et al., 1999; Hazzard, 2003; Kovner et al., 2002; Rhee
et al., 2004; Rubin et al., 2003; Simon et al., 2003; Warshaw et al., 2006).
Any effort to increase geriatric education will find itself limited by the
availability of trained faculty. Furthermore, beyond the need for a greater
number of geriatric faculty, all geriatric fields need strong expert leaders to
develop new knowledge and recruit new students.
It is a controversial question whether advanced geriatric training programs should be designed to train geriatric specialists for clinical practice
or to train them for academic research and leadership. Some argue that, for
the sake of the efficient use of scarce resources, geriatric specialists should
concentrate on their roles of performing research and training the future
health care workforce and should act as clinical consultants in only the
most complex cases.
Beyond academics and clinical care, geriatric leaders need to learn
the skills to manage staff, promote quality, and create a healthy work
environment. For example, the relationship between nursing supervisors
and nurse aides plays a significant role in the development of a hospitable
work environment that leads to increased job satisfaction (see Chapter
5 for more on job satisfaction and turnover among direct-care workers)
(Tellis-Nayak, 2007). In addition, certain management principles, such as
providing rewards to nurse aide staff, have been associated with improved
patient outcomes (Barry et al., 2005). This relationship will also have
increased importance as direct-care workers assume more patient responsibility in the cascading mechanism of job delegation (discussed more later
in this chapter).
To increase the number of geriatric leaders, a number of public and
private entities have developed programs to promote research and teaching
capacities in geriatrics. Examples include the following:
•
The Hartford Geriatric Social Work Faculty Scholars Program,
funded by the John A. Hartford Foundation, aims to develop leaders in geriatric social work through research support, mentoring,
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•
•
•
•
•
skills-based workshops, and nurturing of professional relationships
(GSWI, 2007; Maramaldi et al., 2004).
HRSA’s Geriatric Training for Physicians, Dentists, and Behavioral/
Mental Health Professions Program is the country’s sole source
of postgraduate training for preparing dentists to teach geriatrics
(HRSA, 2005a). In fiscal year 2005 HRSA funded 13 programs with
a total of $6.3 million in grants. It is unknown, however, whether
all of these programs filled their available dental positions.
The Atlantic Philanthropies and the John A. Hartford Foundation
support the Dennis W. Jahnigen Career Development Scholars
Awards to develop geriatric academic leaders in surgical and related specialties, such as anesthesiology, ophthalmology, and emergency medicine. The two foundations are also responsible for the
establishment and continuation of the T. Frank Williams Research
Scholars Award, which supports research by medical subspecialists
in geriatrics or aging.
In July 2004 the Donald W. Reynolds Foundation awarded a total
of $12 million in grants to four academic health centers for them
to train their medical faculty in geriatrics (Donald W. Reynolds
Foundation, 2007).
HRSA grants GACAs (Geriatric Academic Career Awards) directly
to junior faculty at allopathic and osteopathic medical schools to
support teaching (HRSA, 2005a).
The John A. Hartford Foundation’s Centers of Excellence in geriatric medicine, psychiatry, and nursing help to train larger numbers
of competent geriatric academicians and also allow specialists to
devote time to geriatric research in addition to their work training
future clinicians.
Recognizing the scarcity of geriatric leaders, several institutions have
developed innovative approaches to spread knowledge of geriatric principles. For example,
•
•
In 1997 the Practicing Physician Education Project used geriatric
experts to train non-geriatrician physician leaders to educate their
peers on various geriatric syndromes (Levine et al., 2007).
Since 1992, the Nurses Improving Care for Health System Elders
(NICHE) program has worked with nurses in hospital settings
to implement models and protocols that improve the care of geriatric patients. In the Geriatric Resource Nurse (GRN) model,
a geriatric APRN trains a staff nurse to be the clinical resource
on geriatric issues for other nurses (NICHE, 2008).
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•
•
•
•
155
The Boston University Medical Center developed the Chief Resident Immersion Training (CRIT) Program in the Care of Older
Adults to improve understanding and teaching of geriatric principles among residents in non-geriatric fields (ADGAP, 2007a). The
program is being disseminated nationally.
In 2003-2004 the Society of General Internal Medicine and the
John A. Hartford Foundation worked in Collaborative Centers for
Research and Education in the Care of Older Adults to enhance
the ability of general internists to teach geriatrics (Williams et al.,
2007).
HRSA administers the National Advisory Council on Nurse Education and Practice, which, in response to the Nursing Reinvestment
Act, provided grants for the geriatric education and training of
registered nurses so that they can act as leaders and trainers for
CNAs and LPNs (HRSA, 2003).
Geriatric experts have tried to infuse geriatrics into training programs for personnel who might not normally gain exposure to
geriatric principles. Faculty at Northern Michigan University developed a training program for correctional workers that focused
on the needs of the aging prison population (Cianciolo and Zupan,
2004).
Special Populations
Ethnogeriatrics As discussed in Chapter 2, the elderly population of the
future will be more diverse than today’s older adults. Thus increased knowledge of different cultural belief systems will be important to the development of comprehensive and effective plans of action. For example, older
Asian adults may not disclose their non-Western health beliefs, including
the use of herbal medications or alternative health procedures, unless directly asked (McBride et al., 1996). These concerns are especially important
considering the potential mismatch between the diversity of the health care
workforce and the diversity of the older adult population. For example, the
high proportion of IMGs among fellows in geriatric medicine and geriatric
psychiatry was demonstrated earlier in this chapter. However, concerns exist for issues of communication and cultural competency in particular when
IMGs care for older adults (Howard et al., 2006; Kales et al., 2006).
Several efforts have been started to improve upon the ethnogeriatric education and training of the health care workforce in settings where providers are responsible for taking care of diverse populations. For example, the
Collaborative for Ethnogeriatric Education produced a five-module Core
Curriculum in Ethnogeriatrics and 11 Ethnic Specific Modules which can be
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BOX 4-3
Knowledge and Skills Needed in Ethnogeriatrics
Knowledge:
•
•
•
•
Differential health risks
Diverse cultural health beliefs and practice systems
Historic experiences that cohorts of older adults are likely to have
experienced
Palliative care
Skills:
•
•
•
•
•
Showing culturally appropriate respect to older adults
Performing culturally appropriate assessments
Eliciting elders’ explanatory models of their conditions
Working with older adults’ families from different cultures
Identifying cultural guidesa
aCultural guides are often individuals from the local community who help patients navigate
the health care system, keeping cultural preferences in mind.
SOURCE: Yeo, 2007.
used as resources in different geographic areas to provide content on local
populations (www.stanford.edu/group/ethnoger). Box 4-3 lists some of the
knowledge and skills needed to properly care for diverse populations.
Lesbian, gay, and bisexual persons Approximately 1 million to 3 million
adults ages 65 and older are gay, lesbian, or bisexual (GLB), and by 2030
that number is expected to rise to 4 million (Cahill et al., 2000). The few
existing studies on the health care needs of older GLB patients report similarities to the health care needs of heterosexual older adults, with a few
important differences. Many GLB patients do not feel comfortable disclosing their sexual orientation to their health care providers. Surveys reveal
that discrimination based on sexual orientation is widespread in health care
and other social-service settings, and it often causes GLB persons to avoid
seeking health care (Cahill et al., 2000; Ryan and Futterman, 1998; Schatz
and O’Hanlan, 1994). The discomfort of revealing sexual orientation to
health care providers is heightened for older adults who came of age at a
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time when society was even less accepting of homosexuality (Brotman et
al., 2003).
Knowledge of a patient’s sexuality can be critical to high-quality patient
care. A recent study estimated that approximately 100,000 adults ages 50
and older are HIV positive (ASA, 2007). Older adults with HIV/AIDS may
be misdiagnosed because health care providers do not perceive HIV/AIDS
to be a risk among older adults and because older adults often do not
disclose the nature of their sexual activity to health care providers (AIDS
InfoNet, 2007; NAHOF, 2007). Additionally, GLB older adults often do
not have the same family support systems as heterosexual older adults,
particularly since GLB older adults are less likely to have children and are
more likely to live alone (Cahill et al., 2000).
The Continuum of Care
Geriatric education is highly variable in its level of comprehensiveness,
and it often fails to address the health care needs of older adults across the
continuum of care, ranging from preventive to palliative care. Health care
professionals should be aware that older adults have a vast range of health
care needs. Many students still are not taught about or exposed to older
populations at either end of the continuum of care.
Health promotion/disease prevention Health promotion is beneficial for
people of all ages and all health conditions, but it may be especially important to the growing cohort of healthy older adults—that is, the 20 percent
of older Americans who have no chronic disease and who require only
preventive and episodic care. Traditionally, the training of professionals in
the care of older adults has focused only on the treatment of disease and
has given little attention to the promotion of health. For example, poor
nutrition is prevalent among seniors (IOM, 2000), but most professionals are still not trained in the nutritional needs of older adults (Bonnel,
2003; Rhee et al., 2004). Government agencies and professional societies
have developed guidelines for health promotion and disease prevention
in elderly populations which include goals typically promoted for other
populations, including increased physical activity, smoking cessation, and
weight management (Fields and Nicastri, 2004). These guidelines are based
on research that shows the benefits of health promotion and disease prevention in elderly populations. For example, studies have shown that older
persons who practice tai chi experience fewer falls (Li et al., 2002, 2005;
Wolf et al., 1996).
Screening guidelines are important in nursing homes for the early detection of depression and pressure ulcers (McElhone et al., 2005). Unfortunately, prevention and screening guidelines often lump all elderly persons
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into one group (65 years and older), and recommendations are often based
on studies performed in younger age groups (Nicastri and Fields, 2004).
More research is needed on preventive services for older adults, especially
for the “oldest old,” and health care professionals need to be aware of the
value of these services for all of their older patients.
The activities of professional groups today reflect a growing awareness
of the importance of health promotion and disease prevention for older
patients. For example, the Geriatrics Section of the American Physical
Therapy Association has an interest group on “Health Promotion & Wellness” that aims to improve the education, clinical practice, and research
of physical therapists in health and wellness among older adults (APTA,
2007). The American Geriatrics Society lists “health promotion and disease prevention strategies” among the areas of knowledge needed for the
successful preparation of internal medicine physicians who care for older
adults (AGS, 2004). The American Dietetic Association includes the provision of nutrition care across the lifespan, “infants through geriatrics,” as
one of the core competencies for entry-level dietitians and dietetic technicians (ADA, 2008).
Palliative care Within geriatric education and training programs, palliative care skills are especially important since 80 percent of American
deaths occur among those over age 65 (Ersek and Ferrell, 2005). Skills
that are particularly important include identification and relief of physical and emotional stress, effective communication, interdisciplinary team
work, recognition of the signs and symptoms of imminent death, and support of the bereavement process (National Consensus Project for Quality
Palliative Care, 2004). The opportunities for exposure to these topics has
improved greatly in recent years; almost all medical schools offer some
form of end-of-life care education, and 62 percent of pharmacy schools
surveyed reported didactic training in end-of-life care (Billings and Block,
1997; Herndon et al., 2003).
Despite such improvements, however, the overall education and training of the health care workforce in palliative care is deficient (Billings and
Block, 1997; Ersek and Ferrell, 2005; Holley et al., 2003; IOM, 1997;
Paice et al., 2006; Walsh-Burke and Csikai, 2005). In one survey of medical students, residents, and faculty, less than 20 percent reported that they
received formal education in end-of-life care, 39 percent felt unprepared to
address patient fears, and almost half felt unprepared to deal with their own
feelings about death (Sullivan et al., 2003). Another survey showed that less
than half of graduating family medicine and internal medicine residents (41
percent and 43 percent, respectively) felt very prepared to counsel patients
on end-of-life issues (Blumenthal et al., 2001). In contrast, a 2005 study
showed 70 percent of geriatric medicine fellows reported completing rota-
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tions in palliative care, end-of-life care, or hospice, and only 2.7 percent felt
unprepared to care for dying patients (Pan et al., 2005).
In October 2006 the American Board of Medical Specialties (ABMS)
announced Hospice and Palliative Medicine as a new subspecialty for ten
different specialty boards (ABMS, 2006). The first certifying exams will be
administered in October 2008.
Interdisciplinary Team Training
One element common to many models described in Chapter 3 is the
use of interdisciplinary teams. The value of interdisciplinary teams for the
care of older adults with complex care needs has been increasingly acknowledged in recent years (Dyer et al., 2003; Howe and Sherman, 2006;
Inouye et al., 2000; Maurer et al., 2006; Wheeler et al., 2007; Williams et
al., 2006). The term “interdisciplinary team” implies an interaction and an
interdependence among practitioners with different areas of expertise who
are working together to treat a single patient. Still, health care professionals
are typically trained separately by discipline, which fosters ideas of hierarchy and responsibility for individual decision making (Hall and Weaver,
2001). As a result, providers may gain little understanding of or appreciation for the expertise of other providers or the skills needed to effectively
participate in an interdisciplinary team. However, most health care professions identify interdisciplinary team practice as a necessary competency in
the care of older adults.
The field of geriatrics led the movement toward team training in health
services. In the 1970s the VA developed the Interdisciplinary Team Training in Geriatrics (ITTG) Program, and in the 1980s HRSA began awarding
grants for GECs to teach collaboration and teamwork to health care professionals working in geriatrics (Heinemann and Zeiss, 2002).
In 1997 the John A. Hartford Foundation funded eight national programs to develop geriatric interdisciplinary team training (GITT) programs
for students in nursing, social work, and medicine in order to foster the
skills needed for effective team care. These programs often included other
professionals, such as pharmacists, dentists, and rehabilitation therapists.
GITT seeks to train health professionals to work more effectively on geriatric care teams. The announced goals included the creation of a national
model to forge partnerships between geriatric care providers and institutions of education, the development of educational curricula for interdisciplinary team training, training health care professionals in team skills, and
the testing of new models of training for practicing professionals (Flaherty
et al., 2003).
To evaluate this training, several measures have been developed to assess trainees’ knowledge of interdisciplinary geriatric-care planning, their
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knowledge of team dynamics, their attitudes toward geriatrics and teams,
and their skills in team care (Flaherty et al., 2003). One evaluation showed
that the most improvement came on measures of attitudes, especially selfreported measures of team skills; no changes were seen in care planning,
and few changes were seen in team dynamics, depending on the question
and the discipline (Fulmer et al., 2005). Obstacles identified for interdisciplinary training within the GITT programs included differing lengths of
rotation among the disciplines, differing levels of experience among the
participants, and the inability of clinicians to supervise students from other
disciplines (Reuben et al., 2003, 2004). Physicians were the least experienced with and the most averse to sharing responsibilities of patient care.
Similar results have been documented in studies of other similar models
(Fitzgerald et al., 2006; Leipzig et al., 2002; Williams et al., 2006).
HRSA has been a strong supporter of interdisciplinary training in geriatrics and has stated that interdisciplinary geriatric education should be a
core requirement for every health profession (HRSA, 1995). As mentioned
above, GECs provide interdisciplinary training of faculty, students, and
practitioners in the diagnosis, treatment, and prevention of disease, disability, and other health problems of older adults (HRSA, 2007c). While more
and more professionals are gaining experience in interdisciplinary training,
little evidence exists to determine which methods are best for imparting the
knowledge and skills necessary to work as a team member or to show how
such training affects patterns of practice (Cooper et al., 2001; Hall and
Weaver, 2001; Remington et al., 2006).
Conclusions
The education and training of professionals in geriatrics has improved
because of the expansion of school-based opportunities, increased efforts
in interdisciplinary training, and the development of alternative pathways
to gaining geriatric knowledge and skills (discussed in more detail later in
this chapter). Professional groups, private foundations, and public agencies
all support and promote multiple efforts.
Even so, the committee concludes that in the education and training of
the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not
robust.
This is true in general for all the relevant professions. Very few professions have robust advanced training programs in geriatrics; of those
professionals that do have options for advanced training, few individuals
take advantage of these opportunities. One barrier to the development of
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more opportunities for advanced training in geriatrics is a lack of funding
(discussed later in this chapter).
Professionals may also learn about the care of older adults through
continuing-education activities. Most licensed professionals have statebased requirements that they must complete a specific number of continuingeducation approved hours in order to maintain their licenses. Requirements
vary widely among states, both in the number of hours required and regarding the content of those activities. Continuing-education requirements may
also depend on requirements for board certification or for membership in
professional societies. The content of the continuing education required
of professionals is usually not specified. Many professionals fail to receive
adequate education and training in geriatric issues while in school, and of
those who do receive such education and training, some fail to keep up to
date with this knowledge.
Since almost all professionals find themselves caring for older adults
to some degree, they need to have a minimum level of competence in geriatrics. The general competence of health care professionals is ensured via
mechanisms of state- or jurisdiction-based licensure and national board certification, both of which may require completion of a verbal examination, a
written examination, or minimum amounts of annual education and training. Professional licensure provides the primary and most comprehensive
route to ensure that practitioners are competent in the principles of geriatric
care, since virtually all health care professionals must be licensed in order
to provide care. Board certification, a voluntary process, is a secondary
mechanism to ensure geriatric competency of professionals. Often neither
licensure nor certification examinations have explicit geriatric content, or,
if they do, the content is inadequate to ensure competency. By comparison,
many of these examinations have explicit content concerning other patient
populations, most notably pediatric populations.
The committee considered many mechanisms for facilitating the improvement of competence in geriatrics, including requiring schools to improve curricula as a basis of accreditation or requiring a certain percentage
of continuing education hours to be spent on geriatric issues. Ultimately,
the committee concluded that the most comprehensive way to facilitate
this change would be through the explicit inclusion of geriatrics content on
examinations for licensure and certification.
Recommendation 4-2: All licensure, certification, and maintenance of
certification for health care professionals should include demonstration
of competence in the care of older adults as a criterion.
For many professionals, education and training programs are devised
to prepare students for licensure and certification examinations, and so the
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inclusion of geriatrics in standardized examinations may encourage schools
to increase the levels of geriatric education in their curricula. Exceptions
may be made where appropriate (i.e., certain pediatric specialists and obstetricians). More will need to be done to improve the tools that evaluate
this competence, such as ensuring the breadth and depth of questions on
examinations are adequate to prove competence. In addition, educators,
professional organizations, board examiners, and state licensing boards will
need to work together to determine the best methods for assuring that the
educational and training curricula for each discipline are devised to impart
the competencies (i.e., knowledge, skills, and abilities) that these examinations will assess.
TRENDS AFFECTING THE FUTURE OF
EDUCATION AND TRAINING
Developing an effective health care workforce for older Americans will
require taking a number of factors into account, including the demands of
the future elderly population and changes that may affect the education and
training of professionals. Furthermore, needs may develop for new types
of workers and new skill sets, especially in light of new models of care
and the emergence of new technologies. This section describes alternatives
to traditional education, including the greater use of distance education
and community colleges. Distance education is an efficient way to spread
geriatric knowledge held by a small number of experts to large numbers
of professionals, while community colleges can train certain types of new
and existing workers, providing a source of education for some professionals who might have previously received only on-the-job training and also
offering a way to standardize training. Finally, the section examines how
emerging technologies and models of care may create needs for new types of
workers or skill sets. This includes the possibility of having current workers
take on different jobs so as to create a more flexible workforce that uses all
individuals efficiently (to their maximum levels of competence).
Internet-Based Education
In recent years there has been a significant increase in the use of
Internet-based education for the initial and continuing education and training of professionals in geriatrics (Gainor et al., 2004; Supiano et al., 2002;
Swagerty et al., 2000). This is one way to achieve wider dissemination of
geriatric knowledge, especially to those—such as health care providers in
rural areas—who are unable to attend courses because of geographic, financial, and time-based constraints (Murphy-Southwick and McBride, 2006).
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Internet-based education is also a useful tool for dealing with the lack of
available leaders to teach the various courses.
Educators recognize that distance education has a number of valuable
attributes, such as improved access to geriatric materials for non-traditional
students, increased access to experts, and an increased ability to share information among disciplines. A survey of members of the Association for
Gerontology in Higher Education found that 35 percent of the member
institutions used distance education, with most of them (79 percent) having
been using the modality for less than 5 years (Johnson, 2004). A survey of
various medical education programs found that 79 percent used the Internet
for geriatric education, and 56 percent reported that they were currently
developing Internet-based products (Hajjar et al., 2007). There is also evidence, however, that some Internet-based geriatric information is of poor
or inadequate quality (Hajjar et al., 2005).
Community Colleges
Innovative community college programs have great potential for playing a role in both the initial and the continuing geriatric education of
certain professionals. Indeed, community colleges have already been instrumental in the education and training of large parts of the health care
workforce for older patients. For example, community colleges educate a
large number of the nurses who receive associate degrees (Mahaffey, 2002),
and they provide refresher courses to those nurses already in the workforce
(Sussman, 2006). Community colleges may provide career ladder programs
for entry-level workers and partner with nursing homes and home health
agencies to develop programs for continuing education.
Community colleges have also been essential in the development of
many new certificate programs and education courses. Community colleges
have the advantage of being able to tailor programs to local needs and statebased requirements and to use approaches that will be most acceptable
to workers in that community. Recognizing this, the Allied and Auxiliary
Health Care Workforce Project, sponsored by the California HealthCare
Foundation and the California Endowment, funded seven model programs
at community colleges to create new courses and credentialing processes for
health care workers (Chapman et al., 2004). Mt. San Antonio College, one
recipient of the funding created a new certificate program for entry-level
mental health workers. City College of San Francisco and Jewish Vocational
Services created a “Gateway to Health Careers Program” to introduce local residents to health care careers and to provide basic skills training for
college readiness. Community college programs offer one approach to standardizing curricula for new types of workers who care for older patients
and to ensuring the competency of those workers.
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The federal government supports the use of community colleges to train
new health workers. For example, the Employment and Training Administration within the U.S. Department of Labor supports Community-Based
Job Training Grants that increase the capacity of community colleges to
provide training in high-demand industries. Examples include a $2 million grant to Polk Community College in Florida to address the shortage
of cardiovascular technologists and technicians to meet the demand from
older patients and a $2.1 million grant to Manchester Community College
in Connecticut to produce a larger number of graduates in nursing and allied health (DOL, 2006).
Technology
New technologies will affect how health care is delivered. These technologies may require providers to acquire new skills, such as how to operate new devices or to monitor patients from a distance via telemedicine,
and that may change which types of providers are used to perform certain
functions (Mullan, 2002). For example, imaging clinicians may need to expand their skill sets by learning how to operate and interpret a number of
different imaging modalities, or new sub-specialty jobs may be created for
people with expertise in a single specific imaging modality. The technologies
most likely to affect the health care workforce in terms of types of workers
and the necessary skill sets include
•
•
•
•
technologies that may alter clinical practice, such as new forms of
imaging and minimally invasive surgery;
technologies that may use the workforce more efficiently, such as
remote monitoring;
technologies that may improve access to information, such as electronic health records; and
technologies that may improve ergonomics, such as assistive devices for patient mobility and transport, and that may help prevent
injury to workers (Health Technology Center, 2007).
As new technologies emerge, current workers will have to adapt to their
use by acquiring new skills, or new types of workers may appear. While
some technologies may impose new responsibilities on the health care workforce, others may relieve workers of their current duties or replace them
altogether. One class of technologies that will be of particular importance to
the health care workforce in light of current and future shortages are those
technologies that will help older adults in the performance of activities of
daily living (ADLs) and thus reduce the need for health care workers in this
area. These technologies are discussed in more depth in Chapter 6.
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New Professions
The health care workforce has a history of creating new professions in
response to need, often as a result of the emergence of new technologies or
the development of new models of care. At other times, new professions
arise because of a serious shortage of providers. The profession of physician
assistants, for example, was created in the 1960s to meet the urgent need
for providers of primary care. In the same way, new professions may arise
in response to the demand for services from older populations.
One type of new worker that has recently emerged in the care of older
adults is the geriatric care manager. This new role stems from the development of a formal title for a care coordinator, a job which currently is often
undertaken by a variety of providers without formal recognition. In most
states, anyone can use this title without any requirement of training or certification (Stone et al., 2002), although many geriatric care managers are
certified in other professions, most often in either social work or nursing.
Recently, however, the number of certification programs for care managers
has surged; one survey found more than 40 different certification designations that might be appropriate for care managers, such as “certified family
life educator” and “certified case manager” (Reinhardt, 2003). As more
people become aware of the importance of care coordination, especially
for the older, frail elderly population, it can be expected that there will be
increased need for health care workers who can fill this role. At the same
time, the competencies needed to be an effective care manager will need to
be developed, a task that will be made more difficult by the fact that no
one profession “owns” this position.
Expanding Roles
To compensate for the serious shortages of providers that will characterize the coming decades, workers will need to be used more efficiently.
More specifically, health care providers of all levels of education and training will need to assume additional responsibilities—or relinquish some
responsibilities that they already have—to help ensure that all members
of the health care workforce are used at their highest level of competence.
Some professionals will likely need to increase their skills in order to be
competent in more areas of care, while higher-level professionals may need
to delegate some duties in order to be able to devote more of their time to
providing the complex services that only they can provide. (See Chapters
3 and 5 for more on job delegation.) However, professionals are often not
prepared for the role of delegator. For example, while RNs are increasingly responsible for supervision and delegation of care tasks to assistive
personnel, they often are not taught the necessary decision-making skills
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associated with this role (Parsons, 1999). One survey of newly graduated
baccalaureate nurses pointed to lack of education as the single most important barrier to effective delegation and that skills were generally learned
through trial and error (Thomas and Hume, 1998). Formal efforts to help
nurses learn these skills are increasing, often through continuing education
(Kleinman and Saccomano, 2006).
States can play a role in changing the structure of the health care
workforce by passing laws that recognize scopes of practice for new types
of providers and that expand the legal scope of work for existing providers,
although this may be controversial among professional groups (CarsonSmith and Minarik, 2007; RCHWS, 2003; Rossi, 2003; Wing et al., 2004).
For example, there has been a great deal of debate in the United States over
the use of advanced dental hygienists—known as dental therapists in other
countries—to provide some basic dental services to underserved patients
(Mertz and O’Neil, 2002; Ryan, 2003). And, as has been seen with teambased training, physicians are often reluctant to delegate responsibilities for
care to other workers (Reuben et al., 2004). Among nurses, the delegation
of medication administration duties from RNs to CNAs or unlicensed personnel has received much attention (Reinhard et al., 2003). First, there is
extreme variation and ambiguity in state laws regarding which tasks may
be delegated, ranging from the ability to merely remind patients to take
their medications to physical administration of the medication. Confusion
about these tasks has led to concern for liability among nursing supervisors. Second, there have been some concerns for patient safety. However,
little research has been performed to examine the impact of using CNAs or
unlicensed personnel for medication administration on patient care, such
as comparison of medication error rates between RNs and unlicensed staff.
But, some RNs argue that these workers have fewer distractions, leading to
more accurate delivery of medications (Reinhard et al., 2003).
There is good deal of precedent for the idea of expanding scopes of
work or delegating responsibilities in response to workforce needs. Both
the physician assistant and the advanced nurse practitioner professions,
for instance, have undergone expansions of their legal scopes of practice,
most notably in the state-based regulations regarding prescription authority. There has also been an expansion of work roles among many types of
allied workers. For example, some physicians have trained their medical
assistants to teach self-management skills to patients (Bodenheimer, 2007).
And pharmacy technicians have assumed increased responsibility for tasks
not requiring professional clinical judgment (Muenzen et al., 2005). While
pharmacy technicians most often dispense medications and maintain inventory, they have increasingly become involved in more skilled areas, such
as in supervising processes of quality assurance (e.g., medication order
entry and separating similar-looking or similar-sounding medications). In
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response, many state boards of pharmacy have allowed a broadening of
pharmacy technician responsibilities.
As new or enhanced scopes of practice are developed, effort will be
needed to avoid policies that impede the flexible and effective use of these
personnel. While a detailed discussion of state scope-of-practice laws is beyond the scope of this report, the issue is central to improving the capacity
of the health care workforce for older Americans.
RECRUITMENT AND RETENTION
Health care providers who care for older patients serve a complex,
challenging population, and evidence shows that working with geriatric
patients is highly satisfying. One study showed, for example, that geriatric
medicine has the highest percentage of “very satisfied” specialists among
physicians surveyed in the 1996-1997 Community Tracking Physician Survey (Leigh et al., 2002). Another study found that 79 percent of geriatricians surveyed felt their geriatric fellowship had a positive effect on their
career satisfaction level, and almost 90 percent said they would recommend
a geriatric fellowship to others (Shah et al., 2006). In spite of this, many
geriatric fellowship positions remain unfilled. Among professionals who
have a choice, most do not choose geriatric specialties or choose to work in
long-term care settings. Among high school students considering a nursing
career almost half have no interest in specializing in geriatrics, whereas 87
percent report having an interest in pediatric nursing (Evercare, 2007). In
2002, 15 percent of the RN positions and 13 percent of the LPN positions
at nursing homes were vacant (National Commission on Nursing Workforce for Long-Term Care, 2005).
This section describes the barriers to recruitment and retention of professionals in geriatric fields, with a particular emphasis on the recruitment
technique of offering financial support in exchange for service commitments. Many of these barriers are not unique to the health care professionals who care for older patients, but this section will focus specifically on
these issues as they relate to the health care professionals who care for older
patients or who work primarily in long-term care settings.
Barriers
The barriers to recruiting and retaining health care professionals in the
geriatric field include negative stereotypes of working with older patients,
the complexity of geriatric cases, a lack of mentors, the availability of
more attractive opportunities in non-health care professions, and also various financial disincentives. It is particularly difficult to retain and recruit
care providers into institutional long-term care because of the stressful
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and physically demanding working conditions, relatively low salaries, and
low job satisfaction. Turnover of health care professionals in these settings
contributes to poorer patient outcomes and increased turnover of other
workers. For example, increased turnover of RNs has been associated with
decreased quality of care (Castle and Engberg, 2005); high rates of turnover
among nursing home administrators and managers has been associated with
both poorer patient outcomes and increased turnover of RNs and LPNs
(Castle, 2001, 2005).
This section highlights some of the challenges to the recruitment and
retention of health care providers to care for older patients. The first challenge discussed is that the workforce itself is aging. Large groups of workers are expected to retire in the coming decades, and they will have to be
replaced, which will only heighten the need for health care providers. The
second challenge is that stereotypes persist about caring for older patients;
many assume that the work is depressing and that most older patients are
extremely sick, frail, or demented. Next is the lack of opportunity for providers to receive advanced training in geriatrics; if no training opportunities
exist, health care professionals will be unable or unwilling to specialize in
geriatric care. The last challenges discussed are the financial ones. Because
of the costs of extra training and the failure of payment systems to compensate geriatric specialists properly, financial disincentives are probably the
greatest obstacles to the recruitment and retention of more geriatric-specific
health care professionals. The section concludes with an examination of
the use of programs that offer financial support in exchange for service
commitments.
Aging of the Health Care Workforce
One challenge to the health care workforce in general is the aging of
its members. As of January 2007, 23.3 percent of all active physicians were
60 or older (AAMC, 2007a). In 2001, 81 percent of all dentists were over
age 45, and the number of dentists expected to retire by 2020 is larger
than the number of new dentists expected to enter the workforce by that
time (Center for Health Workforce Studies, 2005). By 2020 almost half
of all registered nurses will be over age 50 (AHA, 2007; Buerhaus et al.,
2000), and about one-third of all currently practicing social workers will
soon be of retirement age (National Commission for Quality Long-Term
Care, 2007).
More needs to be done to retain some of these older workers, recognizing their importance as on-the-job mentors, most likely by the development of less physically demanding roles or more flexible work schedules
(Rosenfeld, 2007). Their roles could be made less physically demand-
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ing, for instance, by the development of technologies that perform the
more labor-intensive of their duties. Another retention strategy would be
to recruit older workers into leadership roles (Rosenfeld, 2007). Retired
geriatric-health professionals have invaluable knowledge and expertise, and
they could become academic leaders in the training of future generations.
This would be of great value, especially considering the scarcity of faculty
described above. Retired generalists, with additional training, could also
re-enter their fields as geriatric experts. The social work profession has
embraced this concept with the development of the Retired Social Workers
Project, which uses both distance and in-person education to train retired
social workers in geriatric concepts so that they might return to the workforce to assist older patients (IGSW, 2007).
Negative Stereotypes
While the current elderly population is healthier and more educated
and has higher rates of volunteerism than previous generations of the same
age, negative stereotypes of older adults persist, including that they are
typically physically disabled, senile, and disconnected from social activities
(Krout and McKernan, 2007; Wood and Mulligan, 2000). In spite of the
job satisfaction that has been documented among geriatric providers, students still see working with these populations as depressing, which may be
one of the reasons that when students are asked about their specialization
preferences, they continue to rank geriatrics near the bottom (Anderson and
Wiscott, 2004; Cummings and Galambos, 2002).
Early exposures to a broad range of geriatric patients—and especially
to healthier older adults—has a positive effect on interest in geriatric fields
(Bernard et al., 2003; Cummings et al., 2003, 2005; Linn and Zeppa,
1987; Medina-Walpole et al., 2002; Reuben et al., 1995; Woolsey, 2007).
One particularly effective strategy for providing students with this sort of
positive experience is pairing them with older patients who act as mentors
(Corwin et al., 2006; Stewart and Alford, 2006; Waldrop et al., 2006). In
such a mentoring program a student will typically meet regularly with a
healthy older adult over a certain period of time, often to complete specific
assignments; the older patient acts to sensitize the student to the positive
aspects of aging, to dispel myths, and to create empathy for the frustrations faced by seniors. A second strategy whose effectiveness is supported
by evidence is to expose students to professional role models or mentors
who reinforce the positive aspects of geriatric care and, by doing so, inspire
students to enter geriatric fields themselves (Hazzard, 1999; Johnson and
Valle, 1996; Maas et al., 2006; Mackin et al., 2006; Medina-Walpole et
al., 2002).
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Lack of Opportunity
The recruitment of health care professionals to become geriatric specialists is often hindered by a simple lack of opportunity. As discussed previously, many professionals have neither adequate introduction to geriatrics
nor opportunities for advanced training in the field. While GME supports
the general training of physicians in geriatrics, workers in other professions
often lack the opportunity for advanced training in geriatrics, usually because there is not enough funding for the programs or not enough funding
for salary support.
Indeed, this is part of a pattern that extends far beyond geriatrics.
Generally speaking, with the exception of physicians, few professionals
have significant support for advanced training. In response, some efforts
have arisen in recent years to increase the training opportunities for these
professionals. The Medicare program, for example, not only supports the
training of residents but has made some payments to hospitals for its share
of the direct costs of nursing and allied health training programs. In 2001
Congress introduced the All Payer Graduate Medical Education Act,12
which would collect additional GME funds through a 1 percent tax on
private health plans. Part of this revenue was directed toward the graduate education of “non-physician health professionals” (AAMC, 2007b).
The Nurse Education, Expansion, and Development Act13 proposes to
provide grants to nursing schools, in part, to develop “post-baccalaureate
residency programs to prepare nurses for practice in specialty areas where
nursing shortages are more severe.” These measures are for the training of
professionals in general, however, and do not necessarily support advanced
geriatric training.
In the area of geriatrics, advanced training programs for professionals
other than physicians often must look to private foundations for support,
or else it falls to the individual students to pay for the programs without
any source of subsidy. For example, in 2007 the John A. Hartford Foundation awarded a $5 million renewal grant to the Gerontological Society of
America for the purpose of preparing doctoral students in geriatric social
work (The John A. Hartford Foundation, 2007).
Financial Concerns
Financial burdens create great challenges in the recruitment and retention of all types of professionals.
12 All
Payer Graduate Medical Education Act of 2001. HR 2178. 107th Congress. June 14,
2001.
13 Nurse Education, Expansion, and Development Act of 2007. S 446. 110th Congress, 1st
session. January 31, 2007.
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Recommendation 4-3: Public and private payers should provide financial incentives to increase the number of geriatric specialists in all
health professions.
Specific types of financial incentives will be recommended throughout
the rest of this chapter. Medicare and Medicaid policies will be especially
important in the implementation of financial incentives due both to their
role in the financing of health care services for older adults as well as the
influence of their policies on other payers.
The costs associated with extra years of geriatric training do not translate into additional income, and geriatric specialists tend to earn significantly less income than specialists in other areas and often less than the
generalists within their own fields. In fact, the additional training needed to
become a geriatric specialist has been shown to have a negative effect on future earnings. In 1999 a physician who pursued a 1-year geriatric medicine
fellowship stood to lose $7,016 annually, and the completion of a 2-year
fellowship translated into a net annual loss of $8,592 (Weeks and Wallace,
2004). In 2005 a geriatrician’s median salary was only 93 percent of the
median salary for a general internist (ADGAP, 2007b). Similar disparities
exist for other professions. For instance, compared with nurses in hospital
settings, full-time RNs who work in nursing homes or other extended-care
facilities receive lower annual earnings on average, even though they work
more hours per week, incur more hours of overtime, and have a larger
percentage of overtime hours that are mandatory (HRSA, 2006b). PAs who
specialize in geriatrics have lower salaries than other types of PAs (AAPA,
2007). One survey of recent MSW graduates showed that while 70 percent
strongly agreed that geriatric care is an important part of social work, only
36 percent strongly agreed that geriatric social work offered good career
opportunities (Cummings et al., 2003).
In part this income disparity is due to the fact that a larger proportion
of a geriatric specialist’s reimbursement tends to come from Medicare and
Medicaid. Additionally, as the population ages, many non-geriatric specialists will experience similar difficulties. Rates of reimbursement are low for
primary care codes in general, especially as compared with the procedural
codes typically used by other specialists. Medicare and Medicaid reimbursements do not take into account the fact that the care of frail older adults
with complex care needs is very time-consuming, a situation that causes
geriatric specialists to have fewer patient encounters and fewer billings
(MedPAC, 2003).
Recommendation 4-3a: All payers should include a specific enhancement of reimbursement for clinical services delivered to older adults by
practitioners with a certification of special expertise in geriatrics.
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This enhancement should apply to all types of professionals certified in
geriatric care. Several mechanisms can and should be used to facilitate this
enhancement due to the variety of providers and mechanisms for delivery
of compensation. Whatever the mechanism, this enhancement should raise
salaries enough to create greater appeal to entering geriatric fields.
As one example, in 2005, the net clinical compensation of a geriatrician
was about $163,000, while that of a general internal medicine physician
was about $175,000 (ADGAP, 2007d). However, the disparities between
geriatric medicine and other subspecialties of internal or family medicine
are even greater. Table 4-5 shows that other non-procedure driven subspecialties of internal medicine have markedly higher fill rates for advanced
training programs, as well as substantially higher salaries.
In this example, to raise salaries for the existing geriatricians from
$163,000 to $200,000 (to be in accordance with other similar subspecialties) for each of the existing 7,128 geriatricians would cost about $263
million. However, the committee supports creating incentives to markedly
increase the number of providers. The committee presents two hypothetical
examples of estimates for extra annual costs (due to payment enhancements)
under assumptions associated with two different goals for the growth in
number of certified geriatricians. Under the first scenario (Table 4-6), the
goal is to double the number of geriatricians over 10 years; this goal requires
a 20 percent increase in the number of geriatric fellows graduating annually.
Under the second scenario (Table 4-7), the goal is to triple the number of
geriatricians over 20 years; this goal requires a 10 percent annual increase
in the number of fellows graduating annually. The committee recognizes
both of these goals are ambitious and beyond the capacity of the current
system to produce these numbers of graduates unless significant changes
are made. These differing scenarios, however, serve to provide two different
TABLE 4-5 Fill Rate for Subspecialty Training in Internal Medicine
Programs and Median Compensation
Subspecialty
Number of
Program
Year 1 Positions
Filled (as of
12/31/2006)
Total Number
of Program
Year 1 Positions
Available (as of
12/31/2006)
Fill
Rate
(%)
Median
Compensation
(in Thousands)
(2005)
Geriatric medicinea
Endocrinology
Hematology and oncology
Infectious disease
Rheumatology
253
232
410
324
176
468
252
432
348
184
54%
92%
95%
93%
96%
$163
$189
$358
$205
$207
aIncludes
fellowships as a subspecialty of either internal medicine or family medicine.
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TABLE 4-6 Timeline for Extra Costs Associated with Geriatrician Salary
Increase Assuming Doubling of Numbers Over 10 Years
Year
Annual Number of Graduates
(Assuming 20% Annual Increase)
Total Number
of Geriatricians
Extra Annual Costs
(in Millions,
2008 Dollars)
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
253a
304
365
438
526
631
757
908
1,090
1,308
1,570
7,381
7,685
8,050
8,488
9,014
9,645
10,402
11,310
12,400
13,708
15,278
$273.1
$284.3
$297.8
$314.1
$333.5
$356.9
$384.9
$418.5
$458.8
$507.2
$565.3
NOTE: These estimations calculate growth in the number of geriatricians based on an assumption of growth in the number of fellows and do not include estimations of attrition. Costs were
estimated assuming $37,000 in extra annual costs for each of the geriatricians practicing in
that year, and have not been adjusted for cost-of-living increases or inflation.
aThe initial number of graduates is based on the current number of first-year fellows in
geriatrics.
strategies that highlight the amount of effort that will be needed to close
the gap between the numbers of current supply and the numbers needed
in the future. Ultimately, the chosen strategy will depend on the ability of
the current system to increase its capacity, the development of an increased
interest in geriatrics among providers, and the availability of immediate and
future funding sources. While the committee recognizes the current high
level of attrition among these providers, it also contends that attrition will
likely decrease if greater financial incentives exist. Estimates do not take
attrition into account.
One mechanism to increase salaries would be to develop a special fee
schedule for services provided by geriatric specialists that increased the relative value of the provider. Another option would be to create a new modifier
that allows for increased payment. Modifiers are added to billing codes to
indicate special circumstances surrounding the delivery of a service. For
example, the “22” modifier recognizes that “For any given procedure code,
there could typically be a range of work effort or practice expense required
to provide the service. Thus, carriers may increase or decrease the payment
for a service only under very unusual circumstances based upon review of
medical records and other documentation” (CMS, 2007). This modifier is
currently only available for surgical procedures and involves much documentation to justify its use, but it serves as an example of how a modifier
could be developed for use by geriatric specialists for billing purposes.
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TABLE 4-7 Timeline for Extra Costs Associated with Geriatrician Salary
Increase Assuming Tripling of Numbers Over 20 Years
Year
Annual Number of Graduates
(Assuming 10% Annual Increase)
Total Number
of Geriatricians
Extra Annual Costs
(in Millions,
2008 Dollars)
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
253a
278
306
337
371
408
449
494
543
597
657
723
795
875
963
1,059
1,165
1,281
1,409
1,550
1,705
7,381
7,659
7,965
8,302
8,673
9,081
9,530
10,024
10,567
11,164
11,821
12,544
13,339
14,214
15,177
16,236
17,401
18,682
20,091
21,641
23,346
$273.1
$283.4
$294.7
$307.2
$320.9
$336.0
$352.6
$370.9
$391.0
$413.1
$437.4
$464.1
$493.5
$525.9
$561.5
$600.7
$643.8
$691.2
$743.4
$800.7
$863.8
NOTE: These estimations calculate growth in the number of geriatricians based on an assumption of growth in the number of fellows and do not include estimations of attrition. Costs were
estimated assuming $37,000 in extra annual costs for each of the geriatricians practicing in
that year, and have not been adjusted for cost-of-living increases or inflation.
aThe initial number of graduates is based on the current number of first-year fellows in
geriatrics.
Other aspects of reimbursement policies can create financial disincentives to geriatric specialization. For instance, Medicare and Medicaid often
lack codes for care coordination and other advance services; by supporting these types of advanced services through the development of “medical
homes,” Medicare could realize savings of as much as $194 billion over
10 years (Commonwealth Fund, 2007). And insurers often allow only for
a pharmacist dispensing fee, failing to reimburse for advanced pharmacist
services, including those activities shown to improve patient outcomes or
lower health care costs. In response to these concerns, the 2006 implementation of the Medicare Modernization Act of 2003 established a mechanism by which pharmacists are eligible to receive payment for providing
medication-therapy management services as a benefit of the Part D program
(CMS, 2005). Psychiatrists thinking of specializing in geriatrics may be
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175
pushed toward other areas since Medicare requires a 50 percent copayment
for outpatient mental health services, compared to 20 percent for most
other medical services (ADGAP, 2007a). Furthermore, Medicare does not
cover any routine oral-health services.
Financial burdens affect the recruitment and retention of clinical
and academic geriatric experts. A 2004 survey of second-year MSW students found that over 60 percent expressed interest in an aging-related
internship—if a stipend were available for this activity (Cummings et al.,
2005). Junior faculty in geriatrics have lower compensation than those in
family or internal medicine (ADGAP, 2004). At higher faculty positions the
median dollars paid to those in geriatrics become similar to those paid for
other specialties, but the pay of geriatrics specialists still lags behind that
of the higher-paid procedural specialties. Between 2002 and 2003 salaries
for geriatric physician faculty decreased by 3 percent; during this time period, family medicine salaries increased by 1.5 percent, and general internal
medicine salaries remained the same.
GACAs have been instrumental in the development of academic geriatricians. These awards are especially appealing since the grants directly
support teaching services during the life of the award.
Recommendation 4-3b: Congress should authorize and fund an enhancement of the Geriatric Academic Career Award (GACA) program
to support junior geriatrics faculty in other health professions in addition to allopathic and osteopathic medicine.
The committee supports the extension of GACAs to all doctorate-level
health care professionals. As has been discussed, many of the geriatric specialties are limited by the availability of faculty and mentors. The creation
of GACAs for other doctoral-level health care professions would help to
promote not only the geriatric professions, but would enable educational
programs to better educate all professionals in the care of older adults.
Recognizing the lag time between the initial training of professionals until
the time they are available to become faculty, these training opportunities
should begin now.
In June 2007, Senator Bingaman introduced a bill14 that would provide
GACAs to doctorate level nurses certified in geriatrics or geropsychiatry.
This bill proposed a funding level of $1.875 million per fiscal year (plus
administrative costs) to allow for a total of 125 5-year awards for $75,000
in total between 2008 and 2015. A loftier goal could be to have one GACA
at every institution that prepares advanced practice professionals. For ex14 Nurse
faculty and physical therapist education act of 2007. S 1628. 110th Congress, 1st
session. June 14, 2007.
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RETOOLING FOR AN AGING AMERICA
ample, about 81 programs exist to prepare geriatric nurse practitioners.
The availability of a $75,000 GACA for each of these 81 faculty positions
would amount to about $6.1 million annually (plus administrative costs)
for the nursing profession alone. (Similar efforts should be made for other
professions.) The committee recognizes that geriatric educators are also
needed at institutions that do not have specific programs in geriatrics, as all
professionals need to be trained in geriatric principles. However, the availability of these awards at advanced programs is an achievable first step.
To avoid some of the pitfalls experienced by the GACA program for
physicians, the committee supports making the GACA an institutional award
(instead of an individual award). Additionally, as the number of professionals
entering the different disciplines increases, the number of GACAs needs to
proportionately increase.
Linking Financial Support to Service
Most efforts to recruit and retain professionals for in-need populations
seek to relieve professionals of at least part of the financial burden associated with their education and training. These recruitment efforts usually
consist of offering some type of financial support—generally scholarships
or loan forgiveness, or both—in exchange for the professional promising to
serve a certain number of years with a population in need. Programs exist
at both the state and national levels, and many programs entail a collaboration between the two. Five general types of programs link financial support
and service (Table 4-8).
Scholarships and loan repayments are by far the most common types
of programs. However, very few studies have assessed the effect of these
programs on completion of service or retention of practitioners (Pathman et
al., 2000). These programs also change frequently without any evidence of
immediate or lasting effectiveness. Since they are the most common, the rest
of this section will focus on scholarship and loan-repayment programs.
State Efforts
Many states attempt to recruit needed members to the health care
workforce with programs that offer financial support in exchange for future
service. Such programs date back to the 1940s. In 1987 HRSA created the
State Loan Repayment Program (SLRP), which authorizes the National
Health Service Corps (discussed below) to provide matching funds to states
that develop educational loan-repayment programs. These funds are specifically designated for primary care physicians in exchange for service in a
so-called health-professions shortage area, or HPSA.
Some state-level programs operate with federal support, while others
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Senior
residents and
practitioners
Senior
residents and
practitioners
Loan
repayment
Direct
financial
incentive
Required
Required
Unrestricted
Repayment of
educational
loans
Variable
Up-front
training costs
Up-front
training costs
Use of Funds
Unrestricted funds for graduating
residents and practitioners in exchange
for service
Funds to repay outstanding educational
loans of graduating residents and
practitioners in exchange for service
Unrestricted funds for junior and,
occasionally, senior residents, with service
expected after training
Loans to students for tuition, fees, books,
and living expenses; loan is repaid after
training either financially or by providing
service
Funds to students for tuition, fees, books,
and living expenses, with service expected
after training
Typical Design
See “Resident Support Programs”
Longest retention
See “Resident Support Programs”
Shortest retention
Combined with next 2 groups, only 2.3%
repay loans instead of providing service
On average, 93% complete service
obligations (combined with next two groups)
On average, 44.7% complete service
obligations; 49.2% repay loan rather than
provide service
Second shortest retention; least likely to
repeat the process
On average, 66.5% complete service
obligations; 27.2% repay loans instead of
providing service
Impact in State-Based Programsb
bBased
service is “required” for some types of programs, many have buyout options (with associated penalties).
on one study (Pathman et al., 2004).
SOURCE: Pathman et al., 2000, 2004. Copyright 2000, American Medical Association. All rights reserved.
aWhile
Junior
residents
Resident
support
Required
Optional
Students
Loan
Servicea
Required
Eligibility
Scholarship Students
Program
Type
TABLE 4-8 Classification of Support-for-Service Programs
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operate without. A 1996 survey found that 82 programs in 41 states supported almost 1,700 professionals (Pathman et al., 2000). Most of these
programs (84 percent) supported medical students, residents, and practicing
physicians; about half (44 percent) were available to PAs and APRNs, and
about 20 percent were available to other professionals, such as dentists
and podiatrists. The programs offered support amounts that ranged from
$3,000 to $38,000 annually, and they had service commitments ranging
from 1 to 60 months.
When Pathman and colleagues sought to evaluate the effectiveness of
state-level support-for-service programs, they found that participants in
such programs practiced in needier areas and cared for more Medicaid and
uninsured patients than non-participants (Pathman et al., 2004). Retention
was also slightly higher for participants in the program than it was for nonparticipants. Overall, loan repayment and direct financial incentives proved
to be the most successful methods. Scholarships and other student-focused
programs were challenged by the administrative burden of keeping track of
these students over the course of their educational paths.
Some state-level loan-repayment programs focus specifically on geriatricians. For example, in May 2005 South Carolina introduced the Geriatric Loan Forgiveness Program, which forgives $35,000 of medical school
debt for each year of fellowship training in geriatric medicine or geriatric
psychiatry; loan forgiveness is dependent on the physician practicing in
the state of South Carolina for at least 5 years (Lt. Governor’s Office on
Aging, 2005).
Indian Health Service
The Indian Health Service (IHS) Loan Repayment Program repays up
to $20,000 in education loans per year (plus additional tax benefits) for
practitioners in certain health professions who commit to practicing for
at least 2 years in an IHS facility or other approved program (IHS, 2007).
While all professionals are eligible for this program, physicians and nurses
usually get highest priority.
National Institutes of Health Loan Repayment Program
The National Institutes of Health (NIH) offers loan repayment to
doctoral-level researchers in exchange for commitments to perform research. For a 2-year commitment the NIH pays off up to $35,000 per year
of educational debt, plus additional tax benefits. Individuals may perform
the research at any nonprofit organization, university, or government organization. Loan repayment is currently available for researchers in
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•
•
•
•
•
179
clinical research;
pediatric research;
health-disparities research;
clinical research for individuals from disadvantaged backgrounds;
and
contraception and infertility research (NIH, 2007g).
Repayment for researchers in clinical research comprises more than
half of the NIH repayment program’s contracts and funds. For fiscal year
2006, 38 percent of the 1,044 new applications and 71 percent of the 777
renewal applications for clinical research were accepted (NIH, 2007a).
More than half of the contracts for clinical research were made with medical doctors; other clinicians given contracts included optometrists, dentists,
psychologists, pharmacists, doctors of naturopathic medicine, and doctors
of osteopathic medicine (NIH, 2007d). Contracts for clinical research totaled almost $40 million (for 945 contracts), and contracts for pediatric
research totaled $18.8 million (for 403 contracts). Contracts for all five areas of research together added up to approximately $70 million (for 1,651
contracts) (NIH, 2007b,c,d,e,f).
National Health Service Corps
Perhaps the best known program offering health professionals financial
support for educational and training expenses in exchange for service is the
National Health Service Corps (NHSC). The NHSC, which was established
in 1972 in an amendment to the Emergency Health Personnel Act, operates
as part of the Public Health Service and places health care practitioners in
HPSAs. Under the loan-forgiveness program, practitioners receive up to
$25,000 per year of service for the first 2 years of service. After completing
that 2-year minimum, commitments may be extended annually, and practitioners who extend their service in the HPSA beyond the first 2 years can
receive as much as $35,000 in loan forgiveness per year in the succeeding
years. Reviews of the effectiveness of the NHSC have been mixed, mostly
because of questions about its ability to retain practitioners over the long
term (Mullan, 1999; Pathman et al., 2006). The fiscal year 2006 budget
for the NHSC was about $125.4 million, of which $85.2 million was used
for the loan-repayment and scholarship programs (HRSA, 2007a). Over its
entire history, more than 27,000 professionals have served with the NHSC,
and currently about 4,000 are in service (HRSA, 2007d). The NHSC recruits the following types of professionals:
•
•
Primary care physicians
Nurse practitioners
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RETOOLING FOR AN AGING AMERICA
•
•
•
•
•
Dentists
Mental and behavioral health professionals
Physician assistants
Certified nurse-midwives
Dental hygienists
In addition to loan forgiveness for the various types of professionals,
the NHSC offers scholarships for students in
•
•
•
•
•
allopathic medical schools;
osteopathic medical schools;
family nurse practitioner and nurse-midwifery programs;
physician assistant programs; and
dental schools.
These scholarships pay for up to 4 years of education, including tuition
and related educational expenses plus a stipend. Students commit to 1 year
of service in a shortage area for each year of financial support (with a 2year minimum).
Little has been done to evaluate the impact and effectiveness of the
NHSC. However, a 1995 report found that, as is the case with in-state
programs, NHSC scholarship programs have worse outcomes (in terms
of service completion, satisfaction, and retention) and higher administrative costs than loan-repayment programs (GAO, 1995). Indeed, the report
showed that loan-repayment participants end up costing the government
one-half to one-third less than scholarship recipients.
Recently, members of Congress proposed the use of NHSC to improve
the recruitment and retention of geriatricians. The most recent attempt
was the Geriatricians Loan Forgiveness Act of 2007,15 which called for
fellowship years in either geriatric medicine or geriatric psychiatry to be
recognized as a period of service to an underserved population. Similar bills
have been introduced in both the House and Senate multiple times, so far
without success.
The committee concluded that programs that link financial support
to service have been effective in increasing the numbers of health care
professionals that serve in underserved areas of the country and that
they serve as good models for the development of similar programs to
address shortages of geriatric providers.
15 Geriatricians
Loan Forgiveness Act of 2007. HR 2502. 110th Congress, 1st session. May
24, 2007.
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181
For example, as discussed above, some geriatric professions have existing opportunities for advanced training, but practitioners do not pursue the
positions (e.g., only 54 percent of available first-year positions in geriatric
medicine were filled in 2006-2007). If financial support was available, it
might encourage professionals to pursue such advanced training. The availability of scholarships could also get students interested in geriatrics earlier
in their careers, which in turn would create a need for the development of
more robust geriatric curricula and more advanced training options.
Recommendation 4-3c: States and the federal government should institute programs for loan forgiveness, scholarships, and direct financial
incentives for professionals who become geriatric specialists. One such
mechanism should include the development of a National Geriatric
Service Corps, modeled after the National Health Service Corps.
One mechanism to create incentives for students to enter geriatric
specialties is a National Geriatric Health Service Corps which would offer
loan repayment for newly graduating professionals in geriatrics. There are
many mechanisms for achieving this increased recruitment and retention;
loan repayment is one example. For example, the committee estimated the
costs required to institute loan repayment for graduating fellows of geriatric
medicine. As in Tables 4-6 and 4-7, the committee presents costs for a loan
repayment program associated with two hypothetical goals: to either double
the number of geriatricians over 10 years, or to triple their numbers over
20 years. Under these scenarios, the costs for loan repayment for physicians
is estimated at $35,000 per year for 4 years (or $140,000 per physician).
Tables 4-9 and 4-10 demonstrate rough estimates for loan repayment to
graduating fellows of geriatric medicine based on 2008 dollars assuming,
as in Tables 4-6 and 4-7, either a 20 percent or 10 percent annual increase
in the number of geriatric fellows.
CONCLUSION
This chapter addressed the education, training, recruitment, and retention of the professional health care workforce. Overall, there is an
inadequate supply of professionals in general for meeting the health care
needs of the future older adults and also an inadequate number of geriatric
specialists both to care for these patients and to teach other professionals
about geriatric care. Although the situation is improving, most professional
education programs still do not have sufficient geriatric content in their
curricula or adequate experiences in clinical settings. When the opportunity
exists, most professionals are not choosing to receive specialized training in
geriatrics, and some professions lack the opportunity for advanced geriatric
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RETOOLING FOR AN AGING AMERICA
TABLE 4-9 Timeline for Costs Associated with Geriatrician Loan
Repayment Assuming Doubling of Numbers Over 10 Years
Year
Annual Number of Graduates
(Assuming 20% Annual Increase)
Total Number
of Geriatricians
Annual Costs for
Loan Repayment
(in Millions, 2008 Dollars)
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
253a
304
365
438
526
631
757
908
1,090
1,308
1,570
7,381
7,685
8,050
8,488
9,014
9,645
10,402
11,310
12,400
13,708
15,278
$35.4
$42.6
$51.1
$61.3
$73.6
$88.3
$106.0
$127.1
$152.6
$183.1
$219.8
NOTE: These estimations calculate growth in the number of geriatricians based on an assumption of growth in the number of fellows and do not include estimations of attrition. Annual
costs were estimated assuming $140,000 in loan repayments for each of the fellows graduating
in that year, and have not been adjusted for cost-of-living increases or inflation. Administrative
costs have also not been included in these estimates.
aThe initial number of graduates is based on the current number of first-year fellows in
geriatrics.
training. Distance-education programs and community colleges are providing viable alternatives for the education and training of many professionals
in geriatric principles. The future workforce will likely need to fulfill new
roles, be more flexible, and possess new skills. The committee recommends
that more be done to increase the breadth of geriatric experiences among
health care professionals and to ensure the geriatric competence of all
providers.
Barriers to recruitment and retention include the aging of the workforce
itself and negative stereotypes about working with older adults. Financial
disincentives include disparities in the reimbursement system, such as lack
of payment for care coordination, and the high costs associated with advanced training. The committee recommends that financial incentives be
implemented in order to encourage more professionals to become geriatric
specialists; such incentives should include the enhancement of payments to
geriatric specialists, an expansion of the GACA program, and the institution of loan forgiveness, scholarships, or direct financial incentives to assist
with the high costs of tuition among all types of health care professionals
who care for older adults. While all of these areas have shown improvement, much more needs to be done to educate, train, recruit, and retain a
competent and ample professional workforce to care for the older population in 2030.
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THE PROFESSIONAL HEALTH CARE WORKFORCE
TABLE 4-10 Timeline for Costs Associated with Geriatrician Loan
Repayment Assuming Tripling of Numbers Over 20 Years
Year
Annual Number of Graduates
(Assuming 10% Annual Increase)
Total Number
of Geriatricians
Annual Costs for
Loan Repayment
(in Millions, 2008 Dollars)
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
253a
278
306
337
371
408
449
494
543
597
657
723
795
875
963
1,059
1,165
1,281
1,409
1,550
1,705
7,381
7,659
7,965
8,302
8,673
9,081
9,530
10,024
10,567
11,164
11,821
12,544
13,339
14,214
15,177
16,236
17,401
18,682
20,091
21,641
23,346
$35.4
$42.1
$42.8
$47.2
$51.9
$57.1
$62.9
$69.2
$76.0
$83.6
$92.0
$101.2
$111.3
$122.5
$134.8
$148.3
$163.1
$179.3
$197.3
$217.0
$238.7
NOTE: These estimations calculate growth in the number of geriatricians based on an assumption of growth in the number of fellows and do not include estimations of attrition. Annual
costs were estimated assuming $140,000 in loan repayments for each of the fellows graduating
in that year, and have not been adjusted for cost-of-living increases or inflation. Administrative
costs have also not been included in these estimates.
aThe initial number of graduates is based on the current number of first-year fellows in
geriatrics.
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Wheeler, B. K., S. Powelson, and J. H. Kim. 2007. Interdisciplinary clinical education: Implementing a gerontological home visiting program. Nurse Educator 32(3):136-140.
Williams, B. C., T. L. Remington, M. A. Foulk, and A. L. Whall. 2006. Teaching interdisciplinary geriatrics ambulatory care: A case study. Gerontology & Geriatrics Education
26(3):29-45.
Williams, B. C., V. Weber, S. F. Babbott, L. M. Kirk, M. T. Heflin, E. O’Toole, M. M. Schapira,
E. Eckstrom, A. Tulsky, A. M. Wolf, and S. Landefeld. 2007. Faculty development for
the 21st century: Lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the care of older adults. Journal of the American Geriatrics Society
55(6):941-947.
Wing, P., M. H. Langelier, E. S. Salsberg, and R. S. Hooker. 2004. The changing professional
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Physician Assistants 17(1):37-40, 42, 45.
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frailty and falls in older persons: An investigation of Tai Chi and computerized balance
training. Journal of the American Geriatrics Society 44(5):489-497.
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64(11):763-771.
Woolsey, L. J. 2005. Geriatric medicine and the future of the physician assistant profession.
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Yeo, G. 2007 (unpublished). How will the U.S. health care system meet the challenge of the
ethnogeriatric imperative? Paper commissioned by the IOM Committee on the Future
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5
The Direct-Care Workforce
CHAPTER SUMMARY
This chapter describes the direct-care workforce—nurse aides, home health
aides, and personal- and home-care aides—which is in many respects the
linchpin of the formal health care delivery system for older adults. This
collection of workers supplies a major portion of the direct care provided
to older adults, including the provision of some clinical services plus assistance with bathing, dressing, housekeeping, and food preparation. Directcare workers have rewarding but difficult jobs, and they are typically very
poorly paid and receive little or no training for their duties. As a result,
turnover rates are high, and recruitment and retention of these workers
is a persistent challenge. In the context of rapidly increasing demand for
direct-care services, the need for these workers is beginning to reach a crisis
stage. This chapter discusses a range of approaches to improve the quality
of direct-care occupations, including needed increases in pay and benefits.
In addition, improvements in the education and training of these workers
are needed to ensure that they have the knowledge and skills required to
meet the care needs of older patients.
Direct-care workers, also referred to as paraprofessionals, are the primary providers of paid hands-on care, supervision, and emotional support
for older adults in the United States. While not all direct-care workers care
for older patients, they work primarily in settings important in the care of
older adults, such as nursing homes, assisted living facilities, and home-care
settings. According to the Bureau of Labor Statistics (BLS), about three
199
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RETOOLING FOR AN AGING AMERICA
million workers were employed in direct-care occupations in 20061 (BLS,
2008c,d). Still, the current number of direct-care workers is insufficient
to meet demand (GAO, 2001a,b; Stone, 2004). The need for direct-care
workers is expected to increase in the coming decades, mainly because of
the aging of the population but also because the number of females aged 25
to 54—the typical direct-care worker demographic—is projected to remain
flat (PHI, 2001).
A further trend that may exacerbate this unfulfilled need, especially for
personal- and home-care aides, is a shift away from institutional care to
home- and community-based care. Policy makers and payers are increasingly implementing home- and community-based care programs in response
to consumer preferences and legal mandates and with the hope that costs
will be lower for at least some types of services. However, caring for older
adults in these settings may require proportionately more direct care-level
staff than in institutional facilities (National Center for Health Workforce
Analysis, 2004). The workforce providing non-institutional personal assistance and home health services tripled between 1989 and 2004, and
Medicaid spending for these services also increased significantly during
that time (Kaye et al., 2006). Over that same time period, the workforce
providing similar services in institutional settings remained relatively stable.
In fact, the BLS predicts that personal- and home-care aides and home
health aides will represent the second- and third-fastest growing occupations between 2006 and 2016 (BLS, 2007b). This trend will not only lead
to an increase in demand for services in non-institutional settings but will
also require home-based workers to deliver more skilled care to patients
with more complex needs (Seavey, 2007b). In home- and community-based
care settings, carers work more independently and rely on personal skill and
judgment; however, many direct-care workers do not receive the education
or training they need in order to be prepared for the care of older patients
with complex care needs.
A major factor in the deficit of direct-care workers is the poor quality of
these types of jobs. Direct-care workers typically receive very low salaries,
garner few benefits, and work under high levels of physical and emotional
stress. In 2005 the median hourly wage for all direct-care workers was
$9.56, about one-third less than the median wage for all U.S. workers
(Dawson, 2007). Direct-care workers are more likely to live in poverty,
to lack health insurance, and to rely on food stamps than other workers
(GAO, 2001b). Additionally, these workers have high rates of job-related
injury, most often due to overexertion in the care of a patient (BLS, 2007a).
All of these factors contribute to the unacceptably high rates of vacancies
1 It
is important to note that this figure does not include the many workers who are hired
privately by patients and their families.
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THE DIRECT-CARE WORKFORCE
201
and turnover among these occupations, which can, in turn, lead to poor
quality of care for patients.
Much of this chapter focuses on issues concerning direct-care workers
in general because there is relatively little data on the group of direct-care
workers solely involved in the care of older adults; whenever possible, however, issues related specifically to the care of older adults will be highlighted.
The chapter begins with descriptions of direct-care occupations and the
basic demographics of the current workforce, followed by an overview of
the current state of education and training of these workers. The chapter
then discusses challenges to the recruitment and retention of direct-care
workers, including financial disincentives and difficulties in work environment. The chapter concludes with an examination of strategies to improve
the recruitment and retention of direct-care workers, including enhancing
the quality and quantity of basic education and training, increasing overall
job satisfaction (including expanding roles and responsibilities), improving economic incentives, and broadening the labor pool. Overall, in order
to create a more effective and efficient direct-care workforce, much more
needs to be done to educate and train these workers to care for older adults,
and much more needs to be done to enhance the quality of these jobs.
DIRECT-CARE OCCUPATIONS
Direct-care workers are often grouped into three categories: nurse aides
(also known as nursing assistants); home health aides; and personal- and
home-care aides (Harmuth and Dyson, 2005). Forty-two percent of directcare workers care for patients in the home setting, 41 percent work in nursing homes, and the remaining 17 percent are employed in hospitals (Smith
and Baughman, 2007). Table 5-1 provides details about the various types
of direct-care workers, including their most common employers, the types
of services they provide, and typical supervision requirements.
Nurse Aides and Home Health Aides
The occupation of nurse aide goes by a number of job titles which vary
by state, setting, and situation; these titles include certified nursing assistant
(CNA), geriatric aide, orderly, and hospital attendant (BLS, 2008c). Nurse
aides are employed primarily in nursing homes but also work in other institutional settings, such as hospitals and assisted living facilities. They assist
residents with activities of daily living (ADLs), including bathing, dressing,
eating, and toileting, and they can perform such clinical tasks as taking
blood-pressure readings and, in some states, administering oral medications
(Reinhard et al., 2003). These workers have a major role in institutional
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TABLE 5-1 Comparison of Direct-Care Occupations
Nurse Aides
(Assistants), Orderlies,
and Attendants
Home-Health Aides
Personal- and HomeCare Aides
Common
employers
Nursing and
residential-care
facilities; hospitals
Home health care
agencies; social assistance
agencies; nursing and
residential-care facilities
Home-care agencies;
individual and family
services; private
households
Examples
of typical
services
provided
Answer patients’
call lights; deliver
messages; serve meals;
make beds; help
patients eat, dress,
and bathe; escort
patients to medical
appointments; take
vital signs; observe
patients’ physical and
mental conditions
Administer oral
medications; take vital
signs; help patients bathe,
groom, and dress; assist
with prescribed exercises
Help clients get out
of bed, bathe, dress,
and groom; assist with
housekeeping, grocery
shopping, and cooking;
accompany clients to
doctors’ appointments
or on other errands
Periodic check-ins/visits by
supervisors (e.g., nurses,
physical therapists, social
workers, case managers)
Periodic check-ins/visits
by supervisors (e.g.,
case managers, patients’
families, nurses)
Supervision On-site nursing and
medical staff
SOURCE: BLS, 2008c,d; Fishman et al., 2004.
settings, providing 70 percent to 80 percent of direct-care hours to those
older Americans who receive long-term care (Harmuth and Dyson, 2005).
Home health aides (HHAs) are generally hired through a home health
agency and assist individuals with ADLs in their homes. They may also assist with food preparation and housekeeping. Both nurse aides and home
health aides provide a degree of clinical services (e.g., wound care) and
work under the supervision of a registered nurse (RN).
Personal- and Home-Care Aides
Personal- and home-care aides may work in group or individual home
settings and are somewhat more difficult to classify. These aides may be
referred to as personal-care attendants, personal assistants, or direct support professionals, and they may be employed through an agency or hired
directly by an individual (BLS, 2008d; Harmuth and Dyson, 2005). They
help older adults maintain their independence and remain in their homes
and communities by providing assistance with both ADLs and instrumental
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THE DIRECT-CARE WORKFORCE
203
activities of daily living (IADLs), such as meal preparation and transportation. Personal-care services have been growing and all states now have
waiver programs through Medicaid that provide these services to seniors
and people with disabilities (Kitchener et al., 2007; Seavey and Salter,
2006).
Whereas home health aides who provide Medicare-certified home
care perform their jobs under the supervision of a registered nurse (RN),
personal- and home-care workers frequently have no supervision, even
though they may perform many of the same services. Furthermore, many
personal- and home-care workers may be hired privately by patients, without the involvement of an agency. Because of these hiring practices, little
can be done to track the workers in this “grey market,” which makes it
difficult to create a demographic profile of the workers or to regulate their
work practices (Seavey, 2007b).
As patients move rapidly away from institutional long-term care and
toward home- and community-based settings, they are increasingly relying
on direct-care workers to provide needed care, including more complex
services than previously provided in these settings. Assisted-living facilities, which are community-based facilities that provide more services than
a typical home setting but less than a nursing home, are a rapidly growing
option for the residential care of older adults (Lyketsos et al., 2007), and
the workers serving patients in these settings (including the patients with
more complex needs) are typically personal- and home-care aides rather
than home health or nurse aides. There is little to no federal regulation
regarding the training or staffing requirements for assisted-living facilities;
instead, each state regulates workers in these settings.
WORKFORCE DEMOGRAPHICS
Direct-care workers are overwhelmingly female (89 percent) and are
typically between the ages of 25 and 55, unmarried (including those who
are widowed, divorced, or separated), without college degrees, and citizens
of the United States (Montgomery et al., 2005; Smith and Baughman,
2007; Yamada, 2002). Approximately 30 percent of direct-care workers are
African American and 15 percent are of Hispanic or Latino origin (BLS,
2008a), although this can vary by setting and job title.
In 2005 Montgomery and colleagues examined data from the 2000
Census to create a profile of home-care aides who provide direct long-term
care services, including those who are hired privately (Montgomery et al.,
2005). The study revealed that as compared to hospital aides and nursing
home aides, home-care aides are on average older, more likely to be of
Hispanic or Latino origin, more likely to be self-employed, and less likely
to have steady year-round employment (Table 5-2).
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RETOOLING FOR AN AGING AMERICA
TABLE 5-2 Characteristics of Direct-Care Workers, 1999
Characteristic
Demographic Characteristics
Gender (% female)
Average age (years)
White, non-Hispanic (%)
Hispanic or Latino (%)
U.S., native-born (%)
Marital status (% married)
Education—less than high school (%)
Employment Characteristics
Year-round, full-time employment (%)
Part-year, part-time employment (%)
Self-employed (%)
Hospital
Aides
Nursing Home
Aides
Home-Care
Aides
81.2
40.5
48.4
10.7
81.5
46.2
17.6
91.3
38.0
55.6
7.8
85.5
42.7
26.3
91.8
46.2
50.3
15.9
75.1
44.2
30.9
52.4
13.0
0.0
48.3
14.8
0.3
34.3
24.3
16.8
SOURCE: Montgomery et al., 2005.
A recent study found notable differences between female direct-care
workers and the female workforce overall (Table 5-3) (Smith and Baughman,
2007). Black women, for example, make up a disproportionately large percentage of the female direct-care workforce relative to their presence in the
female workforce overall (29 percent versus 13 percent). A second difference is that female direct-care workers are more likely to be single mothers
than are female workers in general (24 percent versus 14 percent); of those
who are single parents, 35 percent to 40 percent are below the poverty line
(GAO, 2001b).
EDUCATION AND TRAINING REQUIREMENTS
The education and training of the direct-care workforce is insufficient
to prepare these workers to provide quality care to older adults. Although
there are a number of state and federal requirements for the education and
training of nurse aides, home health aides, and personal- and home-care
aides, these requirements are minimal (Table 5-4). Many direct-care workers have no more than a high school education, and some have even less
(Montgomery et al., 2005; Smith and Baugham, 2007). Minimum training requirements for these workers are often inadequate or non-existent,
and they vary across occupational categories and settings of care as well
as among states. A number of other training-program characteristics vary
among states as well, including the specific qualifications that instructors
are expected to have, maximum student/instructor ratios, and the required
program approval and oversight processes (AARP, 2006).
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THE DIRECT-CARE WORKFORCE
TABLE 5-3 Demographic Characteristics of Female Direct-Care Workers
Versus All Female Workers, 2006
Characteristic
Average age (years)
Race and Ethnicity (%)
White, non-Hispanic
Black, non-Hispanic
Other, non-Hispanic
Hispanic
Foreign-born
Marital Status (%)
Married
Previously married
Never married
Children under 18 years
Single mothers
All
Female
Workers
All Female
Direct-Care
Workers
Female
Hospital
Aides
Female
Female
Nursing
Home Health
Home Aides Aides
42
41
40
38
45
70
13
6
11
13
51
29
5
15
20
55
30
5
11
19
51
35
4
10
17
49
24
7
21
22
54
21
25
41
14
38
31
31
43
24
35
27
38
32
17
38
27
36
50
28
39
37
24
40
22
NOTE: The direct-care worker category consists of the three types listed in the last three
columns (hospital aides, nursing home aides, and home health aides). The table excludes the
11 percent of the direct-care workforce that is men. Percentages listed are based on weighted
data for female workers aged 19 years and older. Percentages may not sum to 100 because
of rounding.
SOURCE: Smith and Baughman, 2007.
This section describes the current requirements for education and
training of direct-care workers. Where possible, direct-care education
and training issues that are particularly relevant to the older patient population are highlighted.
TABLE 5-4 Education and Training Requirements for Direct-Care
Occupations
Nurse Aides, Orderlies,
and Attendants
Federal requirements of
75 hours of training (for
nurse aides); competency
evaluation results in state
certification; high school
diploma and previous work
experience not always
required
Home Health Aides
Per federal rules, if employer
receives Medicare/Medicaid
reimbursement, workers
must pass competency test
(75 hours of classroom and
practical training suggested);
high school diploma and
previous work experience not
always required
Personal- and
Home-Care Aides
Dependent on state, with
some requiring no formal
training; high school
diploma and previous work
experience not always
required
SOURCES: BLS, 2008c,d; Fishman et al., 2004.
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RETOOLING FOR AN AGING AMERICA
Nurse Aides
The Omnibus Budget Reconciliation Act of 19872 established the Nurse
Aide Training and Competency Evaluation Program, which created minimum federal requirements for the education and training of nurse aides
(OIG, 2002). Nurse aides working in Medicare- or Medicaid-certified nursing homes or home health agencies are required to successfully complete
the following:
•
•
•
At least 75 hours of state-approved training by, or under the general
supervision of, an RN with at least 2 years of experience in nursing
and at least 1 year of experience in a long-term care environment
(or in home health care for training of home health aides)
A competency evaluation (state certificate exam to become a certified nursing assistant)
At least 12 hours per year of continuing education; for nursing
homes, this must include training on providing services to individuals with cognitive impairments and on aide-specific areas of
weakness identified in performance reviews
Many states have established additional requirements beyond the federally mandated minimums. For example, 27 states and the District of
Colombia require more than 75 hours of initial training and 12 states plus
the District require 120 hours or more (Seavey, 2007a). Under federal rules
the initial 75 hours of nurse aide training must cover a number of specific
subject areas (Box 5-1). That time must include 16 hours of supervised
practical, or “hands on,” training in a clinical setting, and the trainee must
demonstrate the ability to perform specific tasks, such as taking vital signs.
The 75-hour training requirement is low compared to other service professions. For example, California requires significantly more hours of training
for manicurists (350 hours), skin-care specialists (600 hours), and hair
stylists (1,500 hours) (Harrington, 2007a).
States are responsible for ensuring compliance with educational requirements and administering (or contracting with someone who administers)
competency exams. Subject to the 75-hour minimum, states have flexibility
in developing training programs. These training programs can be offered
by vocational schools, nursing homes, or home health agencies as long as
the institution maintains its certification requirements. Instructional facilities that are judged to be providing substandard care can lose their right to
2 Omnibus
Budget Reconciliation Act of 1987. Public Law 100-203. 100th Congress. December 22, 1987.
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THE DIRECT-CARE WORKFORCE
207
BOX 5-1
Federal Requirements for Nurse Aide Training,
by Subject Area
•
•
•
•
•
•
Basic nursing skills, such as monitoring vital signs and height/weight; reporting
abnormal changes in body functioning; and caring for the dying resident.
Personal-care skills, including activities of daily living such as bathing, grooming, dressing, toileting, and skin care; feeding and hydration; and transferring,
positioning, and turning.
Mental health and social service skills, such as responding to a resident’s
behavior; allowing the resident to make personal choices; and drawing upon
the resident’s family to be a source of emotional support.
Caring for cognitively impaired residents, such as addressing the behaviors of dementia patients and responding to residents with other cognitive
impairments.
Basic restorative skills, such as training the resident in self-care; use of assistive devices; maintaining range of motion; eating, dressing, and ambulation;
and bowel and bladder training.
Residents’ rights, such as maintenance of privacy and confidentiality; promoting residents’ rights to make personal choices; helping to resolve grievances
and disputes; reporting any instances of abuse, mistreatment, and neglect.
SOURCE: OIG, 2002.
offer a nurse-aide training program, which generally makes it more difficult
and more costly to recruit new aides.
Home Health Aides
Home health aides must meet federal requirements only if their employer receives Medicare or Medicaid reimbursement. Specifically, home
health aides in such institutions must pass a competency test that covers
12 subject areas (Box 5-2). Federal law suggests that home health aides
be provided at least 75 hours of classroom and practical training that is
supervised by an RN. These training programs vary by state.
Personal- and Home-Care Aides
Since residential-care services, such as those provided in assisted-living
facilities, are not paid for under the Medicare and Medicaid programs (except under some state Medicaid waivers), there are no federal requirements
for residential-care personnel, and states have the primary responsibility
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RETOOLING FOR AN AGING AMERICA
BOX 5-2
Subject Areas Covered in
Home Health Aide Competency Tests
•
•
•
•
•
•
•
•
•
•
•
•
Communication skills
Observation, reporting, and documentation of patient status and the care or
services furnished
Reading and recording vital signs
Basic infection-control procedures
Basic elements of body function and changes
Maintenance of a clean, safe, and healthy environment
Recognition of, and procedures for, emergencies
The physical, emotional, and developmental characteristics of the patients
served
Personal hygiene and grooming
Safe transfer techniques
Normal range of motion and positioning
Basic nutrition
SOURCE: Home Health Aide Training. 2006. 42 C.F.R. § 484.36.
for regulating residential-care facilities (IOM, 2001). When aides are hired
directly by individuals (i.e., through consumer-directed programs), the patient or the patient’s family member assumes responsibility for deciding
what the worker needs to know and for providing training for those tasks,
most often through direct observation (PHI and Medstat, 2004). In turn,
patients may need to learn training and supervisory skills (as was discussed
in Chapter 4 for the case of professionals), including effective communication and problem-solving.
While no federal requirements exist for personal-care attendants who
work outside a nursing home or home health agency, states may conduct
checks on the background, training, supervision, age, health, and literacy
of these service providers if they receive Medicaid reimbursements (OIG,
2006). Training checks may include verification of instruction in topics such
as first aid, assistance with ADLs, and basic health and hygiene. In 2006
the Office of Inspector General (OIG) found that the median number of
training hours required of personal-care attendants was 28 hours, but state
requirements ranged from 2 hours to 120 hours. As more personal-care
attendants are hired privately by patients, making sure that these workers
have the appropriate abilities will become an even more complex task.
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209
RECRUITMENT AND RETENTION CHALLENGES
Health care workers serving older patients have high rates of turnover,
and maintaining adequate levels of staffing within the industry overall is a
persistent challenge. This challenge is especially pronounced among directcare workers, who have a number of immediate, less stressful job alternatives, such as those offered by the food and hospitality industries. In 2006,
for example, personal- and home-care aides had median wages of $8.54 per
hour while counter attendants in cafeterias, food concessions, and coffee
shops had median wage-and-salary earnings of $7.76 per hour (including
tips) (BLS, 2008b).
One study found that 40 percent to 60 percent of home health aides
leave after less than 1 year on a job, and 80 percent to 90 percent leave
within the first 2 years (PHI, 2005). Staff turnover in assisted-living settings ranges from 21 percent to 135 percent, with an average of 42 percent
(Maas and Buckwalter, 2006). In nursing homes CNA turnover averages
71 percent per year, and the turnover rate in many states is much higher
(Decker et al., 2003). Turnover may have negative effects on the quality
of patient care and may also increase employer costs because of the need
for continuous recruitment and training. A study of direct-care workers in
Pennsylvania estimated annual recurring training costs due to turnover to
be almost $24 million for nursing homes and almost $5 million for home
health and home-care agencies (Leon et al., 2001). It has been estimated
that turnover among direct-care workers in the United States costs providers a total of $4.1 billion per year (Seavey, 2004).
While many direct-care workers find the work of caring for frail older
individuals to be rewarding, the appeal of these professions is weakened
by a number of other factors including low wages, few (if any) benefits,
high physical and emotional demands, and a significant potential for onthe-job injury (Newcomer and Scherzer, 2006; Pennington et al., 2003).
Job dissatisfaction among these workers can also result from factors related
to the work environment including poor relationships with supervisors, a
lack of respect from other health professionals, and few opportunities for
advancement (Fleming et al., 2003; Stone, 2000). Not surprisingly, high job
dissatisfaction has been associated with increased turnover (Castle et al.,
2007). Conversely, improved job satisfaction can result in a greater intent
to stay.
Researchers examining the predictors of high turnover in nursing homes
have identified a number of key variables, including low staffing ratios, forprofit ownership, and higher numbers of beds (Castle and Engberg, 2006);
low reimbursement rates, a high Medicaid census, low wages, and low administrative expenses (Kash et al., 2006); and inadequate benefits and not
having a good social environment at work (Grau et al., 1991). One study
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RETOOLING FOR AN AGING AMERICA
examining predictors of turnover in a residential-care setting found that the
physical condition of the neighborhood3 in which the facility was located
was by far the strongest predictor of turnover, outweighing other factors
such as starting wages, availability of health insurance, Medicaid census,
and average case mix (Konetzka et al., 2005).
In the following sections, several of these challenges are discussed in
more detail, along with the effect that these factors have on patient outcomes. Initiatives to overcome these barriers are also discussed later in this
chapter. It is important to note that the chapter provides only a general
discussion of challenges to the recruitment and retention of direct-care
workers and that, depending on the type of direct-care worker, the setting,
and the source of dissatisfaction, these various factors may weigh more or
less heavily in a particular situation.
Financial Disincentives
Direct-care workers receive low hourly wages, which contributes to
the lower appeal of these jobs. In fact, in 2007 Forbes magazine profiled
personal- and home-care aides as one of the top 25 worst-paying jobs in
America (Maidment, 2007). Table 5-5 shows the median wages for directcare occupations in a variety of settings that are important in the care of
older adults.
The average annual earnings of female direct-care workers are significantly lower than the average annual earnings of female workers in general
($17,228 versus $30,441), and 19 percent of female direct-care workers
have incomes below the poverty level versus 8 percent of female workers
in general (Smith and Baughman, 2007). The low incomes of direct-care
workers are due in part to the fact that many direct-care workers do not
have predictable hours or the opportunity to work more hours if desired
(Dawson, 2007).
Direct-care workers have limited access to employee benefits, including health insurance coverage, sick leave, and retirement benefits (Brady
et al., 2002; Dawson, 2007; GAO, 2001b; Smith and Baughman, 2007).
Approximately one-quarter of direct-care workers lack health insurance
coverage (Hams et al., 2002; Lipson and Regan, 2004). Often these workers are unable to afford their share of the health insurance premiums or
they are ineligible for coverage because they work part time or they work
independently of an agency. As can be seen in Table 5-6, female directcare workers are considerably less likely to have health insurance coverage
than are female workers in general. This situation can vary dramatically
by occupation and region, however. A study of home-care workers in Los
3 The
condition of the neighborhood was likely a proxy for many of the resource issues that
cannot be measured well and typically cannot be included in these studies.
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THE DIRECT-CARE WORKFORCE
TABLE 5-5 Median Hourly Wages for Direct-Care Occupations by
Setting, 2006
All settings
Community care facilities for older persons
Services for older or disabled persons
Home health care
Nursing care facilities
Nurse
Aides
Home Health
Aides
Personal- and
Home-Care Aides
$10.67
$10.07
NA
NA
$10.37
$9.34
$8.87
$9.26
$9.14
$9.76
$8.54
NA
$9.18
$7.19
NA
NOTE: NA = not available.
SOURCE: BLS, 2008c,d.
Angeles, for instance, found that about 45 percent of them were uninsured
(Cousineau, 2000). And health insurance is not the only benefit that directcare workers are less likely to receive. For example, approximately threefourths of nurse aides in nursing homes and home health settings have no
pension benefits (GAO, 2001b).
Non-Financial Factors
While concerns about poor wages and lack of benefits are significant,
non-financial job characteristics also play a major role in the job satisfaction of direct-care workers (Bowers et al., 2003). Factors that influence job
satisfaction include professional growth opportunities, adequate training,
rewards for performance, and manageable workloads (Castle et al., 2007;
Parsons et al., 2003). Direct-care workers often report that they do not
receive enough respect for their knowledge and skills, that they have little
discretion or input into care planning (despite being responsible for most
of the patient care hours), and that they sense a lack of trust by manageTABLE 5-6 Health Insurance Coverage of Female Workers and DirectCare Workers, 2005 (percentage)
Type of
Coverage
All Female
Workers
All Female
Direct-Care
Workers
Female
Hospital
Aides
Female
NursingHome Aides
Female
Home Health
Aides
All private
Employer-based
Public
None
78
51
12
16
60
38
22
25
84
63
10
13
63
44
19
24
49
23
29
30
NOTE: Percentages are based on weighted data for female workers aged 19 years and older.
Columns may sum to more than 100 percent because some workers are covered by more than
one type of health insurance.
SOURCE: Smith and Baughman, 2007.
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RETOOLING FOR AN AGING AMERICA
ment (Bowers et al., 2003). Other factors contributing to worker dissatisfaction include excessive paperwork, frequent patient deaths, combative
and uncooperative patients, and inadequate staffing (Cherry et al., 2007).
Aides who work in understaffed facilities feel extra time pressure, which
contributes to burnout and absenteeism (Bowers et al., 2000). Research has
shown that job satisfaction and organizational culture are strong predictors
of worker commitment to an organization (Sikorska-Simmons, 2005), and,
as discussed in Chapter 4, poor supervisory relationships are a key driver
of turnover (Tellis-Nayak, 2007).
Caring for older patients can be emotionally draining, especially when
patients are at the end of life (Haley et al., 2003; Holland and Neimeyer,
2005; Jezuit, 2000; Viles, 2000). Moreover, the work can be physically
taxing. Direct-care staff in nursing homes have one of the highest rates of
workplace injury among all occupations. In 2006, according to the BLS, the
rate of non-fatal occupational injury and illness involving days away from
work was 526 incidents per 10,000 workers among nursing aides, orderlies,
and attendants (BLS, 2007a). This was four times the average rate among
all occupations and was a higher rate than found among either construction workers (488) or truck drivers (411). Fifty-six percent of injuries and
illnesses among direct-care workers were directly related to patient interaction, and 86 percent of these injuries and illnesses were due to overexertion. Nursing aides, orderlies, and attendants also had the highest rate of
musculoskeletal disorders among all occupations examined.
Among personal-care aides, the documentation and treatment of onthe-job injuries is impeded when aides change employers, which can affect
an individual worker’s ability to access worker’s compensation benefits
(Scherzer, 2005, 2006b). In addition, the rate of injury to personal-care
aides may be severely underestimated, largely because independent providers are generally ignored by current surveillance mechanisms.
In 1996 the IOM recommended that all personnel who provide direct
care (especially in nursing homes) should receive annual training in lifting
and transferring patients. The committee also concluded that hospitals and
nursing homes should develop effective programs to reduce work-related
injuries (IOM, 1996). Chapter 6 of this report identifies a number of technologies that have been developed to assist both direct-care workers and
informal caregivers in performing some of the physically demanding tasks
that are involved in caring for older adults.
Finally, trends in the care of older adults, such as the movement toward
more home-based care, can affect the job environment for these home- and
community-based workers. For example, as more workers are hired directly
by patients under consumer-directed models of care, home-care workers
may have to contend with a more ambiguous situation in terms of their lack
of supervisory management. This in turn can make it less likely that these
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213
workers will have someone to deal with regarding such concerns as onthe-job injury and access to workers’ compensation. One study of injured
home-care workers found that individually hired workers faced greater
obstacles (e.g., barriers to creating a safe working environment, receiving
appropriate care for injuries, or receiving compensation benefits) than did
agency-hired workers (Scherzer, 2006a).
Impact on the Quality of Patient Care
Several issues related to the difficulties of recruiting and retaining directcare workers may have direct effects on the quality of care provided to older
patients. Studies have shown, for example, that a significant relationship
exists between staffing levels and the quality of patient care (Harrington,
2007b; Harrington and Swan, 2003; IOM, 1996, 2001). Research has also
linked turnover rates with quality of care, although the details of that relationship remain equivocal (Bostick et al., 2006; Castle and Engberg, 2005,
2006; Cohen-Mansfield, 1997). Most of the studies simply demonstrate
associations, for instance, so it is not possible to estimate the magnitude of
a potential causal effect. Furthermore, most studies of turnover to date have
suffered from inconsistencies in the way that turnover is calculated, both in
terms of its definition and its use as a linear measure.
Although historically it has been difficult for researchers to prove direct
causal links between recruitment and retention challenges and the quality of
care delivered to patients, there is some evidence that the two are related.
In a series of research publications, Castle and Engberg concluded that, in
general, high turnover is associated with poor quality and that staff characteristics such as turnover, staffing levels, and worker stability all affect the
quality of care of nursing homes (Castle and Engberg, 2007). The researchers also found that increases in nurse aide turnover, especially those from
moderate to high levels, result in decreases in quality as measured by rates
of physical restraint use, catheter use, contractures, pressure ulcers, psychoactive drug use, and quality of care deficiencies reported on certification
surveys (Castle and Engberg, 2005). Castle and Engberg found evidence of
a nonlinear relationship between turnover and quality in their examination
of 1-year turnover rates among nurse aides and licensed practical nurses
(LPNs) in nursing homes (Castle and Engberg, 2006). While there was no
significant relationship between turnover and the quality of care at lower
levels of turnover, they found that when turnover rates were greater than
50 percent, there was a significant negative relationship between turnover
rates and quality.
In nursing homes, nurse aides often have to manage heavy patient
loads, which not only increases the burden placed on them but can also
decrease the quality of care that they provide (Schnelle et al., 2004). A
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report released in 2001 by the Centers for Medicare and Medicaid Services
(CMS), which investigated the appropriateness of minimum nurse staffing
ratios in nursing homes, noted the following:
[W]ith one nursing assistant commonly responsible for nine or more residents on the day shift and twice as many at night, time management often
degenerates into triage. Baths and meals are given on a tight schedule and
at the convenience of the home’s routine rather than the residents, leading to things like waking residents in the middle of the night for showers.
Call lights are left unanswered, nonessential tasks such as nail care are
neglected, and practices are often adopted that endanger either residents
or staff. (CMS, 2001)
Conversely, improving some aspects of job quality (e.g., reducing turnover) may lead to improvements in the quality of patient care. For example,
allowing nurse aides to have greater responsibility in care decisions is associated with higher social-engagement scores among patients, and lower
rates of turnover and higher rates of retention have been associated with
lower incidence of pressure ulcers (Barry et al., 2005). One study of residents and staff at assisted-living facilities found that a high-quality work environment, including an organizational culture that emphasizes teamwork
and participatory decision-making, is associated with greater satisfaction
among the residents (Sikorska-Simmons, 2006). Another study examined a
skilled nursing facility that had created a staffing program that emphasized
consistent scheduling, with staff permanently assigned to specific residents.
The facility reported that the program had positive effects both on worker
satisfaction (including a 10 percent decrease in turnover and a 50 percent
decrease in injuries) and on patient outcomes (including a 40 percent decrease in pressure ulcers and an 83 percent decrease in complaints) (ASA,
2008). Again, however, it is difficult to prove a causal relationship between
job satisfaction and turnover and the consequent effects on patient care.
Strategies to improve the quality of direct-care jobs and the effects of these
strategies on reducing turnover and increasing intent to stay are discussed
in the next section.
IMPROVING RECRUITMENT AND RETENTION
In order to overcome the challenges to recruitment and retention of
direct-care workers, more needs to be done to improve the overall quality and, therefore, desirability of these jobs. Strategies to do this can be
grouped into three broad categories:
•
Enhancing the quality and quantity of basic education and
training
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•
•
215
Increasing economic incentives (i.e., increased wages and benefits)
Improving the work environment (e.g., empowerment strategies
and culture change)
These strategies not only are important for developing a robust health
care workforce but also have direct implications for the quality of care
provided to older adults. In addition to improving the quality of these jobs,
the sheer number of workers needed to care for the future population of
older adults makes it imperative that new sources of workers be considered.
The following sections outline strategies both to improve job quality and to
broaden the potential labor pool, and they include examinations of several
large-scale efforts to improve the recruitment and retention of direct-care
workers.
Enhancing Basic Education and Training
There are a number of indications that the current training requirements for direct-care workers are insufficient, both in terms of quality of
content and quantity of training hours. Most nurse aide educators, as well
as nurse aides themselves, agree that current levels of education and training for initial certification is inadequate (CMS, 2001). Moreover, 58 percent
of ombudsmen identified inadequate training as a major impediment to
quality care in nursing homes, and CNAs rank inadequate training among
the top three problems that they face (Hawes, 2002). Poor training has
also been identified as one of the factors that contributes to occurrences of
neglect and abuse in nursing homes, especially for patients with behavioral
difficulties associated with dementia (Hawes, 2002; IOM, 2002).
Very little is known about the quality of training for home health aides
or personal- and home-care aides. Moreover, little is known about how
training translates into practice. Some have suggested that these home- and
community-based workers need to receive more training than workers in
nursing-home settings because of the breadth of their responsibilities and
their relative lack of supervision (Benjamin and Matthias, 2004; PHI and
Medstat, 2004). Others have criticized attempts to standardize the training
of these workers. As consumer-directed care has become more important,
for example, some patients have expressed fears that personal- and homecare aides hired directly by patients or their families may not respond to
the consumers’ personal preferences if training standards are made too
rigid. (See Chapter 6 for a fuller discussion of issues related to the trend of
consumer-directed care.) However, most agree that certain basic skills and
aptitudes are needed for the delivery of personal assistance.
Both the initial training and the continuing education of direct-care
workers appear to be inadequate. In a survey of direct-care workers across
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RETOOLING FOR AN AGING AMERICA
multiple settings, only a little more than half said that their initial training
was adequate, while 40 percent to 50 percent said that they could benefit
from further training; 45 percent said continuing education was only somewhat useful (Menne et al., 2007). These workers identified a number of areas where their knowledge and skills needed further development, including
dementia, end-of-life care, teamwork, and problem solving.
Much more research is needed to determine the competencies that
direct-care workers need in order to provide high-quality care to older
patients. Unfortunately, as is also the case with the professional health care
workforce, expansion of training opportunities for direct-care workers is
limited both by the availability of qualified trainers and by the funding
available to pay for additional training.
While there is limited research on how different levels and types of
training affect the quality of care provided, there is some evidence that
a relationship does exist (IOM, 2001). For example, studies have shown
that dementia, a common geriatric syndrome, is inadequately diagnosed
and treated in assisted-living facilities, which can contribute to a quicker
discharge to a nursing home (Lyketsos et al., 2007; Rosenblatt et al., 2004).
In fact, in residential settings such as assisted-living facilities, the level of
staff training is a key factor in determining whether residents will need to
be relocated to nursing homes as their needs become more acute (Maas and
Buckwalter, 2006).
Adequate training also has an effect on recruitment and retention. High
levels of training have been positively associated with recruitment of home
health workers (Leon et al., 2001). Increasing the skills of personal-care
aides through a geriatric case-management program has shown strong influence on the workers’ intent to stay and also some effect on job satisfaction
(Coogle et al., 2007). Similarly, nurse aides who have received adequate
training have been found to provide higher-quality patient care (Goldman
et al., 2004) and to be less likely to want to leave their jobs (Castle et al.,
2007).
In 2001 the IOM recommended that “all long-term care settings, federal and state governments, and providers, in consultation with consumers, develop training, education, and competency standards and training
programs for staff based on better knowledge of the time, skills, education,
and competency levels needed to provide acceptable consumer-centered
long-term care” (IOM, 2001). This still holds true.
Content of Training
One area in which the content of direct-care worker training does not
reflect the current environment is its relative lack of geriatric-specific educational content. A 2002 OIG study found that more than half (63 percent)
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of nursing-home supervisors interviewed believed that training had not
kept pace with the care demands imposed by the increasing complexity of
resident diagnoses, including Alzheimer’s disease and other behavioral and
cognitive disorders. Some of the specific skills for which additional training
was found to be needed were related to catheter and colostomy care, lifting,
skin care, feeding, hydration, and infusion therapies (OIG, 2002).
The committee concluded that direct-care workers who attend to
older adults, especially frail older patients with complex health care
needs, need to have specific training that will prepare them for these
patients.
In addition to instruction that applies to older patients generally, staff
may also need specific training in cultural competence for working with ethnically diverse patients and co-workers (Fuller, 1995; Minore and Boone,
2002). This type of training is not currently specified in federal requirements. Another area where training is inadequate is in palliative care;
workers in both nursing homes and home-care settings are typically not
well trained in the care of patients at the end of life (Ersek et al., 2006;
Ferrell et al., 1998). Additionally, many direct-care workers need soft skills
training, such as communication skills.
Quantity of Training Hours
In recent years there have been calls to increase the number of hours
required for direct-care worker training. In 1998 the National Citizen’s
Coalition for Nursing Home Reform called for nursing assistants to be
given a minimum of 160 hours of training (NCCNHR, 1998). Also in the
late 1990s a panel of experts convened by the Hartford Institute for Geriatric Nursing recommended that training requirements for nursing aides be
doubled, from 75 hours to 150 hours (Harrington et al., 2000). In 2002 an
OIG survey of state-level directors of the Nurse Aide Training and Competency Exam Program found that 40 of the 49 respondents believed that
the 75-hour federal minimum was insufficient to ensure adequate preparation for the job (OIG, 2002). In 2006 AARP examined nurse aide training
programs in 10 states and found that the majority of officials interviewed
believed that federal minimums need to be increased to between 100 and
120 hours (Hernandez-Medina et al., 2006).
Curricula are often overloaded, and there are challenges in covering
all of the included ground in just 2 weeks (CMS, 2001). It may also be
unrealistic to expect students to assimilate all of the necessary material in
so little time (OIG, 2002). Moreover, the educational content for direct-care
worker training has not kept pace with changes in the patient population,
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such as the increased prevalence of dementia and other cognitive disorders.
As a result, more geriatric-specific educational content is needed. Additional
hours will be required to cover this added material.
Recommendation 5-1: States and the federal government should increase minimum training standards for all direct-care workers. Federal
requirements for the minimum training of certified nursing assistants
(CNAs) and home health aides should be raised to at least 120 hours
and should include demonstration of competence in the care of older
adults as a criterion for certification. States should also establish minimum training requirements for personal-care aides.
As described previously, more than half of states currently require
more than the 75-hour federal minimum for nurse aide training, and about
one-quarter require at least 120 hours (Table 5-7). This minimum should
be raised in order to provide direct-care workers with the enhanced preparation they need to do their work. The committee ultimately decided to
recommend 120 hours in order to raise the entire nation to the minimum
standards of the top quartile of states. While data on the exact competencies needed by different types of direct-care workers when caring for older
adults are minimal, the committee concluded that there is an immediate
need to increase current federal minimum requirements to a higher standard. The committee recommends this new 120 hour minimum anticipating that even higher levels of required training hours may be needed to
adequately cover additional knowledge and skill areas as more evidence
is accumulated concerning the specific competencies that these workers
need when caring for older adults. States, individual disciplines, regulators,
patients, and others will need to work together to determine these competencies. This will be especially important as direct-care workers assume
increasingly complex responsibilities and work more often in alternative
sites of care. As data are gathered on the competencies needed for these
additional and changing responsibilities, the minimum number of training
hours needs to be raised accordingly.
The committee’s recommendation does not offer any detail on the
composition of those hours with respect to clinical training. At this time
the states differ substantially in terms of how much training comes in the
form of classroom instruction and how much is covered through practical training (Table 5-7). For example, North Carolina and Wyoming both
require a minimum of 75 hours of nurse aide training, but North Carolina
requires only 16 of those hours to be devoted to clinical training (the federal
minimum), while Wyoming requires 48 hours of clinical training.
While there is already an established system for training and certifying
home health aides and certified nursing assistants—a system that the com-
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THE DIRECT-CARE WORKFORCE
TABLE 5-7 Nurse Aide Training Requirements (by
State), 2007
Hours
State
Minimum Training Hours/
(Minimum Clinical Hours)
120+ hours
(12 states +
DC)
Missouri
California
Delaware
Maine
Oregon
Alaska
Arizona
District of Columbia
Florida
Idaho
Illinois
Virginia
West Virginia
175
150
150
150
150
140
120
120
120
120
120
120
120
(100)
(100)
(75)
(50)
(75)
(80)
(16)
(N/A)
(40)
(40)
(40)
(40)
(55)
76-119 hours
(15 states)
Indiana
Connecticut
Hawaii
Maryland
New Hampshire
New York
Rhode Island
Kansas
New Jersey
Georgia
Washington
Louisiana
South Carolina
Utah
Nebraska
105
100
100
100
100
100
100
90
90
85
85
80
80
80
76
(75)
(50)
(70)
(40)
(60)
(30)
(20)
(45)
(40)
(16)
(50)
(40)
(40)
(16)
(N/A)
75 hours
(23 states)
Alabama
Arkansas
Colorado
Iowa
Kentucky
Massachusetts
Michigan
Minnesota
Mississippi
Montana
North Carolina
North Dakota
Nevada
New Mexico
Ohio
75
75
75
75
75
75
75
75
75
75
75
75
75
75
75
(16)
(16)
(16)
(30)
(16)
(16)
(16)
(37.5)
(16)
(25-30)
(16)
(16)
(N/A)
(N/A)
(16)
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TABLE 5-7 Continued
Hours
State
75 hours
(23 states)
(continued)
Oklahoma
Pennsylvania
South Dakota
Tennessee
Texas
Vermont
Wisconsin
Wyoming
Minimum Training Hours/
(Minimum Clinical Hours)
75
75
75
75
75
75
75
75
(16)
(37.5)
(16)
(35)
(24)
(16)
(16)
(48)
NOTE: N/A = Not Available.
SOURCE: Seavey, 2007a.
mittee is proposing to strengthen—the methods for training and certifying
personal- and home-care aides are much more inconsistent from state to
state, with no formal system in existence. The committee’s recommendation
with regards to these workers is intended to create a basic framework for
further requirements that may be implemented by states and the federal
government in the future, especially as the knowledge base about the education and training of all types of direct-care workers develops.
Increasing Economic Incentives
As described previously, wages for direct-care workers are low and do
not appear to adequately support the recruitment and retention of these
workers. In a classic economic model of a labor shortage, wages, benefits, and other job attributes would simply improve until enough workers
were willing to fill the positions, and the shortage would no longer exist.
However, given that Medicaid and Medicare are responsible for about 70
percent of all long-term care dollars spent (Komisar and Thompson, 2007),
there is little room for the market to adjust without the government’s being
willing to commit additional funds.
Evidence shows that higher wages do in fact lead to lower rates of
turnover among all types of direct-care workers (Howes, 2005, 2006;
Sherard, 2002). In seeking to find ways to increase wages for direct care
workers in this environment, several mechanisms have been employed, including: setting a minimum service rate percentage that must to be passed
through to direct-care labor costs; creating rate enhancements for providers that compensate their workers at a higher level; establishing automatic cost-of-living-adjustments to be passed through to direct-care labor
costs; and establishing procurement and contracting standards that specify
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221
minimum staffing standards that providers must meet, such as worker
compensation.
By far the most prevalent mechanism for stimulating increased directcare worker pay is the wage pass-through, a state-level allocation of Medicaid funds that are added to reimbursement rates for the specific purpose
of increasing direct-care staff wages. A review and evaluation of state wage
pass-through laws conducted in 2003 found that 21 states had implemented
such programs; nine of those programs were for skilled nursing facilities
only, while the others also included home health or personal care (PHI,
2003b). Most of these programs were mandatory, but participation was
voluntary in at least six of the states, and some states allowed flexibility in
exactly how the funds were to be used to improve staffing.
Evaluation data for wage pass-throughs are limited and show mixed
results, especially in terms of the effect on recruitment and retention. The
effects on actual wages were also unclear. One reason for the lack of clarity is that Medicaid is only one payer among several and workers are not
payer-specific, so facilities with different proportions of Medicaid residents
received different total amounts to be spent on wage increments. A variety
of other obstacles to analyzing these programs also exist, including the use
of differing measures of recruitment and retention, an inability to monitor
how wages are actually transferred to the employees, and difficulty in separating the effects of the wage pass-through from other interventions. The
lack of data suggests the need for careful monitoring and auditing of wage
pass-through programs. The evidence that is available, however, indicates
that the wage increases were often too small, were unreliable year to year,
lacked accountability mechanisms, and were time consuming and expensive
to implement. However, some states, such as Wyoming, have implemented
programs that have been deemed successful by assessors (Seavey and Salter,
2006).
Increasing wages is only one step toward improving the recruitment
and retention of direct-care workers; benefits also need to be improved.
This is especially true of direct-care workers in home settings, who typically have very limited benefits (Howes, 2006). According to a 2005 study,
nine states had developed or were in the process of developing programs
that would address the lack of health insurance among health care workers
(Harmuth and Dyson, 2005). State strategies for expanding access to coverage for these workers include subsidizing employer-sponsored insurance,
designing innovative employer-based insurance packages, and, in the case
of Massachusetts, including the workers in a near-universal state health
coverage plan (Seavey and Salter, 2006). In states such as Wisconsin, wage
pass-throughs have also been considered as an option for funding the health
care benefits of direct-care employees (PHI, 2006).
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Recommendation 5-2: State Medicaid programs should increase pay
and fringe benefits for direct-care workers through such measures as
wage pass-throughs, setting wage floors, establishing minimum percentages of service rates directed to direct-care labor costs, and other
means.
The committee also supports efforts to address the issue of variable
hours and unstable income among direct-care workers. For example, the
Guaranteed Hours Program implemented by Cooperative Home Care Associates (a home-care staffing agency in New York City) aims to reduce
turnover and vacancy rates (PHI, 2007). Under this program, home health
workers are considered full-time employees, are guaranteed full-time wages,
and effectively serve on an “on call” basis during work hours when no
client visit is scheduled. Although it has not been evaluated in isolation, it
is part of a set of workforce interventions that have been documented to
reduce turnover to nearly half the industry average (PHI, 2007).
Improving the Work Environment
Besides pay and benefits, a number of other factors may increase job
satisfaction among direct-care workers, such as participation in decisions
related to care planning and workplace improvement, the availability of
career advancement opportunities, and high-quality supervision. Research
has shown that job satisfaction and changes in organizational culture are
strong predictors of commitment to an organization (Sikorska-Simmons,
2005) and that improved job satisfaction can result in a greater intent to
stay (Castle et al., 2007). A variety of approaches, including mentoring
(Hegeman, 2005), use of self-directed work teams (Yeatts et al., 2004),
and career ladders (Maier, 2002), have all been closely linked to employee
satisfaction.
Improving Relationships with Supervisors
As discussed in Chapter 4, the relationship between nursing supervisors
and direct-care staff plays a significant role in the development of a hospitable work environment that leads to increased job satisfaction (Bishop
et al., 2006; Tellis-Nayak, 2007). Positive supervision (as opposed to more
punitive approaches) can greatly increase the direct-care worker’s sense of
value and ultimately can increase his or her level of job satisfaction and
intent to stay. Evidence shows that perceived support by supervisors is also
an important determinant in decreasing job-related stress (McGilton et al.,
2007). A strengthening of the relationship between supervisors and staff
may also enhance the practice of job delegation, as members of a workforce
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develop better and more interactive relationships, including improved recognition by supervisors of each worker’s skills.
Increasing Recognition
Direct-care workers often feel that they do not receive adequate recognition for their work or for the contributions that they make toward quality
patient care. Studies looking at the implementation of empowered CNA
teams at skilled nursing facilities found that giving CNAs added decisionmaking responsibilities led them to become more competent and also to develop better attitudes about their jobs. This approach also takes advantage
of the fact that CNAs have the most direct knowledge about the preferences
of nursing home residents and as a result are often in the best position to
make decisions relating to day-to-day care (Yeatts and Cready, 2007). Efforts to increase the involvement of direct-care workers in decision-making
have also been linked to increased overall job satisfaction and, ultimately,
decreased turnover. One study, for example, found that turnover among
nursing home aides was significantly reduced when they were involved in
interdisciplinary care-plan meetings (Banaszak-Holl and Hines, 1996). In
a study of Pennsylvania’s direct-care workforce, increased involvement of
direct-care workers in care planning was associated with decreased rates of
staff shortages and fewer job vacancies (Leon et al., 2001).
The Wellspring nursing home quality improvement model is one example of an effort to improve the recognition of CNAs as important members of the care team by enabling them to become leaders in continuous
quality improvement. The program encourages individual staff members to
acquire knowledge and skills in particular clinical areas (e.g., incontinence
and pressure ulcers) so that they can lead care-resource teams in the careplanning and decision-making processes for residents (Wellspring Institute,
2005). (See the next section on career lattices for more on the development
of specialty areas among direct-care workers.) These areas of training are
based on best practices determined by the guidelines of both the Agency
for Healthcare Research and Quality and the American Medical Directors Association as well as on other national standards of best practices
(Wellspring Institute, 2005).
Evaluation of the program has shown that its training and organizational change methods have had measureable impact on retention and job
satisfaction among its staff, as well as on resident satisfaction. Turnover
rates were lower than at comparable facilities in the area; staff was more
actively involved in assessing resident needs and providing care; and there
was observational evidence of improved quality of life and interactions with
staff among residents (Stone et al., 2002).
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Creating Career Lattices
Another approach to increasing overall job satisfaction among directcare workers is to expand their roles and responsibilities and to enhance
their ability to develop new skills. The term “lattice” refers to how some
workers move laterally in their careers (i.e., through the development of
specialized skill areas) while others move linearly up the career “ladder”
(e.g., advancement from CNA to LPN to RN) (CAEL, 2005). There have
been many efforts to encourage the development of lattices for direct-care
workers, sometimes in concert with the ability to move up a career ladder.
For example, the Office of Apprenticeship in the U.S. Department of Labor
(DOL) awarded grants to the Council for Adult and Experiential Learning
(CAEL) and PHI with the goal of creating apprenticeship opportunities for
direct-care workers to develop special skills through on-the-job training,
related instruction, and mentoring (DOL, 2008c). The increased skill development associated with apprenticeships often leads to increases in wages
as well (CAEL, 2005).
Council for Adult and Experiential Learning (CAEL) The CAEL has
implemented the nursing career lattice program in nine sites (including
both acute and long-term care settings) to develop more CNAs, LPNs, and
RNs (CAEL, 2008; DOL, 2008c). As a first step, many apprentices are recruited from auxiliary areas such as housekeeping, clerical staff, and food
service to be trained for CNA certification. Next, CNAs are encouraged to
develop enhanced skills in specific areas including geriatrics, dementia care,
and peer mentoring. CNAs are given flexible training schedules and wage
increases in alignment with their increased responsibility. In this manner,
the program prepares CNAs to take the required examination to become
LPNs. LPNs also receive additional training based on specific competencies.
For the next step on the career ladder, LPNs receive online education along
with clinical training at local community colleges that prepares them to
take the required examination to become RNs. This program has resulted
in increased retention, reduced recruitment costs, and decreased worker
shortages (CAEL, 2005, 2008).
PHI Under its grant, PHI developed the Home Health Aide Registered
Apprenticeship at five sites to help home health aides gain basic skills
and develop skills for specialty areas, such as hospice and palliative care,
geriatrics, dementia, and peer mentoring (DOL, 2008c). As in the CAEL
program, the training programs are based on specific competencies. Apprentices are required to demonstrate competence in basic skills as well as
the skills needed for two specialty areas. They also receive mentoring from
experienced home health aides.
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Creating New Jobs and Delegating Responsibilities
As discussed in previous chapters, efficient use of the workforce will
require more delegation of job duties in the coming years. This delegation
has a cascading effect, with specific tasks being handed off to people in various professions and occupations, depending on the situation, which allows
each worker to be used at his or her highest level of skill. The combination
of the need to delegate additional duties and the desire of some direct-care
workers to assume more responsibilities creates opportunities to restructure
workforce assignments in ways that are potentially more satisfying for
direct-care workers.
In some new models, direct-care worker roles may become much
broader. For example, the Green House model described in Chapter 3 gives
a more expansive role to direct-care workers. Under that model, frontline
caregivers take responsibility for a broader range of tasks that include personal care, cooking, housekeeping, and making sure that residents spend
time according to their preferences.
In other cases, direct-care workers take on specific tasks that require a
higher level of skill than is usually expected of them. One example of this is
the delegation of medication administration duties from RNs, as discussed
in Chapter 4. Although there have been some concerns raised regarding
patient safety, some RNs who have assessed the delegation of these responsibilities to CNAs have argued that CNAs may be able to deliver medications with greater accuracy because they face fewer distractions than RNs
(Reinhard et al., 2003). If so, giving this responsibility to CNAs has the
potential to increase efficiency, benefit patients, and facilitate the recruitment and retention of direct-care workers. Similarly, having home health
aides assume responsibility for medication administration from RNs could
help decrease the need for RN visits to homes.
If direct-care workers are to assume these increased responsibilities,
they may in turn need to delegate certain of their own tasks. One example
of this is the use of feeding assistants in the long-term care setting. Nurse
aide training includes instruction in how to assist older adults with eating
and hydration, and this is one of the primary responsibilities of CNAs. In
2003, however, CMS issued regulations allowing states to permit long-term
care facilities participating in Medicare or Medicaid to use paid feeding
assistants to supplement CNA services under certain conditions. Requirements for feeding assistants include the successful completion of a minimum
of 8 hours of training in a state-approved course. The use of the feeding
assistant has been controversial, but a preliminary analysis found that the
quality of feeding done by feeding assistants was comparable to the quality
of feeding by CNAs and, furthermore, that facilities did not decrease CNA
hours in response (Kasprak, 2007; Simmons et al., 2007).
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Using Technology
New technologies will make possible the more efficient use of the
direct-care workforce in a variety of ways. As was discussed in previous
chapters, the development and use of health information technologies will
likely improve the coordination of patient care and enhance communication
among caregivers. The development and use of assistive technologies may
help patients be more independent, thereby reducing their need for assistance, especially personal-care assistance (see Chapter 6). Furthermore, the
use of these technologies can reduce the physical demands of many tasks,
perhaps leading to a reduction in the rate of injury among direct-care workers. One such example would be technologies that can assist with tasks that
often result in muscle strain on the part of workers, such as lateral transfers,
repositioning patients up or side-to-side in bed, and bed-to-chair or bed-towheelchair transfers (Baptiste, 2007).
Improving Safety
In addition to the use of these assistive technologies, a number of other
efforts have been undertaken to prevent injuries among direct-care workers.
For example, the Occupational Safety and Health Administration (OSHA)
has developed ergonomic guidelines aimed at preventing musculoskeletal
disorders among nursing home workers (OSHA, 2008). These guidelines
offer safe methods for lifting and repositioning patients and help meet the
training needs of workers in nursing home settings. Additionally, in 2002
OSHA announced a new National Emphasis Program for nursing and
personal-care facilities, which aims to address ergonomics, exposures to
health risks, and slip-and-fall injuries (OSHA, 2002).
OSHA also awards Safety and Health Achievement Recognition Program (SHARP) designations to small employers who exemplify high standards of safety and health management. In 1998 one such recipient, the
Good Shepherd Nursing Home of Wheeling, West Virginia, analyzed its
injury reports and determined that most of the injuries were the result of
heavy lifting (OSHA, 2007). Subsequently, the nursing home procured a
mechanical lifting device to assist with transfers and also implemented a
safety program which included training, workplace analysis, and hazard
prevention. In its first year the program led to a 62 percent decrease in
worker injuries at the nursing home, and, thanks to the improved safety,
between 2000 and 2005 the nursing home reduced its workers’ compensation insurance premiums by over $800,000. The nursing home’s administrator commented that “a highly efficient and highly skilled workforce makes
fewer mistakes, reduces exposure to liability, and keeps insurance premiums
low” (OSHA, 2007).
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Broadening the Labor Pool
While improving the quality of direct-care occupations is important
to the recruitment and retention of this workforce, sources for new workers also need to be considered, especially the possibility of recruiting
workers from other, currently underutilized sources. A number of options exist for broadening the pool of direct-care workers (Hussein and
Manthorpe, 2005; National Center for Health Workforce Analysis, 2004;
Stone, 2004; Stone and Wiener, 2001). Some of the groups of people who
might be recruited to enter the direct-care workforce are described below.
Men
As described previously, the population of direct-care workers is overwhelmingly female (Montgomery et al., 2005; Smith and Baughman, 2007).
As a result, men represent a potential source of new workers that has so
far remained essentially untapped. Given that the number of women in the
United States between the ages of 25 and 54 is expected to remain level
in the coming years and will not provide a labor pool sufficient to meet
projected demand, more men will be needed to fill these roles. However,
special consideration may be needed for male workers, including a culture
change to accept male workers in an occupation that is currently dominated
by females (PHI, 2003a).
Immigrants
Immigrants are already a significant part of the direct-care workforce,
especially in major cities (Wilner and Wyatt, 1998), and they are frequently
pointed to as a potential source of new workers in long-term care (Priester
and Reinardy, 2003). However, few programs exist to train and place immigrants for careers as direct-care workers. Preparing immigrants for these
roles will require instruction not only in technical skills but also in language
skills and in the cultural competence needed to work with patients. Successful training models also need to help trainees to navigate immigration
systems, seek housing, and prepare for higher education. Limited experience shows that with the proper training and support, immigrant workers
may be an effective source of direct-care workers; without proper support,
however, their presence may exacerbate existing cycles of low pay and high
turnover (Leutz, 2007).
Many countries in the industrialized world have modified their immigration laws to allow an influx of low-wage workers to fill vacancies for
direct-care positions (AARP, 2005). The advantage of this approach is that
the number of new workers in the labor pool can potentially be increased
without drawing workers away from other industries. On the other hand,
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this approach could have potentially serious side effects. Specifically, costs
for public services and government supports could increase (National Center for Health Workforce Analysis, 2004), there may be undesirable competition for other low-wage jobs (Stone, 2004), and the difficulties that can
arise when caregivers and patients are from different cultures could become
more common. (See Chapter 4 for more on ethnogeriatrics.) More research
is needed on the appropriate use of immigrants, including information on
both the benefits and the unintended consequences.
Older Workers
As discussed in Chapter 4, as the population of older patients grows,
the workforce itself will be aging. As current health care workers approach
retirement age, there will be a need to recruit new health care workers
as well as to find ways to retain older workers. This issue will also affect
the informal workforce, particularly since spousal caregivers are becoming increasingly older themselves. From 1989 to 1999, for example, the
proportion of spouse primary caregivers ages 75 or older increased from
38.2 percent to 47.4 percent (Wolff and Kasper, 2006), and by 1999, 11.1
percent of spouse caregivers (both primary and secondary) were 85 years
or older (Spillman and Black, 2005). (See Chapter 6 for more on informal
caregivers.)
Because of this aging of the workforce, in recent years there has been
an increasing emphasis on strategies to recruit and retain older workers.
These strategies include giving older workers greater access to education
and training, providing them with additional tax deductions for continuing
to work, and offering them opportunities for phased retirement and flexible
schedules. For example, AARP has helped older workers obtain federally
subsidized training through a local community college in order for them to
gain needed technology skills (Taylor, 2007). Retaining older workers has a
number of potential benefits aside from increasing the size of the workforce.
These benefits include preventing the loss of the older workers’ acquired
expertise and avoiding the various costs associated with replacing these
workers, such as recruitment expenses, paying for temporary replacements
(per diem workers), and paying to retrain other workers.
The idea of recruiting older, non-health care professionals into new
health-related careers has received increased attention. In a survey of lowincome workers over the age of 55, a significant percentage (43 percent)
expressed interest in direct-care work (Kosniewski and Hwalek, 2006). Additionally, more than half of employers for nursing homes and home health
agencies said that older workers were more likely to be loyal employees
and have desirable skills and less likely to leave the position. On the other
hand, employers also thought that older workers would be more averse to
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using technology, and the wage expectations of the older workers who were
surveyed were higher than the average for these positions. Furthermore, the
older workers expressed more interest in the emotional support of patients
than in hands-on tasks.
The recruitment and retention of older workers may require the creation of positions with fewer physical demands. Parsing CNA responsibilities might enable the productive use of older adults in the workforce who
lack the strength to do all CNA tasks. In one example of such an approach,
McKesson, a health care services company, has recruited older workers
for their call centers to advise patients on medication use (Taylor, 2007).
Similarly, strategies to retain existing older workers in clinical positions will
likely demand the creation of health care delivery processes that are more
ergonomically oriented (Buerhaus et al., 2000). Emerging technologies may
assist in this regard (see Chapter 6).
Volunteers
In addition to recruiting new paid workers, workforce needs could be
partially satisfied by using volunteers, both in clinical and in academic settings. Older adults themselves would seem to be a likely target group from
which to recruit such volunteers, given that baby boomers have the highest
volunteerism rate of any age group—they volunteer more often than past
generations did at the same ages—and they constitute a very large pool of
potential volunteers (Foster-Bey et al., 2007).
Members of younger generations may also be willing to provide needed
services, especially community-based personal- and home-care services
that would allow fellow community members to remain in their homes.
Community-based models such as Beacon Hill Village in Boston have been
developed to allow older adults to “age in place” (Gross, 2006). In these
models older adults within a narrow community pay dues to receive support, such as accompaniment to medical appointments, delivery of meals,
exercise classes, lectures on aging-related topics, and assistance with daily
errands. Volunteers provide many of these services, such as transportation.
Other more advanced services, such as home health aide services and home
repairs, are often available for a discounted fee. These options may become
more appealing as more older adults prefer to stay in their home settings
and trends toward consumer-directed care continue (see Chapter 6).
Examples of Efforts to Improve Recruitment and Retention
While some efforts to improve the recruitment and retention of directcare workers focus on a single strategy, other programs and organizations
have developed a mixture of policy- and provider-based interventions. Some
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large-scale efforts, including those of the federal government, are detailed
below. In addition, there have been several large-scale efforts to build an
evidence base for the best practices in the recruitment and retention of
direct-care workers. These efforts are also described below.
Better Jobs Better Care
The Better Jobs Better Care national program, which was completed in
2007, supported five state-based coalitions (in Iowa, North Carolina, Oregon, Pennsylvania, and Vermont) that designed and tested practice-based
interventions and policy changes over a 4-year period. These coalitions
attempted to reduce turnover and vacancy rates and improve the working
environment of direct-care staff in long-term care (BJBC, 2007). Since each
state used different approaches to reach these goals, no single method can
be fairly highlighted over the others. All of the participating states demonstrated a range of positive results from this effort, including improvement
in worker satisfaction and increased recruitment (BJBC, 2008). To accomplish this, the program improved employee pay and also pushed employers to demonstrate respect for direct-care workers in a variety of ways:
by providing supervision, peer mentoring, and team building; by offering
opportunities for educational advancement; and by encouraging greater
communication and understanding (McDonald, 2007).
Employment and Training Administration Programs
A number of efforts to bolster the direct-care workforce have been undertaken by the Employment and Training Administration (ETA) within the
DOL, which has invested hundreds of millions of dollars in grants aimed at
strengthening the pipeline of needed workers. The ETA’s efforts to improve
career lattices through the programs of its Office of Apprenticeship were
discussed above. Many of the ETA’s grants focus on long-term care workers (Freking, 2007). For example, since 2004 the Community-Based Job
Training Grants have funded a number of programs to prepare students for
careers in high-growth industries (DOL, 2008b). In March 2008 the DOL
awarded $125 million to 69 community colleges, and 24 of these grants
(totaling almost $40 million) were for developing workers for the health
care industry (DOL, 2008a,d).
The ETA’s High Growth Job Training Initiative is aimed at giving workers the skills necessary to build a career in one of several different industries, including health care. Under this initiative, the ETA is investing more
than $46 million to address health care workforce shortages, particularly
among long-term care workers (DOL, 2007). The initiative will focus on
such things as increasing the number of younger workers entering the mar-
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ket, identifying alternative labor pools, developing new educational tools
and curricula, increasing faculty, and improving recruitment and retention.
The initiative intends to develop approaches that can be replicated across
the country.
Centers for Medicare and Medicaid Programs
CMS has also funded several initiatives to strengthen the quality of
direct-care work and its services. In 2003, for instance, CMS initiated the
Direct Service Workforce Demonstration, which provided grants to 10
states to test the effectiveness of various workforce interventions on the recruitment and retention of direct-care workers in the communities. According to an assessment of this program, the grants were shown to decrease
worker turnover and increase retention rates. For example, over a 2-year
period Kentucky reported a decrease in turnover rates from 43 percent to
29 percent and an average increase in retention rates of 5 months (University of Minnesota and The Lewin Group, 2006). Such improvements were
primarily achieved by increasing the visibility of available positions and by
using more accurate selection strategies to hire well-matched workers to
those positions.
Later, in 2006, the National Direct Service Workforce Resource Center
was created by CMS, and it continues to address the recruitment and retention challenges of direct-care workers by providing information, resources,
and assistance to all relevant stakeholders (e.g., policy makers, researchers,
employers, workers, and patients) involved in the provision of quality care
to older adults at the state and local levels (CMS, 2008a).
Another effort by CMS to improve health services to older populations in all 50 states is its Real Choice Systems Change Grants. Since 2001
CMS has provided a total of approximately $270 million in these grants
to provide support for community living (CMS, 2008b). This funding has
helped build effective foundational improvements in community-integrated
services and long-term care systems by allowing states to address issues
regarding personal assistance services, direct-care worker shortages, and
respite service for caregivers and family members, along with many other
issues. Several states improved their support of the direct-care workforce
by targeting the areas of recruitment, training and career development, and
administrative activities (CMS, 2005). Some of the more common or effective strategies used by states to achieve better recruitment and retention of
this workforce were altering training strategies, allowing for more flexibility
in worker responsibilities, and broadening the definition of who can serve
as a personal assistant (CMS, 2007). The funding provided to the states by
this grant program has been put to use effectively, CMS reports, and “the
infrastructure that has been developed enables individuals of all ages to
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live in the most integrated community setting suited to their medical needs,
have meaningful choices about their living arrangements, and exercise more
control over the services they receive” (CMS, 2008b).
The PAS Workforce Project
The 5-year PAS Workforce Project, run through the Center for Personal
Assistance Services, has the goal of building and disseminating an evidence
base for best practices concerning the personal assistance workforce. The
information collected includes data on individual interventions as well as
related legislation and policy efforts. The project pays particular attention to strategies to improve worker retention in consumer-directed programs, including issues related to wages, training, safety, and supervision,
as well as to the development of infrastructures that facilitate consumerdirected programs (CPAS, 2008). To be included, a program must have
documented operational experience as well as evidence of program success
and replicability.
National Clearinghouse on the Direct-Care Workforce
PHI’s National Clearinghouse on the Direct-Care Workforce is a national, online library of information regarding the direct-care workforce
for long-term care. The clearinghouse collects government and research
reports, fact sheets, briefs, and other information on issues such as career
advancement, education and training, recruitment and retention, job environment, and best practices (National Clearinghouse for the Direct-Care
Workforce, 2008). The clearinghouse also produces original research and
analysis, including monitoring of state-based initiatives.
CONCLUSION
Because direct-care workers provide the bulk of paid direct-care services
for older patients in nursing homes and other settings, it is vitally important
that the capacity of this segment of the workforce be enhanced in both size
and ability to meet the health care needs of older Americans. However, the
recruitment and retention of sufficient numbers of these workers is challenging due to serious financial disincentives and job dissatisfaction as well
as high rates of turnover and severe shortages of available workers.
As it exists today, the education and training of direct-care workers
is inadequate to impart the necessary knowledge, skills, and abilities to
these workers, especially as the complexity and severity of older adults’
needs increase and as more adults are cared for in home- and communitybased settings. The government should raise the federal minimum training
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requirement for nurse aides and home health aides to 120 hours and states
should establish minimum standards for personal-care aides if they have not
already done so. All direct-care workers should be required to demonstrate
that they possess the competencies necessary to engage in this type of work.
More research is needed to determine the appropriate content of training
programs, which needs to be individualized for the needs of workers based
on their responsibilities and the settings in which they provide care.
Improving the quality of these jobs will demand significant effort.
Direct-care workers typically receive low wages and have limited access
to other benefits, including health insurance. Economic incentives should
be bolstered to improve the desirability of these jobs. Additionally, much
more needs to be done to improve the workforce environment. Evidence
shows that increased job satisfaction and decreased turnover rates may be
associated with increasing worker responsibilities (including the development of new roles or career lattices), increasing the recognition of the workers’ current contributions, improving safety, and improving supervisory
relationships. Given all these factors, it is clear that a change in culture is
needed—that both health care workers and health care organizations need
to change the way they think about direct-care workers and, in particular,
that direct-care workers need to be seen as a vital part of the health care
team.
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6
Patients and Informal Caregivers
CHAPTER SUMMARY
Patients play a sizable role in their own care, not just as recipients of care
services but also as prominent actors in the delivery process. Moreover,
family members, friends, and other unpaid caregivers provide the backbone for much of the care that is received by older adults in the United
States. This chapter discusses the need to support patients and caregivers
through a number of means, including greater opportunities for training.
These training opportunities can improve the care received by older adults
while also easing the strain on informal caregivers, who often feel unprepared for the tasks they are required to perform. The chapter also discusses
the role that assistive technologies can play in enhancing and prolonging
the independent functioning of older adults, making them less reliant on
direct-care workers and informal caregivers. The committee recommends
that federal agencies take steps to assist in the development and increased
availability of these technologies. Taking these measures to promote the
health and well-being of both patients and caregivers will help ease the
strain on the workforce providing medical care for older adults.
The role of patients in the care process extends far beyond their role
as recipients of services. Patients play a major part in determining treatment plans, navigating the delivery system to obtain services, and ensuring
overall adherence to the selected course of treatment. For older adults, these
care plans often involve multiple providers and settings, and they can find
themselves functioning as coordinators of the entire process. Older adults
241
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frequently communicate relevant information from one provider to another,
or may even detect ways in which the treatment plans are at odds.
As patients continue to age and experience declines in their health, they
begin to require greater assistance in performing their roles in the health
care process. In response, family members and friends assume increasingly
greater responsibility for making treatment decisions, accompanying the
patients on office visits, and providing other sources of support. In a great
many cases, these family members and friends also become informal caregivers, providing many of the same services that direct-care workers provide, including assistance with the activities of daily living (ADLs), such as
bathing and dressing, and the instrumental activities of daily living (IADLs),
such as driving and shopping.
The number of informal caregivers in the United States far exceeds the
number of paid direct-care workers. There are concerns, however, that the
number of caregivers is declining—a trend that is especially worrisome in
light of the fact that the direct-care workforce is already stretched thin. Any
reductions in caregiver support could have serious negative implications
for the adequacy of the direct-care workforce, which makes it particularly
important to determine how best to support caregivers in order to maintain
the availability of their services.
Both patients and informal caregivers are important parts of the health
care team, yet little has been done to impart the necessary knowledge or
skills to these team members. Ensuring adequate communication with this
part of the workforce is especially important for the older adult population
because of hearing, vision, and mental acuity deficiencies (including among
some informal caregivers), thereby increasing the likelihood of adverse effects due to the miscommunication. Additionally, as the use of remote information technologies becomes more common, patients and their families will
need to be educated on their proper use. Ultimately, any plan for enabling
informal caregivers and patients to become more capable members of the
health care team is likely to require increased training along with greater
support from and integration with the formal health care system.
PATIENTS
Given the vital role that patients play in shaping and implementing
their own care, they need to be viewed not just as recipients of care, but
also as members of the care team. This is especially true in light of the increasing prevalence of chronic disease. The management of chronic illness
is complex, and patients are required to take on greater responsibilities than
they typically would for acute care. Managing conditions such as diabetes
involves day-to-day decision making with respect to lifestyle, prevention,
medication use, and other components of health and health care (Newman
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et al., 2004). Self-management extends beyond basic adherence to treatment
guidelines; it includes such things as self-monitoring and the application of
appropriate cognitive, behavioral, and emotional responses.
The evolution of the patient’s role includes an increasing emphasis on
collaborative care. Health care professionals and patients are familiar with
the traditional provider-patient treatment model, in which providers assume
responsibility for all decisions (Funnell, 2000). However, the role of the
patient has undergone a redefinition in recent years and their role is now
considerably more expansive. This has altered the environment that older
adults will encounter as they enter their retirement years and, in most cases,
begin to utilize the health care system more extensively.
Self-Management
In an ideal model of collaborative care, patients first work with their
providers to set realistic goals; this requires skills in collaborative goal setting and in the development of an action plan (Bodenheimer et al., 2002;
Hibbard, 2003). Then, once the goals and the plan are set, patients are
responsible for executing the daily routines that are necessary to effectively
treat or ameliorate their conditions; this part of the process is termed
self-management.
Self-management interventions are designed to help patients understand
how their behaviors affect their illness and their lives and to use that information to shape their decision making. They address real-world challenges,
such as those encountered by patients who are both diabetic and asthmatic
and have trouble maintaining their exercise regimens. Only a small percentage of the educational content of self-management programs concerns
disease-specific information. The majority of the content deals with generic
lifestyle issues, such as exercise, nutrition, and coping skills. This selfmanagement education supplements—but does not replace—traditional
patient education, and it emphasizes the acquisition of skills rather than
just knowledge (Wagner, 2000). Studies show that teaching patients these
types of self-management skills is more effective than providing information
alone (Bodenheimer et al., 2002).
Self-management is predicated on the assumption that patients have
both the ability to understand basic health care information (“health literacy”) and the ability to use that knowledge to help manage their own
care (“patient activation”)1 (Greene et al., 2005). Individuals with low
health-literacy rates report having poorer health status and using fewer
preventive services (Williams et al., 1998). In general, older adults tend to
have lower health literacy and lower activation levels than younger adults
1 These
concepts would not apply to older adults with significant cognitive impairments.
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(Baker et al., 1997; Scott et al., 2002), although baby boomers may prove
to be an exception, as they are better educated than previous generations
(Cutilli, 2007; IOM, 2004) and may be more proactive in their own health
care (CBO, 1993).
While there is evidence that getting older patients engaged in their own
care results in improved clinical outcomes and higher patient satisfaction
(Bodenheimer et al., 2002), there are a number of barriers to educating and
training patients in their own self-care. Many self-management programs,
for instance, are limited to a single disease or lack information on either basic principles of self-management or the long-term benefits of actively managing chronic disease. And while there is evidence that case managers and
others can successfully train frail elders in self-management skills (Chodosh
et al., 2005; Ersek et al., 2003), this type of education and training is not
currently reimbursable under most insurance plans, including Medicare and
Medicaid (Quijano et al., 2007). Nevertheless, supporting these types of
programs is important because if patients are able to manage their conditions more effectively, they are likely to use fewer health care resources and
thereby reduce the strain on the health care workforce.
Assistive Technologies
As the number of older Americans with ADL or IADL limitations increases over the coming years, one likely result will be an increase in the
use of assistive technologies (Tomita et al., 2004). These devices help with
many of the issues that commonly lead older adults to leave their homes for
care institutions, including the need for medical monitoring and medication
management, decreased mobility, caregiver burnout, dementia, and problems with eating, toileting, safety, isolation, transportation, housekeeping,
money management, shopping, and wandering (Haigh et al., 2006). Assistive technologies are designed to support and extend the independent functioning of older adults, which can in turn reduce the need for support from
direct-care workers and family caregivers. These technologies can also help
lower rates of injury among direct-care workers and caregivers by reducing
their physical strain. For example, these technologies can assist with tasks
such as lateral transfers, repositioning patients up or side-to-side in bed,
and bed-to-chair or bed-to-wheelchair transfers (Baptiste, 2007).
The Institute of Medicine (IOM) report The Future of Disability in
America refers to assistive technology devices as “items designed for and
used by individuals with the intent of eliminating, ameliorating, or compensating for individual functional limitations” (IOM, 2007). These items
include a broad range of tools and technologies that help individuals perform ADLs and IADLs and thus reduce their need for personal assistance.
Several studies demonstrate, for instance, that the use of assistive devices
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can reduce the hours of personal assistance that older adults require in their
daily activities (Agree, 1999; Freedman et al., 2006; Mann et al., 1999).
One study found that people who needed assistance with ADLs and who
did not use any assistive devices required an average of 4 additional hours
of personal care per week compared with individuals who did employ the
devices (Hoenig et al., 2003). With newer technologies on the horizon, it
may be possible to make even further reductions in the amount of personal
assistance required.
Examples
Assistive technologies range from the very basic to the highly complex.
Examples include products such as canes, walkers, hand rails, shower seats,
and bath mats, as well as durable equipment such as power wheelchairs and
medical devices such as hearing aids. Recent advances in medication-related
technologies include smart patches, which assist in regulating drug release,
and smart caps, which are placed on medication vials and allow for remote
monitoring of medication adherence.
A number of more complex technologies have also been developed,
such as environmental intelligence systems that assist older adults in maintaining independent functioning, reducing the need for personal assistance
and putting off the time they must leave their homes for some place where
others can help take care of them (Mann et al., 1999). “Smart homes,” for
example, allow older adults to operate household fixtures and appliances
(e.g., lights, televisions, dishwashers, window blinds, and other electrical
devices) more easily. Many of these homes include motion detectors that
sense movement and respond by lighting pathways; other features include
remote control shelves and cupboards that can automatically adjust in
height when needed for use. Smart kitchen components, such as smart
microwaves and smart stoves, can help older adults in cooking their own
meals.
Another group of technologies, telemonitoring and telesurveillance
devices, allow health care providers to monitor older adults in their homes.
For patients with medical needs and cognitive impairments, these devices
provide a direct link to care without the need for visits by medical personnel
to the site. This can improve patient access to care, as well as the efficiency
of the care provided. Although there are privacy concerns, these technologies provide older adults with direct and immediate medical contact if they
need it. In addition to increasing patient safety (Mann et al., 2001), this
type of communication system has been shown in one study to reduce hospital stays, reduce demand for home-care services, and assist in relieving
caregiver stress (Vincent et al., 2006).
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Product Development and Availability
While many of these technologies can be produced and sold at reasonable or even inexpensive prices, others, such as robotics and smart home
components, are much more costly. For patients the cost of these products
can be a major impediment to their purchase and use, especially given that
insurance does not always provide adequate coverage for them.
In addition to cost, another significant barrier to the broader diffusion of these technologies is a lack of product information. Older adults
frequently do not have adequate information on the basic use of specific
devices, or the suitability of these devices to their specific needs (Hoenig
et al., 2002). Furthermore, patients often lack information about product
quality and performance. More technical assessments are needed to help
patients determine the effectiveness of various assistive technologies.
The IOM report The Future of Disability in America also noted that
the financial incentives for developing better assistive technologies and
bringing them to market are currently very weak (IOM, 2007). The report
concluded that this was a persistent problem and recommended a number
of countermeasures. Specifically, the report called upon policy makers to
revise coverage criteria so that the criteria take into account the contribution of a technology to an individual’s overall independence, including the
individual’s participation in the workforce and the community. The report
also recommended that policy makers eliminate or modify Medicare’s requirement of “in-home use” with respect to coverage of durable medical
equipment and that they investigate new approaches for supplying covered
technologies, as well as providing timely and appropriate repairs.
Recommendation 6-1: Federal agencies (including the Department of
Labor and the Department of Health and Human Services) should provide support for the development and promulgation of technological
advancements that could enhance an individual’s capacity to provide
care for older adults. This includes the use of activity-of-daily-living
(ADL) technologies and health information technologies, including
remote technologies, that increase the efficiency and safety of care and
caregiving.
In addition to testing the use of health-information technology to
improve provider communication and promote interdisciplinary care (as
described in Chapter 3), research and demonstrations also need to focus
on the application of assistive technologies. These demonstrations need to
assess the effectiveness of these technologies in promoting functional independence and in easing the physical strain on, and the need for, direct-care
workers and informal caregivers.
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INFORMAL CAREGIVERS
Informal caregivers2 may be relatives, friends, or neighbors who provide assistance related to an underlying physical or mental disability but
who are unpaid for those services. The motivation for providing this type
of assistance is, most commonly, emotional commitment and personal relationship. Public policy has traditionally viewed informal caregivers’ service
as a personal, moral obligation, and not as an extension of the workforce.
Partly as a result, research has not provided a systematic accounting of their
numbers, qualifications, and competence.
Families and friends of disabled older adults are the predominant providers of long-term care and in general are thought to provide task assistance
that is of low cost, high quality, and consistent with older adults’ preferences.
In addition to the home setting, many families provide support to older family members in assisted living facilities, nursing homes and low-income senior
housing and are key components in helping to manage resident decline (Ball
et al., 2004). The vast majority of care recipients report high levels of satisfaction with the assistance received from family and friends (Kasper et al., 2000;
McCann and Evans, 2002), and family members have been characterized
as being more responsive than paid helpers (Greene, 1983). However, for a
number of older adults—such as those who were never married and have no
children—informal caregivers are not available. Moreover, for a number of
reasons, the overall availability of informal caregivers is decreasing, which
has led to calls to increase the support that is provided to them.
While the average informal caregiver provides 20-25 hours of assistance
per week (Johnson and Wiener, 2006; National Alliance for Caregiving and
AARP, 2004), the intensity of help provided varies by disability level and
population subgroup. Spouses, women, co-residents, and caregivers who
support patients with dementia and end-of-life stages typically provide help
with greater frequency and intensity (Bertrand et al., 2006; Donelan et al.,
2002; Schulz et al., 2003b). Nearly 80 percent of adults who receive care
at home rely exclusively on unpaid help from family and friends, while less
than 10 percent received all of their care from paid workers (ILC-SCSHE
Taskforce, 2007). In other words, informal caregivers provide at least
some level of support for more than 90 percent of people receiving care at
home.
The unpaid services provided by informal caregivers have a substantial
economic value when compared against the payment rates that direct-care
workers receive. In fact, the value of informal home care vastly exceeds
the value of paid home care (AARP, 2007). Overall, the economic value
2 Informal
caregivers are also, at times, referred to as family caregivers. For consistency, the
term “informal caregivers” is used throughout this report.
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RETOOLING FOR AN AGING AMERICA
derived by informal caregivers’ collective involvement and time is easily in
the tens to hundreds of billions of dollars annually. Arno estimates that informal caregivers’ contribution to the workforce in 2004 was $306 billion,
almost twice the amount spent on home-care and nursing-home services
combined ($158 billion) (Arno, 2006). Similarly, the AARP calculated that
the value of caregiver services had an economic value of $350 billion in
2006 (AARP, 2007). Questions remain about these numbers, however, as
there are several difficult methodological challenges involved in making the
estimates (see below).
The following sections describe the size and composition of the informal caregiver population in the United States, the responsibilities they
assume and the specific tasks they perform, the effect they have on patient
outcomes, and possible supports that might be provided to them, such
as increased training to help to promote greater competency among this
group.
Size and Composition
Estimates of the number of informal caregivers in the United States
vary widely depending upon the data source and methodology. The most
commonly cited figures indicate that there are between 29 million and 52
million unpaid caregivers nationally, which represents as many as 31 percent of all adults in the United States. Using data derived from population
estimates from two national surveys (the Survey on Income and Program
Participation and the National Survey of Families and Households), Arno
found that in 2004 there were 29 million Americans providing informal
care services (Arno, 2006). AARP estimates that between 30 million and
38 million people above the age of 18 provide care to an adult who has
an ADL or IADL limitation (AARP, 2007). An earlier study conducted by
the Assistant Secretary for Planning and Evaluation (ASPE) and the Administration on Aging (AOA) using broader criteria found that each year
52 million Americans (31 percent of the adult population aged 20 to 75)
provide informal care to a family member or friend who is ill or disabled
(ASPE and AOA, 1998).
National surveys and observational data sets show that informal caregivers for older adults are predominantly spouses or middle-aged daughters
(Johnson and Wiener, 2006; Spillman and Pezzin, 2000). Married older
adults tend to depend on their spouses, while unmarried individuals most
likely rely on an adult child (Barrett and Lynch, 1999; Soldo et al., 1990).
Adult daughters have traditionally served as the primary caregivers of frail
unmarried adults (Johnson and Lo Sasso, 2006). Despite the perception
that many people actively provide care to an older adult while concurrently
raising children (the “sandwich generation”), household surveys indicate
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that such caregivers are actually few in number because most people old
enough to have very elderly parents are too old to have young children
(Spillman and Pezzin, 2000; Wolff and Kasper, 2006). Individuals who
actively provide assistance to an older adult while simultaneously working
are substantially greater in number, representing more than half of all adult
child caregivers (Johnson and Wiener, 2006).
Methodologies
Estimates for the numbers of informal caregivers for older adults in the
United States depend on how these caregivers are defined and identified.
In contrast to the results cited above, household surveys that use a narrower definition of caregiving examine only the care provided to a more
narrowly defined group of disabled older adults, and use much shorter
time-frames for providing care yield substantially smaller estimates of the
number of family caregivers. For example, several iterations of the National
Long-Term Care Survey (NLTCS) found 3.8 million to 4.4 million informal caregivers assisting a disabled older adult in the week prior to being
interviewed (Spillman and Pezzin, 2000). However, informal caregivers who
are assisting older adults because of an acute-onset illness, who assist for
a brief period of time prior to death, or who assist older adults residing in
institutional long-term care facilities are likely to be underrepresented in
many estimates.
AARP identified five publications released between 2004 and 2006 that
were based on nationally representative surveys and that included estimates
of the number of caregivers in the United States. Table 6-1 describes the
sources of data that were used for each publication and the way in which
the term caregiver was defined. Because of the differing definitions of
caregiving in the different survey instruments, the differing ages of care
recipients, and the various dates of the surveys, the number of caregivers
reported is not directly comparable across sources.
Recent Trends
For a variety of reasons, the overall availability of informal caregivers
is decreasing (Wolff and Kasper, 2006). The factors contributing to this
trend include the entry of more women into the workforce (increasing the
number of other obligations they face), decreased birth rates (resulting in
fewer children available to provide care), and the geographic dispersion of
families (stemming from job migration and increased divorce and remarriage rates) (Fleming et al., 2003; Stone, 2000).
The demographic make-up of informal caregivers is also changing,
reflecting various health and demographic trends among older adults. For
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TABLE 6-1 Recent Studies Giving Estimates of Caregiving Prevalence
and/or Hours
Publication
Source Data and Year
Caregiver Definition
Estimated Prevalence and
Economic Value of Family
Caregiving, by State (2004)
(National Family Caregivers
Association & Family
Caregiver Alliance, 2006).
Estimates for 2004,
updated from 1986 Survey
of Income and Program
Participation (SIPP) and
1987-1988 National Survey
of Families and Households
(NSFH)
SIPP: Care recipient 15+, with
health condition, caregiver
15+, within last month;
NSFH: Care recipient 18+,
caregiver 18+, with long-term
illness or disability, within last
month
Many Older Americas
Engage in Caregiving
Activities (Johnson and
Schaner, 2005).
2002 Health and Retirement Care recipient any age,
Study
caregiver 55+, within last
month (for care of spouse)
or last 2 years (for care of
parents/in-laws)
A Profile of Frail Older
Americans and Their
Caregivers (Johnson and
Wiener, 2006).
2002 Health and Retirement Care recipient 65+, ADL or
Study
IADL dependency, caregiver
18+, within last month
Caregiving: A National
Profile and Assessment
of Caregiver Services and
Needs (McKune et al.,
2006).
2000 Behavioral Risk
Factor Surveillance System
Care recipient 60+, with
long-term illness or disability,
caregiver 18+, within last
month
Caregiving in the U.S.
(National Alliance for
Caregiving and AARP,
2004).
Survey designed for the
publication, 2003
Care recipient 18+, ADL or
IADL dependency, caregiver
18+, within last year
SOURCE: AARP, 2007.
example, spousal caregivers are increasingly older themselves. The proportion of spousal primary caregivers who are aged 75 and above increased
from 38 percent in 1989 to 47 percent in 1999 (Wolff and Kasper, 2006).
Given the increasing ages of care recipients and their spouses, children
are fulfilling the role of primary caregiver more and more often (Spillman
and Black, 2005; Wolff and Kasper, 2006). This trend may at least partly
explain why the data show declines in secondary caregiving, as adult children who previously filled in as secondary caregivers now find themselves
assuming principal responsibility. Spillman found that the declines in aggregate numbers of informal caregivers between 1984 and 1994 were largely
attributed to a drop from 1.7 million to 1.1 million individuals serving as
secondary caregivers, with no evidence to suggest fewer primary caregivers
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(Spillman and Pezzin, 2000). Another study found that in 1999 just 28 percent of primary caregivers received assistance from other family members
and friends, a decline from 39 percent in 1989 (Wolff and Kasper, 2006). A
number of studies found that during the decade ending in 1994, chronically
disabled older adults increasingly relied on paid care (Liu et al., 2000). In
many cases, however, primary caregivers simply “go it alone.” In 1999, 53
percent of primary caregivers were the exclusive source of assistance, compared to just 35 percent of primary caregivers in 1989 (Wolff and Kasper,
2006). Primary caregivers with no secondary caregiver involvement were
most likely to be caring for the least impaired recipients and least likely to
be caring for the most disabled.
Tasks and Responsibilities
Informal caregivers assume many different responsibilities in providing
care support for older adults (Table 6-2). In performing these functions,
they in effect take on the roles of both patient and provider. On the one
hand, they take responsibility for much of the patient’s role with respect
to logistics, care management, and medical decision-making. For example,
they often schedule medical appointments for older adults, provide transportation, and handle billing questions. They assume greater responsibility
in presenting the patient’s history and listening to the clinicians’ assessments
and instructions. They frequently make, or influence, decisions regarding
the appropriate course of treatment. They also take on a health status
monitoring function, as envisioned under the self-management paradigm
described previously. On the other hand, caregivers also take on the role
of health care provider, performing many of the functions that direct-care
workers perform on a paid basis, including support with ADLs and IADLs.
The sections below detail several of these roles.
Activities of Daily Living and Instrumental Activities of Daily Living
Informal caregivers provide older adults with help in performing
ADLs—typically bathing, dressing, eating, toileting, and transferring—and
IADLs, such as shopping, meal preparation, money management, light
housework, and laundry. Data from the NLTCS and its Informal Caregivers
Survey indicate that caregivers commonly assist with the full range of these
tasks. In one study, large percentages of primary caregivers reported helping
chronically disabled older adults with shopping and/or transportation (85.3
percent), household tasks (77.7 percent), finances (49.4 percent), personal
care and nursing (48.5 percent), and indoor mobility (35.1 percent) (Wolff
and Kasper, 2006). A substantial portion of informal caregivers (43-53 per-
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TABLE 6-2 Health-Related Responsibilities Assumed by Informal
Caregivers
Role
Function
Examples
Companion
Provide emotional
support
Discuss ongoing life challenges, troubleshoot problems,
facilitate and participate in leisure activities
Coach
Encourage patient
self-care activities
Prompt patient’s engagement in health care, encourage
lifestyle (diet, exercise) and treatment adherence
Homemaker
Manage household
activities
Inventory, purchase food and medications, prepare
meals
Scheduler
Arrange medical
care
Schedule tests, procedures, and services
Driver
Facilitate
transportation
Provide transportation to medical appointments and
emergency hospital visits
Patient
extender
Facilitate provider
understanding
Attend appointments; clarify and expand on patient
history, symptoms, concerns; introduce topics to
provider
Technical
interpreter
Facilitate patient
understanding
Clarify providers’ explanations, technical terms, record
and remember discussions with providers
Decision
maker
Make medical
decisions
Select among treatment alternatives; decide among
settings of care
Coordinator
Coordinate care
across providers
and settings
Ensure flow of information among providers
Financial
manager
Handle financial
issues
Resolve issues relating to insurance claims, secondary
coverage, co-pays, and benefit limits
Health
provider
Deliver medical
care
Administer medications, operate equipment
Attendant
Provide task
assistance
Hands-on personal care task assistance
Monitor
Assess health
status
Ensure that changes in health status are noted and
properly addressed
SOURCE: Wolff, 2007.
cent) also fulfill medically oriented tasks such as helping with wound care,
injections, equipment, or medication administration (Wolff and Kasper,
2006). A study following stroke and traumatic brain injury patients and
their caregivers from hospital discharge found that during the home health
period, families provided three-fourths of total patient care hours (Levine
et al., 2006).
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Other Support Roles
Informal caregivers frequently coordinate and arrange medical appointments for older adults. In fact, the time that they spend performing this
function has given rise to a new line of elder care referral services, which
employers have begun to offer as a way to save lost work time among employees. Caregivers frequently accompany older patients to office visits, and
they are often involved in treatment decisions (Deimling et al., 1990; Kapp,
1991), particularly those involving patients who are older and who carry a
greater disease burden (Ende et al., 1989; Ishikawa et al., 2005). In the case
of critically ill and hospitalized patients, families and friends are often kept
apprised of the patient’s health status, they advocate for needed services
and attention, and they provide patients with emotional support (Hickey,
1990). Family may also assume a role in coordinating patient transitions
across settings of care—for example, from hospital to home (Coleman,
2003; DesRoches et al., 2002). In addition, as providers of assistance to
frail older adults with physical and cognitive disabilities, informal caregivers often help to ensure the safety of the home environment.
When older adults do not speak English, health care providers often
ask family members or friends to interpret. In fact, it is estimated that 79
percent of hospitals frequently rely on family and friends to serve as interpreters (Wilson-Stronks and Galvez, 2007). This practice risks misinterpretation and the transmission of inaccurate information, especially when
the translators are young children. As a result, recent state laws prevent
using the family for this purpose and several organizations have developed
reports and guidelines about how to implement language services in health
care organizations.
Still, the knowledge that family members have about the patient and
their ability to articulate this knowledge allow them to advocate on the
patient’s behalf and to enhance the provider’s understanding of the older
adult’s social environment, health conditions, and care preferences. Similarly, family members’ understanding of the providers’ treatment recommendations and their ongoing interactions with the patient at home and in
the community can influence the patient’s behaviors, treatment adherence,
and health.
Impact on Outcomes
There is strong evidence that informal caregivers have a profound effect on long-term care processes and outcomes. Engaging families in patient
care has been shown to improve outcomes in dementia (Mittelman et al.,
2006; Vickrey et al., 2006) and in schizophrenia care (Glynn et al., 2006)
and also to postpone institutionalization (Miller and Weissert, 2000; Yoo et
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al., 2004). Yet while there is growing recognition of the relevance of family involvement to health care delivery processes (Fisher and Weihs, 2000),
there is still little knowledge about which particular attributes of family
involvement are efficacious in improving health outcomes.
Older adults strongly prefer independent living (Kasper et al., 2000)
and are highly averse to nursing-home placement (Mattimore et al., 1997).
Caregiver support may allow older people to remain in their communities
in cases where it would not otherwise be possible otherwise and the importance of informal caregivers in reducing the risk of nursing home entry is
well documented (Miller and Weissert, 2000). In addition, the availability
of family has been linked to shorter lengths of hospital stays (McClaran
et al., 1996; Picone et al., 2003). The converse is also true, that is, that
an absence of adequate caregiving is associated with problematic hospital
discharges (Procter et al., 2001) and readmissions (Lotus Shyu et al., 2004;
Schwarz and Elman, 2003).
Living alone is associated with greater risk of nursing home entry,
while, conversely, greater familial and caregiver support is associated with
a lower likelihood (Miller and Weissert, 2000; Muramatsu et al., 2007).
Individuals with few social supports are more likely to have unmet needs
in personal care and household tasks (Kennedy, 2001; Lima and Allen,
2001) and are also more likely to miss medical appointments and to fail to
fill prescriptions (Allen and Mor, 1997). One study found that unmarried
individuals present to the hospital with a greater severity of illness than do
their married peers, suggesting that the presence of a spouse leads to admission at an earlier stage of illness (Gordon and Rosenthal, 1995).
The availability and preparedness of informal caregivers can also influence where patients receive their post-acute care following hospitalization
and also the course of their recovery (Kane et al., 2000; Weinberg et al.,
2007). A meta-analysis of 122 studies found that patients who received
instrumental assistance were 3.6 times more likely to adhere to medical
instructions and prescriptions. This was twice as effective as emotional support, which was associated with 1.8 times greater likelihood of adherence
(DiMatteo, 2004). The effect of family support varies, however; individuals
with close and cohesive families are three times more likely to adhere to
instructions than those from conflicted families.
Training
Along with the increasing awareness of the role that family and friends
play in the provision of ongoing chronic care, there has been a growing
understanding of the potential benefits of educating these informal caregivers and integrating them more fully into the health care delivery team.
While it is clear that caregivers are able to provide a tremendous amount
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of support to older adults, the extent to which they are prepared for the
role they assume remains unknown. For example, according to one national
survey, nearly one in five informal caregivers who assisted with medication
management had received no instruction from a health care professional
regarding how to perform this task; for those who assisted with changing
dressings or bandages, one in three had received no training (Donelan et
al., 2002).
As home-based medical technologies have become widely diffused, they
have expanded the range of services that may be provided to technologydependent patients in the community, including at-home parenteral nutrition (i.e., intravenous feeding), intravenous medication infusion, peritoneal
dialysis, mechanical ventilation, and apnea monitoring. Yet there has been
little attention directed toward identifying, developing, and disseminating
the education and training needed to provide patients and caregivers with
the skills and knowledge they need to operate sophisticated equipment and
to manage complex treatment regimens (Given et al., 2001; Thielemann,
2000). Not surprisingly, studies find that informal caregivers perceive themselves as insufficiently prepared to assist with complex home-based technologies (Silver et al., 2004; Winkler et al., 2006) and medically-oriented
treatments in the post-acute period (DesRoches et al., 2002; Mackenzie et
al., 2007). This is also true of more basic tasks, such as lifting, turning,
feeding, and helping those with Alzheimer’s disease.
To improve the care that older patients receive in private settings and
to support informal caregivers who are often ill-equipped to perform the
necessary medical tasks, the committee recommends that more training opportunities be made available.
Recommendation 6-2: Public, private, and community organizations
should provide funding and ensure that adequate training opportunities
are available in the community for informal caregivers.
These initiatives may be modeled after those provided by the AOA,
which has established a program to assist caregivers in making decisions
and solving problems related to their roles. Other potential models include
programs developed by the Centers for Medicare and Medicaid Services
(CMS), the Health Resources and Services Administration (HRSA), and
Geriatric Education Centers. The committee suggests that state attorneys
general recognize these types of caregiver training initiatives as an option
by which non-profit hospitals can satisfy their requirements for providing
benefits to their local communities in exchange for tax-exempt status.
A number of reviews and meta-analyses have synthesized findings from
training initiatives aimed at caregivers for patients with various diseases,
including stroke (Lee et al., 2007), cancer (Harding and Higginson, 2003),
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and dementia (Pinquart and Sorensen, 2006). Sorensen and colleagues identified a number of different approaches to supporting caregivers, including
education about ways to reduce stress, supportive interventions, psychotherapy, patient day care, and training of the care recipient (Sorensen et
al., 2002). Findings indicate that such interventions have a positive, albeit
small effect for several outcomes, most notably caregiver depression, strain,
and burden (Sorensen et al., 2002). There is a growing consensus that the
most successful interventions are comprehensive and individually tailored,
actively engage both caregivers and recipients, and provide a combination
of education, skills, and coping techniques (Brodaty et al., 2003; GallagherThompson and Coon, 2007).
An intervention in the United Kingdom that trained the informal caregivers of hospitalized stroke patients in basic nursing and personal-care
tasks achieved decreases in caregivers’ reported burden, anxiety, and depression (Kalra et al., 2004). And while patients’ mortality, institutional
placement, and disability outcomes remained comparable, annual health
care costs for the intervention group were lower by more than £4000
(roughly $8,000), largely due to shorter hospital lengths of stay (Patel et
al., 2004). A multi-component counseling and support group intervention
for spouses of dementia patients was found to reduce caregivers’ depressive
symptoms (Mittelman et al., 2004) and to delay recipients’ nursing-home
entry by more than 1 year (Mittelman et al., 2006).
Lastly, the Resources for Enhancing Alzheimer’s Caregiver Health
(REACH) study was an ambitious program that enrolled a diverse group
of 1,222 dementia caregivers at six intervention sites (Schulz et al., 2003a).
Nine active interventions were tested, and a coordinating center developed
standard eligibility protocols and measurement procedures. After 6 months,
the study found small but statistically significant improvements for measures of caregiver burden and, in one site, caregiver depression (Gitlin et al.,
2003). An extension of the study found statistically significant and clinically
important improvements in measures of caregivers’ quality of life (including
depression) but not in institutionalization (Belle et al., 2006).
Integration with Medical Team
A more explicit recognition of informal caregivers as providers and
partners in health care processes could benefit both patients and caregivers
in the management of the health needs of older adults in the community.
One aspect of patient-centered care described by the IOM report Crossing
the Quality Chasm is that providers should “focus on accommodating family and friends on whom patients may rely, involving them as appropriate
in decision making, supporting them as caregivers, making them welcome
and comfortable in the care-delivery setting, and recognizing their needs
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PATIENTS AND INFORMAL CAREGIVERS
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and contributions” (IOM, 2001). Exactly when and how providers need to
incorporate the family into health care processes is not yet well understood,
but such incorporation is relevant across the full spectrum of institutional,
ambulatory, and residential patient-care settings.
Despite the potential benefits to older patients of enhancing communication among their many care providers (formal and informal), such coordination has yet to receive adequate attention. Family members describe
a “vortex” of uncertainty and frustration resulting from the medical community’s poor communication and unease with their presence (Kirchhoff
et al., 2002; Teno et al., 2004). The Health Insurance Portability and Accountability Act (HIPAA)3 has further exacerbated this situation by limiting
families’ access to information.
In assuming specific tasks and responsibilities, informal caregivers become part of the health care delivery team and contribute directly to health
outcomes, although this is not always recognized in the health care community. For example, caregivers play a role in promoting patient adherence
to medications, ensuring medication safety, and reducing the likelihood of
adverse drug events. One large cohort study of Medicare beneficiaries who
were treated within a multi-specialty group practice found some 20 percent
of serious adverse drug events in the ambulatory setting to be potentially
avoidable; they were caused by such mistakes as taking the wrong dose,
continuance of medication despite instructions by the physician to discontinue drug therapy, and continuance despite recognition of an adverse
effect or drug interaction (Gurwitz et al., 2003). The authors noted that in
the ambulatory setting, unlike the situation with institutional care, it is the
patient—and often the patient’s family members—who are responsible for
adherence to medical instructions.
Despite this, there have been few patient safety innovations that have
explicitly included the family as an ally in monitoring changes in treatment regimens or symptoms. Electronic personal health records could give
informal caregivers improved access to patient information and provide a
convenient method for them to communicate with the patient’s health care
team online (Seavey, 2005). These electronic records could also provide
decision support for common problems and help older adults in managing
their conditions at home. The Veterans Administration’s HealtheVet record
system provides an example of this type of electronic support. The system
provides veterans with access to the data in their health record, advice on
steps they can take improve their health condition, and a means to selfenter structured medical information (MyhealtheVet, 2008). Establishing
better linkages between the medical care team and informal caregivers is
3 Health
Insurance Portability and Accountability Act of 1996. Public Law 191. 104th
Congress. August 21, 1996.
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potentially beneficial for both older adults and caregivers. The Rosalynn
Carter Institute for Caregiving has sought to do this by bringing paid and
informal caregivers together to learn about caregiving issues, share ways to
work together more effectively, and gain a greater understanding of each
other’s perspectives. Informal caregivers place high value on both the emotional support that is provided through friendships with home-care workers
and also these workers’ affirmation of their caregiver efforts (Piercy and
Dunkley, 2004). Medicare reimbursement changes have been proposed that
would create a more integrated system in which direct-care workers would
be paid to assess the caregiving needs of families, observe their caregiving
skills, and teach them to perform various, duties such as ambulation and
comfort care (Seavey, 2005).
Additional Supports
Taking on the role of informal caregiver has been found to increase
the risk of elevated stress hormones (Kiecolt-Glaser et al., 2003; Vitaliano
et al., 2003), make physical illness and psychological distress more likely
(Emanuel et al., 2000; Pinquart and Sorensen, 2003), and raise mortality
rates (Christakis and Allison, 2006). Caregivers may have to provide constant care day and night, may be unable to leave the recipient alone, and
may even have to provide assistance despite their own physical illness or
impairments; such requirements can affect the caregiver in various ways, including causing interrupted sleep, physical strain, and emotional and financial difficulties (Wolff et al., 2007). Longitudinal studies of spouses find that
both the assumption of the role of informal caregiver and the continuing
long-term provision of high-intensity care are associated with downward
trajectories in terms of depression (Burton et al., 2003; Cannuscio et al.,
2002), social participation, and quality of the marital relationship (Seltzer
and Li, 2000). In spite of this, many informal caregivers are able to adapt
and derive personal benefits from their role (Kramer, 1997; Stuckey et al.,
1996).
Given the demonstrated importance of informal caregivers to older
adults and to society, and given the personal costs that may accompany
the role, there has been considerable interest in how it might be possible
to improve informal caregivers’ experiences and outcomes. A large number of caregiver interventions have been developed, with a large range of
strategies, services, and target populations. Programs have been established
to provide caregivers with greater education and training, strengthened
partnerships with the medical community, and a number of other types
of aid including respite care, web-based monitoring systems, technologies
that reduce physical strain, and financial supports. Several health services
interventions targeted specifically at older caregivers have proven to benefit
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both their health (Silliman et al., 1990) and their well-being (Hughes et al.,
2000; Weuve et al., 2000).
In recent years there has been a significant amount of legislation at the
state and federal levels aimed at providing various types of aid to family
caregivers. According to one accounting, between 2004 and 2006 over
100 bills to assist informal caregivers were introduced in 32 states and
at the federal level, typically focusing on increased tax incentives, family
and medical leave provisions, and respite care supports. Of those, 21 were
passed—16 bills in 13 states and 5 in the U.S. Congress (FCA, 2007).
The National Family Caregiver Support Program (NFCSP), initiated
under the Older Americans Act Amendments of 2000, is the first—and so
far only—federally funded program intended specifically to assist informal
caregivers of older adults. The program funds state initiatives for such
things as information dissemination, organization of support groups, and
the provision of individual counseling, training, respite care, and other
supplemental services. The NFCSP is implemented at the state level in partnership with area agencies on aging and local-area service providers. States
have considerable discretion in the design and delivery of the program, and
eligibility, service offerings, methods of compensation, and approaches to
accessing services vary widely across states, and in some cases, within states
(Feinberg and Newman, 2004, 2006). The program expanded the range of
service offerings to family caregivers, but its modest funding ($162 million
in 2007) has resulted in geographic disparities and gaps in service availability (AOA, 2007).
The Lifespan Respite Care Bill4 was passed by both branches of the
Congress and signed into law by President Bush in December 2006, but it
has not yet received federal appropriations. The objective of the program
is to allow states to develop a network of respite care providers that will
provide family caregivers with high-quality planned and emergency respite
services. There have been discussions of an appropriation of $10 million
for fiscal year 2008, which would be substantially more limited in scale and
scope than the $289 million authorized over 5 years.
Under Medicaid, the movement toward patient-directed care—in which
decision-making responsibility shifts from health professionals to patients—
is a trend that has implications for informal caregivers. State Cash and
Counseling programs (see Chapter 3) give Medicaid recipients a monthly
allowance to hire the providers of their choice and provide counseling and
financial assistance to help them in planning and managing these responsibilities. Many of these state programs permit Medicaid recipients to hire
4 Lifespan
Respite Care Act of 2006. Public Law 442. 109th Congress. December 21,
2006.
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immediate family members to perform caregiving services for pay, as well
as the option to use that money to hire direct-care workers.
These types of consumer-directed programs raise a number of issues,
such as their potential impact on direct-care workers, who typically receive
even lower pay, fewer benefits, and little or no training or supervision relative to workers hired through an agency (Benjamin and Matthias, 2004).
Overall, though, differences in the levels of job stress and satisfaction are
thought to be minor, the experiences of patient-directed workers tended to
more positive (Benjamin and Matthias, 2004; Foster et al., 2007). Moreover, informal caregivers were shown in one study to be more satisfied
with the Medicaid recipients’ overall care and their own lives, as compared
to a control group, and, that they experienced less financial and physical
strain (Foster et al., 2007). In addition, states have put in place a number
of measures to improve the basic functioning of the program, such as processing payroll for directly-hired workers in accordance with tax laws and
providing training and assistance to Medicaid recipients, or their designees,
in recruiting, hiring, training, managing, evaluating, and dismissing workers
(Cash & Counseling, 2006).
While a number of programs and policies either directly target, or
indirectly influence, the well-being of informal caregivers, the supportive
programs that exist are generally small, poorly funded, and fragmented
across the federal, state, and local levels. The sections below highlight the
three areas in which caregivers frequently request additional support: training, respite, and financial assistance.
Training
Informal caregivers are often required to perform a number of functions for which they may feel inadequately prepared. As described previously, this can include basic tasks such as lifting and turning, medical tasks
such as administering medications and injections, and the use of technologies such as mechanical ventilation. Instruction in how to perform these
types of tasks would not only improve patient care, but it would also reduce
the stress and burden placed on caregivers.
Medicare does not currently include any provisions to help informal
caregivers get the education and training they need to competently assist
beneficiaries in the post-discharge period. Direct-care workers might be
able to perform this function, for instance, but they do not currently receive
reimbursement for it. Some have proposed establishing a national training
center that would identify and disseminate best practices, provide training,
and evaluate approaches to improving caregiver competence. Such an effort
would combine the available research with current practices in caregiver
assessment and education.
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To the extent that an older adult is dependent on an informal caregiver—
for example, in transitioning from hospital to home—clinicians need to
explicitly assess the caregiver’s abilities, needs, and competence to perform
the required tasks. Thus developing methodologically rigorous caregiver assessment tools is a necessary first step toward the routine use of these tools
in clinical practice and, eventually, toward developing effective programs
to prepare caregivers for their roles.
Respite
Respite is among the most common requests of informal caregivers
(Jenson and Jacobzone, 2000), and ensuring that it becomes more widely
available is one of the goals of the National Family Caregiver Support
Program and Lifespan Respite Care Bill. At present, support services for
informal caregivers, including respite care, are delivered mainly by state
and local agencies. This approach has the advantage that it makes it easier
to customize services to accommodate various characteristics of geographic
and cultural subgroups, but the resulting variation creates complexity in the
system overall (Feinberg and Newman, 2006; Stone and Keigher, 1994).
Policy makers have considered establishing a defined, national respite
care benefit program for informal caregivers. A number of decisions would
have to be made about the design of such a national program, including
the size and the structure of the benefits (e.g., service voucher versus cash
allowance, and whether the benefit needs to be uniform or needs to vary
according to the severity of the recipient’s disability) and the particulars of
the eligibility criteria (e.g., whether the benefit needs to be means-tested
and whether it needs to be restricted to certain categories of caregivers).
Although the specific provisions vary widely, a number of other countries
have adopted formal respite-care programs for informal caregivers, either
as part of comprehensive long-term care reform (e.g., Germany and Japan)
or as freestanding caregiver programs (e.g., Canada and Australia) (Jenson
and Jacobzone, 2000).
As the predominant health insurance program of older Americans,
Medicare is relevant to—and, in many ways, reliant upon—informal caregivers. Yet aside from covering respite care through the hospice benefit,
the Medicare program does not currently consider informal caregivers in
formal policy.
Financial Assistance
Providing financial assistance to family members acting as caregivers
could have a negative effect on employment and may also have financial
ramifications for the caregivers themselves. Studies indicate that some fam-
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ily members acting as caregivers quit their jobs or take time off work, are
forced to take out loans or mortgages, or make other life changes in order
to be able to provide assistance (Covinsky et al., 2001; Emanuel et al.,
2000). In one study of severely ill patients of all ages, 31 percent of families reported that most of their family savings were lost; smaller numbers
of families reported having to move to a less expensive home (6 percent),
delay medical care (6 percent), or alter educational plans for another family
member (4 percent) because of the cost of patients’ illness (Covinsky et al.,
1994). Adult daughter caregivers have been shown to reduce their own labor participation or leave the workforce entirely (Ettner, 1995; Johnson and
Lo Sasso, 2006). And the opportunity costs related to caregiving, including
foregone earnings, retirement savings, and employer-sponsored benefits,
may actually exceed the direct costs, such as the time spent in direct care,
out-of-pocket expenses, and costs associated with adverse health effects
(Moore et al., 2001).
The existence of these opportunity costs makes it even more important
to come up with effective policies to promote financial, retirement, and
health care security for informal caregivers who leave the workforce to care
for an older adult. Among the strategies that have been considered are tax
incentives (including credits, deductions, or exemptions), cash allowances,
and provisions that allow an accumulation of Social Security credits for
caregivers. Employer-based approaches have focused, among other things,
on restructuring the workplace to facilitate greater flexibility, the provision
of family and medical leave, access to supportive services such as adult
day care, and the availability of tax-deductible dependent-care assistance
programs. And given the high costs and difficulty that individuals face in
getting health insurance outside of the workplace, some have suggested
providing caregivers with government-assured access to coverage through
measures such as broadening Medicare eligibility to include informal caregivers for older adults.
There are limited data with which to assess the relative merits of these
options. One report examined how several countries’ informal caregiver
programs affected women and found that caregiver allowances as typically
implemented did not approach a labor market wage (Jenson and Jacobzone,
2000). Instead of focusing on short-term strategies such as tax credits or
allowances, that report advocated greater emphasis on longer-term compensatory strategies such as pension rights. Several states offer tax incentives
for family caregiving (Stone and Keigher, 1994), which may be structured
in a variety of ways. As some tax incentives may benefit higher-income
families (Keefe and Fancey, 1999; Stone and Keigher, 1994), the establishment of any federal policy requires careful deliberation. While the evidence
is far from definitive, the limited empirical data indicate that the magnitude
of relief afforded to informal caregivers through existing programs and
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PATIENTS AND INFORMAL CAREGIVERS
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policies is largely symbolic rather than meaningful (Jenson and Jacobzone,
2000). Research in this area is critically important and is a task that could
be undertaken by a national center spanning multiple disciplines and federal
agencies.
As described in Chapter 3, the committee recommends that the Congress and private foundations increase support for research that promotes
the effective use of the workforce to care for older persons. One important
topic that needs to be investigated through research is the effect of financial
incentives on informal caregiving.
CONCLUSION
Patients and informal caregivers play a substantial, but often underappreciated, role in the health care delivery process. Their roles will be even
more substantial in the future, given the rising incidence of chronic disease,
which requires greater self-monitoring on the part of patients, and the rapidly increasing number of older Americans, which will place greater responsibilities on family and friends to provide care assistance. Informal, unpaid
caregiving is an essential component of an optimal health care workforce
for an aging population. However, the trend toward fewer informal caregivers at a time when the number of older persons is expanding underscores
the importance of identifying effective strategies to support informal caregivers, such as offering them increased training opportunities. It will also
be important to develop and distribute technologies that promote greater
independent functioning among older adults and reduce their reliance on
the direct-care workforce and on informal caregivers.
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appendix
A
Committee Biographies
John W. Rowe, M.D. (Chair), is a Professor in the Department of Health
Policy and Management at the Columbia University Mailman School of
Public Health. From 2000 until late 2006, Dr. Rowe served as Chairman
and CEO of Aetna, Inc, one of the nation’s leading health care and related
benefits organizations. Before his tenure at Aetna, from 1998 to 2000, Dr.
Rowe served as President and Chief Executive Officer of Mount Sinai NYU
Health, one of the nation’s largest academic health care organizations. From
1988 to 1998, prior to the Mount Sinai-NYU Health merger, Dr. Rowe
was President of the Mount Sinai Hospital and the Mount Sinai School of
Medicine in New York City. Before joining Mount Sinai, Dr. Rowe was a
Professor of Medicine and the founding Director of the Division on Aging
at the Harvard Medical School, as well as Chief of Gerontology at Boston’s
Beth Israel Hospital. Dr. Rowe has received many honors and awards for
his research and health policy efforts regarding care of the elderly. He was
Director of the MacArthur Foundation Research Network on Successful
Aging and currently leads the MacArthur Foundation’s Research Network
on An Aging Society. Dr. Rowe was elected a member of the Institute of
Medicine of the National Academies and a Fellow of the American Academy of Arts and Sciences and a Trustee of the Rockefeller Foundation and
Lincoln Center Theater.
Paula G. Allen-Meares, B.S., M.S.W., Ph.D., is Dean, Norma Radin Collegiate Professor of Social Work, and Professor of Education at the University
of Michigan. Research interests include the tasks and functions of social
workers employed in educational settings; psychopathology in children,
271
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adolescents, and families; adolescent sexuality; premature parenthood; and
various aspects of social work practice. She is the principal investigator of
the School’s Global Program on Youth, an initiative supported by the W.K.
Kellogg Foundation; co-principal investigator of the NIMH Social Work
Research Center on Poverty, Risk, and Mental Health; and a co-investigator
on an NIMH research grant. Dean Allen-Meares serves on several editorial
boards, as well as national professional and scientific committees promoting the intellectual and empirical advancement of the profession. She is a
past member of the Institute for Advancement of Social Work Research,
Treasurer of the Council on Social Work Education, Chair of the Publication Committee for the National Association of Social Workers, and Vice
President for the National Association of Deans and Directors of Social
Work. Dean Allen-Meares serves as a member of the Board of Trustees of
the William T. Grant Foundation, and has served as President of the Society
for Social Work and Research and a University of Michigan Senior Fellow.
She is presently appointed to the New York Academy of Medicine’s panel
on long-term care issues in the United States and is a member of the Institute of Medicine of the National Academies. Dean Allen Meares serves on
numerous committees at the University of Michigan that promote interdisciplinary research and instruction, fundraising, and diversity. Other areas
of research/scholarly interest include school social work, racial issues, social
work practice, and mental health.
Stuart H. Altman, Ph.D., is the Dean and Sol C. Chaikin Professor of
National Health Policy at the Heller School for Social Policy and Management, Brandeis University. He served as dean of the Heller School from
1977 to a 1993; and, in August 2005, he again assumed the deanship of
the Heller School. Professor Altman has had extensive experience with the
federal government, serving as Deputy Assistant Secretary for Planning
and Evaluation/Health in the U.S. Department of Health, Education, and
Welfare, 1971-1976; as the chairman of the congressionally-mandated Prospective Payment Assessment Commission, 1983-1996; and, as a member
of the Bipartisan Commission on the Future of Medicare, 1999-2001. In
addition, from 1973 to 1974, he served as Deputy Director for Health of
the President’s Cost-of-Living Council and was responsible for developing
the council’s program on health care cost containment. Dean Altman has
testified before various congressional committees on the problems of rising
health care costs, Medicare reform, and the need to create a national health
insurance for the United States. He chaired the Institute of Medicine’s
Committee on the Changing Market, Managed Care, and the Future Viability of Safety Net Providers. His research activities include several studies
concerning the factors causing the recent increases in the use of emergency
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APPENDIX A
273
rooms. He holds a Ph.D. in economics from the University of California,
Los Angeles, and has taught at Brown University and the University of
California, Berkeley.
Marie A. Bernard, M.D., is the Donald W. Reynolds Chair in Geriatric Medicine, and Professor and Chairman of the Reynolds Department of Geriatrics
at the University of Oklahoma College of Medicine. She also serves as the
Associate Chief of Staff for Geriatrics and Extended Care at the Oklahoma
City Veterans Affairs Medical Center. She is President of the Association of
Directors of Geriatric Academic Programs, President of the Association for
Gerontology in Higher Education, and Past-Chair of the Clinical Medicine
Section of the Gerontological Society of America. Dr. Bernard’s research
interests include nutrition and function in aging populations, with particular
emphasis upon ethnic minorities. She serves on the following national committees: Chair, National Research Advisory Council, Department of Veterans
Affairs; Board of Directors, American Geriatrics Society; Board of Directors,
Alliance for Aging Research; Board of Directors, International Longevity
Center; Editorial Board, Journal of Gerontology—Medical Sciences; Editorial Board, Geriatrics. She recently completed a 4-year term on the National
Advisory Council on Aging of the National Institute of Aging (2001-2005),
during which time she chaired the Minority Task Force (2004-2005).
David Blumenthal, M.D., M.P.P., is Director, Institute for Health Policy and
Physician at Massachusetts General Hospital/Partners HealthCare System
in Boston, Massachusetts. He is also Samuel O. Thier Professor of Medicine
and Professor of Health Care Policy at Harvard Medical School. He is a
member of the Institute of Medicine, a National Associate of the National
Academy of Sciences, and serves on several editorial boards, including the
American Journal of Medicine and the Journal of Health Politics, Policy
and Law. He is also a National Correspondent for the New England Journal of Medicine. Dr. Blumenthal was the founding chairman of AcademyHealth. He is also Director of the Harvard University Interfaculty Program
for Health Systems Improvement. From 1995 to 2002 Dr. Blumenthal
served as Executive Director for the Commonwealth Fund Task Force on
Academic Health Centers. He has served as a trustee of the University of
Chicago Health System and currently serves as a trustee of the University
of Pennsylvania Health System (Penn Medicine). His research interests include the dissemination of health information technology, quality and safety
management in health care, the determinants of physician behavior, access
to health services, and the extent and consequences of academic-industrial
relationships in the health sciences.
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Susan A. Chapman, Ph.D, R.N., is the Director of the Allied Health Care
Workforce Program at the UCSF Center for the Health Professions and
Assistant Professor in the Department of Social and Behavioral Sciences,
School of Nursing. Her areas of expertise are nursing and allied health
workforce research and policy, program development, managed care, mental health, and health system administration. Dr. Chapman’s research focuses on studies of the supply, demand, and need for allied health workers.
Past research includes a multi-year effort to develop innovative allied health
workforce programs in California, an evaluation of California workforce
initiatives focused on nursing and long-term caregivers, and national studies
of certified nurse assistants, licensed practical nurses, home-care workers,
and other allied health occupations. She teaches health policy and research
in the UCSF School of Nursing and serves on the advisory committees for
several nursing programs and health workforce initiatives.
Terry T. Fulmer, Ph.D., R.N., F.A.A.N., is the Erline Perkins McGriff Professor and Dean of the College of Nursing at New York University. She
received her bachelor’s degree from Skidmore College, her master’s and
doctoral degrees from Boston College and her Geriatric Nurse Practitioner
Post-Master’s Certificate from New York University. Dr. Fulmer’s program
of research focuses on acute care of the elderly and specifically, elder abuse
and neglect. She served on the National Research Council’s panel to review
risk and prevalence of elder abuse and neglect and has published widely on
this topic. She has received the status of Fellow in the American Academy of
Nursing, the Gerontological Society of America, and the New York Academy of Medicine. She is a member of the National Committee for Quality
Assurance geriatric measurement assessment panel and the Veteran’s Administration Geriatrics and Gerontology Advisory Committee. She completed a Brookdale National Fellowship and is a Distinguished Practitioner
of the National Academies of Practice. Dr. Fulmer was the first nurse to be
elected to the board of the American Geriatrics Society and the first nurse
to serve as the president of the Gerontological Society of America.
Tamara B. Harris, M.D., M.S., is Chief of the Geriatric Epidemiology
Section in the Laboratory of Epidemiology, Demography, and Biometry,
Intramural Research Program, National Institute on Aging. The role of
the Geriatric Epidemiology Section is to integrate molecular and genetic
epidemiology with interdisciplinary studies of functional outcomes, disease endpoints and mortality in older persons. This includes identification
of novel risk factors and design of studies involving biomarkers, selected
polymorphisms and exploration of gene/environment interactions. The Section has been particularly active in devising methods to integrate promis-
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APPENDIX A
275
ing molecular or imaging techniques to explore the physiology underlying
epidemiologic associations including adaptation of imaging protocols to
epidemiologic studies. Dr. Harris received her M.D. from Albert Einstein
College of Medicine. She trained in internal medicine at Montefiore Hospital and in geriatric medicine at Harvard University, Division on Aging,
where she was a Kaiser Fellow in Geriatric Medicine. She obtained an M.S.
in Epidemiology from Harvard School of Public Health and also has an
M.S. in Human Nutrition from Columbia University College of Physician’s
and Surgeons.
Miriam A. Mobley Smith, B.S. Pharm., Pharm.D., is the Associate Dean
and Associate Professor at the Chicago State University College of Pharmacy. Before joining Chicago State, she was the Director of Experiential
Education at the University of Illinois at Chicago College of Pharmacy. Dr.
Mobley Smith is an adjunct faculty member in the Allied Health, Nursing and Human Services Department at South Suburban College, South
Holland, Illinois, and served on the curriculum advisory board, “Tech
Prep Medical Professional” advisory committee and re-accreditation review
team. She was a U.S. Department of Health and Human Services 2005 Primary Healthcare Policy Fellow and an American Association of Colleges
of Pharmacy 2006 Academic Leadership Fellow. She has chaired the Pharmacy Technician Certification Examination Standards Setting Committee,
2005 National Practice Analysis and was Past-President of the Pharmacy
Technician Certification Board Certification Council. Dr. Mobley Smith
was featured in the Aetna 2005 African American History Calendar for her
impact in older adult communities, received the Illinois Area Agencies on
Aging 2006 Sid Granet Aging Network Achievement Award, the 2005 Illinois Council of Health-System Pharmacists “Pharmacist of the Year,” and
the 2004 National Pharmaceutical Association’s James N. Tyson Award in
recognition of outstanding achievement in contributions to the profession
of pharmacy. She is a member of the American Society of Health-System
Pharmacists’ Council on Education and Workforce Development, American
Society of Consultant Pharmacists, American College of Clinical Pharmacy,
American Pharmacists Association, The Joint Commission Health Care
Professional Education Roundtable and Illinois Drug Policy Coalition. Dr.
Mobley Smith received her B.S in Pharmacy from the University of Michigan
and her Pharm.D. from the University of Illinois. Her research and grants
focus on preventive health-related issues affecting older adults, including
an Illinois Department on Aging, Title III-D program entitled “Medication
Monitoring and Safety in Older Adults,” the “Senior Medication Education
and Review Program” for the Woodlawn Community Development Corporation and Chicago Housing Authority, and the Chicago Department on
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276
RETOOLING FOR AN AGING AMERICA
Aging Wellness Program (in collaboration with Area Agencies on Aging).
She has delivered over 100 invited local, regional and national presentations
and published in areas relative to her areas of focus.
Carol Raphael, M.P.A., is President and Chief Executive Officer of Visiting Nurse Service of New York (VNSNY), the largest nonprofit home
health agency in the United States. She oversees VNSNY’s comprehensive
programs in post-acute care, long-term care, children’s and family services,
end-of-life care, rehabilitation, mental health and public health, as well as
its health plans for dually eligible Medicare and Medicaid beneficiaries.
Ms. Raphael developed the Center for Home Care Policy and Research,
which conducts policy-relevant research focusing on the management and
quality of home and community-based services. Previously, Ms. Raphael
held positions as Director of Operations Management at Mt. Sinai Medical Center and Executive Deputy Commissioner of the Human Resources
Administration in charge of the Medicaid and Public Assistance programs
in New York City. Between 1999 and 2005, Ms. Raphael was a member of
MedPAC. She served on the New York State Hospital Review and Planning
Council for 12 years (1992-2004) and chaired its Fiscal Policy Committee.
She chairs the New York eHealth Collaborative and is a member of the
IOM’s Committee to Study the Future Health Care Workforce for Older
Americans, Harvard School of Public Health’s Health Policy Management
Executive Council, the Markle Foundation Connecting for Health Steering
Group, Atlantic Philanthropies Geriatrics Practice Scholars Program, the
Advisory Board for The Jonas Center for Excellence in Nursing, the National Advisory Committee of the Caregiving Project for Older Americans,
and the AHA’s Health for Life Expert Advisory Group on Chronic Care
Management. She is also on the Boards of Barrier Therapeutics, Excellus/
Lifetime Healthcare Company, the American Foundation for the Blind, Pace
University and the Continuing Care Leadership Coalition. She has authored
papers and presentations on post-acute, long-term and end-of-life care and
co-edited the book Home Based Care for a New Century. Ms. Raphael
has an M.P.A. from Harvard University’s Kennedy School of Government,
and was a Visiting Fellow at the Kings Fund in the United Kingdom. Ms.
Raphael was recently listed in Crain’s New York Business Top 25 Most
Influential Businesswomen in New York City.
David B. Reuben, M.D., is the Director of the UCLA Multicampus Program
in Geriatric Medicine and Gerontology, Archstone Professor, and Director
of the UCLA Claude D. Pepper Older Americans Independence Center. He
is a Geriatrician-researcher with expertise in studies linking common geriatric syndromes (e.g., functional impairment, sensory impairment, malnutrition) to health outcomes such as mortality, costs and functional decline. He
also has extensive experience with interventional research (e.g., comprehen-
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APPENDIX A
277
sive geriatric assessment) that has focused on health care delivery to older
persons. His most recent work focuses on developing and testing interventions to improve the quality of care that primary care physicians provide for
geriatric conditions. In 2000, Dr. Reuben was given the Dennis H. Jahnigen
Memorial Award for outstanding contributions to education in the field of
geriatrics. He is a past-president of the American Geriatrics Society and the
Association of Directors of Geriatric Academic Programs (ADGAP). Dr.
Reuben is currently a member of the Board of Directors of the American
Board of Internal Medicine and sits on its Executive Committee. He is lead
author of the widely distributed book Geriatrics at Your Fingertips. Dr.
Reuben has served on two previous IOM Committees: Strengthening the
Geriatric Content of Medical Training (1993) and Nutrition Services for
Medicare Beneficiaries (2000).
Charles F. Reynolds III, M.D., is the UPMC Professor of Geriatric Psychiatry
(University of Pittsburgh School of Medicine) and Professor of Behavioral
and Community Health Science (University of Pittsburgh Graduate School
of Public Health). Dr. Reynolds directs the NIMH-sponsored Advanced
Center for Interventions and Services Research in Late-Life Mood Disorders
and the John A. Hartford Center of Excellence in Geriatric Psychiatry. He is
internationally renowned for his research in the mood and sleep disorders of
old age, with a particular focus on mental health services in primary care,
preventive interventions, and suicide prevention. He has served as a member
of the National Advisory Mental Health Council of the NIMH (2003-2006)
and as President of the American College of Psychiatrists (2004-2005) and
the International College for Geriatric Psychoneuropharmacology (2004).
Dr. Reynolds has served on two previous IOM studies (Reducing Suicide:
A National Imperative, 2001-2002; and Sleep Disorders: An Unmet Public
Health Problem, 2005-2006). He currently serves as Senior Associate Dean
of the University of Pittsburgh School of Medicine and is a graduate of the
Yale Medical School (1973).
Joseph E. Scherger, M.D., M.P.H., is Clinical Professor in the Department
of Family and Preventive Medicine at the University of California, San
Diego, School of Medicine. Dr. Scherger is Medical Director for County
Medical Services in San Diego, administered by AmeriChoice, a subsidiary
of United Health Group. He is also Consulting Medical Director of Informatics for Lumetra, the Quality Improvement Organization for California.
Dr. Scherger’s main focus is on the redesign of office practice using the
tools of information technology and quality improvement. Dr. Scherger is
an IOM member and served on the Committee on the Quality of Health
Care in America from 1998-2001. Dr. Scherger has served on the Board of
Directors of the American Academy of Family Physicians and the American
Board of Family Medicine.
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RETOOLING FOR AN AGING AMERICA
Paul C. Tang, M.D., M.S., is an Internist and Vice President, Chief Medical Information Officer at the Palo Alto Medical Foundation (Palo Alto,
California), and is Consulting Associate Professor of Medicine (Biomedical
Informatics) at Stanford University. He received his B.S. and M.S. in Electrical Engineering from Stanford University and his M.D. from the University of California, San Francisco. Dr. Tang is a member of the Institute of
Medicine (IOM), a member of the IOM Health Care Services Board, and
a National Associate of the National Academy of Sciences. He chaired
the IOM Committee on Data Standards for Patient Safety, which published: Patient Safety: A New Standard for Care, and Key Capabilities of
an Electronic Health Record System. He is the Immediate Past Chair of
the Board for the American Medical Informatics Association, a member
of the National Committee on Vital and Health Statistics (NCVHS), and
a member of the American Health Information Community Consumer
Empowerment Workgroup. Dr. Tang chairs the National Quality Forum’s
(NQF’s) Health Information Technology Expert Panel and the Robert Wood
Johnson Foundation’s National Advisory Council for Project HealthDesign
and co-chairs the NCVHS Quality subcommittee and the Measurement
Implementation Strategy work group of the Quality Alliance Steering Committee. Dr. Tang’s medical informatics research interests involve electronic
health record (EHR) systems, personal health record systems, EHR-based
quality measurement, clinical decision support, online disease management,
and health information technology public policies. He is a Fellow of the
American College of Medical Informatics, the American College of Physicians, the College of Healthcare Information Management Executives, and
the Healthcare Information and Management Systems Society.
Joshua M. Wiener, Ph.D., is Senior Fellow and program director of the
Aging, Disability, and Long-Term Care Program at RTI International; he
has more than 30 years of experience as a health care researcher and government official. His specialties are long-term care, Medicaid, and health
care for the elderly population. Dr. Wiener has directed projects analyzing
changes in state health policies, the long-term care workforce, Medicaid eligibility for the aged, blind, and disabled, and Medicaid home and
community-based services. He is the author or editor of eight books and
more than 100 articles on long-term care, people with disabilities, health
reform, health care rationing, and maternal and child health. In addition
to RTI International, Dr. Wiener has done research and policy analysis for
the Urban Institute, the Brookings Institution, the Health Care Financing
Administration, the Massachusetts Department of Public Health, the New
York State Moreland Act Commission on Nursing Homes and Residential
Care Facilities, and the New York City Department of Health.
Copyright © National Academy of Sciences. All rights reserved.
Retooling for an Aging America: Building the Health Care Workforce
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appendix
B
Commissioned Papers
Health Workforce and Future Technologies
Author: The Health Technology Center (HealthTech)
How Will the U.S. Health Care System Meet the Challenge of the
Ethnogeriatric Imperative?
Author: Gwen Yeo, Ph.D., with assistance from Wendy King, Stanford
University School of Medicine
Paraprofessional Health Care Workforce for an Aging Population
Author: R. Tamara Konetzka, Ph.D., University of Chicago
State Profiles of the U.S. Health Care Workforce
Author: Mark Mather, Ph.D., Population Reference Bureau
Successful Models of Comprehensive Health Care for Multi-Morbid
Older Persons: A Review of Effects on Health and Health Care
Authors: Chad Boult, M.D., M.P.H., M.B.A., Johns Hopkins University
Bloomberg School of Public Health
Ariel Green, M.P.H., Johns Hopkins University School of
Medicine
Lisa B. Boult, M.D., M.P.H., M.A., Johns Hopkins University
School of Medicine
James T. Pacala, M.D., M.S.P.H., University of Minnesota
Medical School
279
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280
RETOOLING FOR AN AGING AMERICA
Claire Snyder, Ph.D., Johns Hopkins University School of
Medicine
Bruce Leff, M.D., Johns Hopkins University School of Medicine
Supporting and Sustaining the Family Caregiver Workforce for Older
Americans
Author: Jennifer L. Wolff, Ph.D., Johns Hopkins Bloomberg School of
Public Health
NOTE: All commissioned papers have been placed in this project’s public
access file.
Copyright © National Academy of Sciences. All rights reserved.
Retooling for an Aging America: Building the Health Care Workforce
http://www.nap.edu/catalog/12089.html
appendix
C
Workshop Presentations
March 27, 2007: Workshop on the Health Care Needs of Older
Americans
David B. Reuben, M.D.
University of California, Los Angeles
“Health Care Needs of Today’s Older Americans”
Robyn I. Stone, Dr.P.H.
Institute for the Future of Aging Services (IFAS)
American Association of Homes and Services for the Aging (AAHSA)
“The Demand for Long-Term Care: Implications for Workforce
Development”
Dan Zabinski, Ph.D.
MedPAC
“Medicare in the 21st Century: Changing Beneficiary Profile”
Stephen Goss, Social Security Administration
Alice Wade, Social Security Administration
“Population and Future Needs for Health Care Workers”
Federico Girosi, Ph.D.
RAND
“Projections of Health Status and Utilization for Older Americans”
281
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RETOOLING FOR AN AGING AMERICA
June 28, 2007: Workshop Session I—Models of Care for Older
Americans
Jennie Chin Hansen, M.S., R.N., F.A.A.N.
University of California, San Francisco
“The PACE Model: An Overview”
Gwen Yeo, Ph.D., AGSF
Stanford University School of Medicine
“How Will the U.S. Health Care System Meet the Challenge of the
Ethnogeriatric Imperative?”
Eric Coleman, M.D., M.P.H.
University of Colorado Health Sciences Center
“Looking Forward: Imagining New Models of Care”
Michèle J. Saunders, D.M.D., M.S., M.P.H.
The University of Texas Health Science Center at San Antonio
“The Future Health Care Workforce for Older Americans—Dentistry”
Bruce Leff, M.D.
Johns Hopkins University Schools of Medicine and Public Health
“Dissemination of Models of Geriatric Care: Facilitators and Barriers”
June 28, 2007: Workshop Lunch Session
Steven DeMello
Barbara Harvath, R.N., B.A.
HealthTech
“Health Care Workforce and Future Technologies”
June 28, 2007: Workshop Session II—Recruitment and Retention
Sharon A. Levine, M.D.
Boston University School of Medicine
“Recruitment and Retention of Physicians”
Charlene Harrington, Ph.D., R.N., F.A.A.N.
University of California, San Francisco
“Nursing Home Labor Market Issues”
Copyright © National Academy of Sciences. All rights reserved.
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APPENDIX C
Jeanie Kayser-Jones, R.N., Ph.D., F.A.A.N.
University of California, San Francisco
“Building Academic Geriatric Nursing Capacity Initiative”
Steven Dawson
PHI
“PHI: Quality Care Through Quality Jobs”
Marcia K. Brand, Ph.D.
Health Resources and Services Administration, Office of Rural Health
Policy
“The Future Healthcare Workforce for Older Americans: Rural
Recruitment and Retention”
Copyright © National Academy of Sciences. All rights reserved.
283
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Index
A
Access to care
geographic distribution of health
care professionals, 126–128
insurance coverage for direct-care
workers, 210–211
mental health services, 46
oral health care, 144
Activities of daily living
assistance needs of older adults, 43
mental health problems and, 45
tasks and responsibilities of
informal caregivers, 251–252
technological support, 14, 115, 164,
244–246
trends in health status of older
adults, 40, 55
Advanced Illness Management Plan,
83–84
Advanced medical homes, 100–101
Advanced practice registered nurses,
143–144
African Americans. See Race/ethnicity
Aging and Medical Education, 2,
28–29
Alcohol and substance abuse, 45
All Payer Graduate Medical Education
Act, 170
Allied and Auxiliary Health Care
Workforce Project, 163
Allied health care workers, 152
Alzheimer’s disease
mortality, 44
prevalence, 21, 44
prevalence trends, 55
Ambulance utilization, 47
Ambulatory care, 3, 46
American Association of Colleges of
Nursing, 141
American Board of Family Medicine,
137–138
American Board of Internal Medicine,
137–138
American Dietetic Association, 158
American Geriatrics Society, 158
American Physical Therapy
Association, 158
American Society of Hospital
Pharmacists, 146–147
Apprenticeships, 224
Arizona, 90–91
Arthritis, 42, 45–46, 55
Asian Americans. See Race/ethnicity
285
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286
INDEX
Assistive technologies, 14, 115, 164,
244–246
Association of American Medical
Colleges, 129
Atlantic Philanthropies, 141–142, 150,
154
B
Balanced Budget Amendment, 137
Beacon Hill Village, 229
Better Jobs Better Care, 230
Boston University Medical Center, 155
Bureau of Health Professions, 6, 30
C
California Endowment, 163
California HealthCare Foundation, 163
Cancer, 44, 45–46, 57
Capitated payment, 97–98
Care coordinator. See Geriatric care
managers
Rosalynn Carter Institute for
Caregiving, 258
Cash and counseling program, 92–93
Centers for Medicare and Medicaid
Programs, 231–232
Centers of excellence in geriatric
medicine, 29, 141, 154
Cerebrovascular disease, 44
Certified nursing assistants. See Nurse
aides
Chiropractic services, 49
Cholesterol control drugs, 49
Chronic conditions
definition of long-term care, 27
fee-for-service payment system, 96
future challenges for health care
system, 16
health care utilization for, 42–43,
45–46
Medicare spending, 3, 16, 42–43
mortality, 16
prevalence, 16, 21, 42
City College of San Francisco, 163
Collaborative for Ethnogeriatric
Education, 155–156
Committee on the Future Health Care
Workforce for Older Americans,
25–28
Community-Based Jobs Training
Grants, 164, 230
Community-based services
demand for direct-care workers and,
200
long-term care provision, 48
shortcomings of Medicaid policies,
23
volunteer workers for, 229
Community colleges, 163–164
Compensation for health care workers
direct-care workers, 11, 209,
210–211, 220–222
financial incentives for geriatric
training, 10, 171
geriatric medicine professionals, 171
supply and demand estimates and,
28
wage pass-throughs, 11, 221, 222
Complementary and alternative
medicine, 49
Comprehensive care, 76–77
Comprehensive Geriatric Education
Program, 142
Congress, recommendations for, 6, 11,
13, 30, 108, 175
Continuum of care, 157–159
informal caregivers in, 242
Cooperative Home Care Association,
222
Coordination of care
current shortcomings, 114
goals of health system reform, 77
in Medicare Advantage, 97
in MedPAC, 99
model of end-of-life care, 83–84
in new models of care, 114
significance of, in health care
outcomes, 47–48, 113–114
Cost of care
assistive technologies, 246
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287
INDEX
chronic condition spending, 3, 16,
42–43
cost of geriatric training, 171
economic value of informal
caregiving, 18, 247–248
efficiency of care and, 56
financial assistance for informal
caregivers, 261–263
financing mechanisms for new
models of care, 98–101
future challenges, 24–25
hospice care, 48
IMPACT model of care for
depression, 104
implications for health care system
reform, 28
in last years of life, 44
long-term care spending, 48, 62
outcomes of Medicare
demonstration projects, 88
per beneficiary, 24, 65
projected Medicare spending, 58
Council for Adult and Experiential
Learning, 224
Council on Social Work Education,
149, 150
Crossing the Quality Chasm, 2, 29, 48,
76, 256
Cultural sensitivity
principles of delivery system reform,
77
training for work with special
populations, 155–157
D
Deficit Reduction Act, 86
Definitions, 27
Delirium
definition, 105
HELP model of care, 105–106
prevalence, 105
Dementia
physical health and, 45
prevalence, 44
See also Alzheimer’s disease
Dentists and oral-health care workers
aging of population of, 168
board certification, 145
emerging supply problems, 19, 20
geographic distribution, 126–127
supply and demand projections, 144
training, 144–146, 154
Department of Health and Human
Services, recommendations for,
14, 246
Department of Labor,
recommendations, 14, 246
Depression
physical health and, 45
prevalence, 45
treatment models, 79–80, 103–104
Diabetes, 45–46, 55
Diet and nutrition
feeding assistants, 225
geriatric content of medical training,
157, 158
provider training in health
promotion, 157
Dietary supplements, 49
Dietetics, 152, 158
Direct-care worker recruitment and
retention
causes of turnover, 209–210
challenges, 11, 209–210, 232
current turnover, 209
financial factors, 210–211, 220–222
labor pool expansion, 227–229
model programs for, 229–232
quality of care and, 213–214
recommendations for, 11
reform of roles and responsibilities,
226
strategies for improving, 214–215,
233
work environment factors, 211–
213, 222
Direct-care workers, 32
career lattices, 224
compensation, 11, 200, 210–211,
220–222
employment settings, 201
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INDEX
on-the-job injury risk, 212–213
professional recognition, 223
projected demand, 200
quality of patient care, 213–214
recommendations for compensation,
11, 222
recommendations for training and
certification, 9, 218–220
recruitment and retention. See
Direct-care worker recruitment
and retention
reform of roles and responsibilities,
225
role of, in older adult health care,
199, 203, 232
strategies for workforce
improvement, 201, 217–220
supply, 20–21, 199–200
training costs, 209
training requirements, 204–208,
217–220, 232–233
training shortcomings, 22, 204,
215–218, 232
types of, 27, 201
work environment, 11, 21, 199,
200–201, 209, 211–213, 214,
222–226
workforce demographics, 203–
204
See also Home health aides; Nurse
aides; Personal- and home-care
aides
Direct Service Workforce
Demonstration, 231
Disabilities, older adults with
demographic differences, 50
long-term care utilization,
4, 44
mental health problems and, 45
prevalence, 43
trends, 54–55, 63
Disease prevalence, 40–42
projections, 59
Distance education, 162–163
Diuretic drugs, 49
E
Education and training of health care
workers
adaptation to new models of care,
112
advanced practice registered nurses,
143–144
continuing education, 161
in continuum of care, 157–159
costs to providers, 10, 171
current shortcomings, 4, 5, 21–22,
124, 128, 160, 204
dentists and oral-health care
workers, 144–146
direct-care workers, 9, 204–205,
215–220, 232–233
in disease prevention, 157–158
emergence of new medical
professions and, 165
enrollment patterns, 19
exposure to geriatric patients, 169
faculty recruitment and retention,
10–11, 152, 153–155, 175–176
financial aid for geriatric training in
exchange for service, 176–181
financial incentives for health care
professionals, 10, 11, 171, 181
future prospects, 162
health care outcomes and, 21
in health promotion, 157
home health aides, 207, 215
informal caregivers, 9–10, 242,
254–256, 260–261
for interdisciplinary team work,
159–160
Internet-based, 162–163
leadership, 153–155
licensed practical nurses, 141
licensure and certification
requirements and, 8–9, 161–162
in non-hospital settings, 6–8, 23,
136–137
nurse aides, 206–207, 215
obstacles to improving, 6, 123, 128,
160–161
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INDEX
obstacles to recruitment of health
care professionals, 169, 170
palliative care, 158–159
patient self-management
interventions, 243–244
pharmacists, 146–147
physician assistants, 148
of physicians, 128–138
quality of care and, 21, 216
recommendations for, 6–10, 137,
161–162, 175, 218–220
recruitment and retention linkage,
216
registered nurses, 141–143
role of community colleges in,
163–164
social workers, 149, 150
for use of new medical technologies,
164
for work with special populations,
152, 155–157
Educational attainments of older
adults, 53, 54–55
Efficiency of care, 13, 56, 77
Electronic health records, 14, 114, 257
Emergency Health Personnel Act, 179
Emergency medicine
geriatric training, 151
older adult utilization, 3, 46–47
utilization projections, 57–58
Employment and Training
Administration, 230–231
End-of-life care
AIM model, 83–84
cost of, 44
diversity of needs, 44
goals for new models of care, 109
training for health care professional,
158–159
Epidemiology
chronic conditions, 16, 21, 42
demographic variations in health
care utilization, 49–52
geriatric syndromes, 43
mental health conditions, 44–45
projected morbidity, 55
Evercare program, 85–86
Evidence-based care, 79–80
F
Family caregivers. See Informal
caregivers
Feeding assistants, 225
Fee-for-service reimbursement system,
22, 96–97
Fellowships, 134, 147, 167, 171, 172
Florida, 127
Future of Disability in America, The,
244, 245
G
Gay, lesbian, bisexual, and transgender
persons, 152, 156–157
diversity considerations in new
models of care, 109
Geographic variation
distribution of health care
professionals, 126–128
population age distribution, 51
Geriatric Academic Career Awards,
10–11, 136, 154, 175
Geriatric care managers, 165
Geriatric Education Centers, 129
Geriatric Resource Nurse, 154
Geriatric Resources for Assessment and
Care of Elders (GRACE), 80–81
Geriatric specialists
board certification, 137–138
career satisfaction, 167
centers of excellence, 29
current workforce, 4, 5, 21,
124–125
dentists and oral-health care
workers, 144–146
emergency medicine, 151
emerging supply problems, 19, 167
federal training programs, 134–136
fellowships, 134
financial incentives for, 10, 11,
171–175
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geographic distribution, 127
interdisciplinary team training,
159–160
licensure and certification, 8–9,
161–162
negative stereotypes, 169
obstacles to professional training,
123, 128
older adult utilization patterns, 46
optometry, 152
pay disparities for health care
professionals, 10
physical therapists, 151
physician assistants, 148
podiatry, 152
previous efforts to improve supply
of, 28–29, 30
professional leadership, 153–155
projected need, 5, 19, 20, 125–126
projected supply, 5, 125
recent growth, 2
recommendations for education and
training, 6–10, 161–162, 175,
218–220
recommendations for recruitment
and retention, 10–11, 171–172
registered nurse training, 141–143
roles for retired professionals, 169
shortcomings of federal
reimbursement system, 23
social workers, 5, 21, 125, 148–
149, 150
Geriatric syndromes, 43
Geriatric Training for Physicians,
Dentists, and Behavioral/Mental
Health Professions Program,
136, 154
Geriatrician Loan Forgiveness Act, 180
GRACE. See Geriatric Resources for
Assessment and Care of Elders
Green House, 81–83, 111, 225
H
John A. Hartford Foundation, 29,
79–80, 129, 134, 141, 143, 150,
153–154, 155, 159, 170
Health care needs of older adults
conceptualization of, 27–28
demographic trends and, 52–55,
66–67
gender differences, 49–50
inpatient diagnoses, 47
last years of life, 44
limitations of projections, 64–65
in nursing homes, 44
oral health, 144
principles of delivery system reform,
76–78
reasons for physician office visits,
45–46
scope of, 3, 17
technology development and, 14,
55–56
See also Chronic conditions;
Utilization
Health Insurance Portability and
Accountability Act, 257
Health Resources and Services
Administration, 57, 129,
134–136, 145, 154, 155, 159,
160, 176
Health status of older adults
average, 21
current self-reports, 40, 42
disease prevalence, 40–42, 59
diversity of, 40
geriatric syndromes, 43
in long-term care facilities, 44
mental health conditions, 44–45
racial/ethnic differences, 50–51
in rural areas, 127
socioeconomic status and, 50–51
trends, 2–3, 40, 54–55
See also Health care needs of older
adults
Healthcare Effectiveness Data and
Information Sets, 99
Hearing problems, 43
Heart disease
epidemiology, 42
medication use, 49
mortality, 44
office visits related to, 45–46
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HELP. See Hospital Elder Life Program
Help-seeking behaviors
mental health services, 46
preventive care utilization, 50, 51
sexual orientation and, 156–157
High Growth Job Training Initiative,
230–231
Hispanic population. See Race/ethnicity
HIV/AIDS, 156
Home health aides
recommendations for training, 9,
218
recruitment and retention
challenges, 209
services, 202
supply and demand trends, 17–18
training requirements, 9, 22, 207,
215, 218
workforce characteristics, 203
See also Direct-care workers
Home health care
demand for direct-care workers and,
200
direct-care worker employment in,
201
Medicare coverage, 47, 99–100
projected demand, 58, 200
technology development for, 14, 56
utilization patterns, 47
Hospice
AIM model of care, 83–84
federal program spending, 48
utilization park, 44
Hospital Elder Life Program (HELP),
105–106
Hospitals
direct-care worker employment in,
201
discharge patterns, 47
post-acute care, 47, 254
utilization patterns, 45, 46, 47
utilization projections, 57–58, 59
Hypertension
epidemiology, 42
medication use, 49
physician office visits for, 45–46
I
Immigrant population
in health care workforce, 227–228
language proficiency and health care
utilization, 51
use of interpreters in health care,
253
IMPACT. See Improving Mood:
Promoting Access to
Collaborative Treatment for Late
Life Depression
Improving Mood: Promoting Access
to Collaborative Treatment for
Late Life Depression (IMPACT),
79–80, 103–104, 111–112
Incarcerated population, 54, 155
Incontinence, 43
Indian Health Service, 178
Indiana University, 80–81
Informal caregivers, 32
caregiver characteristics, 248–250
definition, 18, 247, 249
demand projections, 64
economic value, 18, 247–248
financial assistance, 261–263
frequency and intensity of help
from, 247
influence on health care outcomes,
253–254
integration with medical team,
256–258
long-term care provision, 48
new models of care, 113
numbers of, 248, 249
quality of care, 247
recommendations for training,
9–10, 255
respite, 261
role of, in continuum of care, 242,
247, 263
spouses as, 250
stress for, 258
supply concerns, 18, 242, 249–251,
263
support programs, 258–263
tasks and responsibilities, 251–253
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training models, 255–256
training needs, 4, 9, 242, 260–261
Information technology
electronic health records, 14, 114,
257
goals of health system reform, 77
for new models of care, 114–115
recommendations for, 14
Infrastructure development and
maintenance
recommendations for, 12
See also Information technology
Institute for Geriatric Nursing, 141
Intensive care, 57
International medical graduates, 134,
155
Internet-based education, 162–163
Interpreters, language, 253
J
Jewish Vocational Services, 163
K
Kaiser Permanente, 97
Kansas, 126–127
L
Learning organizations, 107
Lewin Group, 61–62
Licensed practical nurses
nursing home needs, 167
scope of practice, 140–141
supervisory role, 141
training, 141
Licensure and certification
board certification for physicians,
137–138, 145
continuing education requirements,
161
geriatric care managers, 165
geriatric competency requirements,
161
goals, 161
nurse aides, 296
pharmacists, 147
recommendations for, 8–9, 161–
162, 218
Life expectancy
gender differences, 49–50
population trends, 16
socioeconomic status and, 51
Lifespan Respite Care Bill, 259, 261
Long-term care
barriers to recruitment of health
care professionals for, 167–168
current utilization, 43, 48
definition, 27, 48
demand projections, 61–62, 63–64
demographic trends and, 54
nurse aides in, 201–202
spending, 48
See also Chronic conditions;
Nursing homes
M
Maine, 90
Manchester Community College, 164
Marital status, 51
Medicaid
compensation for direct-care
workers, 11, 220, 221–222
coordination with Medicare
benefits, 23
demonstration projects, 88–93
financial challenges, 15, 24–25
future of health care system, 30, 31,
56
informal caregiver support,
258–259
long-term care spending, 48
nurse aide training requirements,
206
nursing home bias, 23
projected service utilization, 4
recommendations for, 10, 11, 171,
222
shortcomings of current payment
system, 22, 23, 174–175
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spending on non-institutional
service delivery, 200
spending per beneficiary, 65
spending trends, 24, 65–66
strategies for enhancing recruitment
of geriatric specialists, 171,
174–175
See also Reimbursement
Medical Home demonstration projects,
101. See also Advanced medical
homes
Medical technologies
future demand for health services
and, 14, 55–56
new models of care, 114–115
provider training for, 164
to support activities of daily living,
14, 115, 164, 244–246
See also Information technology
Medicare
additional benefits to support new
models of care, 99–100
Advantage plan, 97–98
chronic care spending, 3, 16, 42–43
coordination of patient care in, 114
coordination with Medicaid
benefits, 23
copayment disparities, 12, 108,
174–175
demonstration projects, 84–88
end-of-life spending, 44
fee-for-service system, 96–97
financial challenges, 15, 24–25, 66
future of health care system, 30, 31,
56
graduate medical education, 23,
136, 137
hospice care, 44, 48
Hospital Insurance Trust Fund, 24,
66
informal caregiver support, 258,
260, 261
long-term care spending, 48
Medication Regimen Review, 146
medication use by enrollees, 49
mental health coverage, 12, 46, 108
nurse aide training requirements,
206
obstacles to new models of care,
107
original purpose, 22
population projections, 53
post-acute care service coverage, 47
projected service utilization, 4,
58–61
recommendations for, 10, 11, 171
research budget, 88
shortcomings of current payment
system, 22–23, 174–175
special needs plans, 98–99
spending per beneficiary, 24, 65
strategies for enhancing recruitment
of geriatric specialists, 171,
174–175
total budget, 88
utilization patterns of consumers,
46
See also Reimbursement
Medicare Modernization Act, 86, 98
Medications
average consumption among older
adults, 21, 49
older adult utilization, 3, 45, 48–49
role of informal caregivers in
administration of, 257
scope of practice reforms in
administration of, 166–167, 225
utilization by type of medication, 49
MedPAC, 99
Mental health, 44–45
geriatric education and training for
physicians, 133
geropsychiatric nursing, 143
help-seeking behaviors, 46
older adult utilization patterns, 46
physical health and, 45
reimbursement reforms to enhance
recruitment of geriatrics
professionals, 174–175
supply of geriatric specialists, 125
training requirements for geriatric
psychiatry, 138
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Minnesota, 91
Models of care delivery, 31
additional Medicare benefits to
support new models, 99–100
advanced medical homes, 100–101
collaborations for dissemination,
107
common features of innovative
models, 93–95, 115
coordination of care in, 113–114
current shortcomings, 6, 11–12, 14
dissemination experiences, 103–106
financing mechanisms, 98–101
goals for improving, 12
interdisciplinary care teams, 113
international models, 27, 110–111
Medicaid demonstration projects,
88–93
Medicare research and
demonstration projects, 84–88
for middle class consumers, 109
new approaches, 78–79
obstacles to diffusion, 103, 107–108
palliative care in, 109
performance evaluations of, 78, 93
population diversity considerations,
109
preventive interventions in, 109
principles, 76–78
private sector models, 79–84
recommendations for, 6, 12–14, 108
reforms in workforce roles and
responsibilities, 13, 111–113,
115
reimbursement reform for, 12
requirements for successful
implementation, 12, 75, 101–102
research needs, 12–13, 108–110
workforce adaptation to, 13, 111
workforce considerations in new
designs, 109–110
Monitoring health care workforce
supply
goals, 30
rationale, 5
recommendations for, 6, 30
Mortality
among older adults, 44
chronic condition-related, 16
circumstances of last years of life,
44
socioeconomic status and, 50–51
Mt. San Antonio College, 163
N
National Advisory Council on Nurse
Education and Practice, 155
National Association of Social
Workers, 150
National Caregiver Support Program,
259
National Citizen’s Coalition for
Nursing Home Reform, 217
National Clearinghouse on the DirectCare Workforce, 232
National Council of State Boards of
Nursing, 141
National Direct Service Workforce
Resource Center, 231
National Family Caregiver Support
Program, 261
National Geriatric Service Corps, 11,
181
National Health Service Corps, 11,
176, 179–181
National Institutes of Health, 178–179
Native Americans. See Race/ethnicity
New Hampshire, 126–127
Northern Michigan University, 155
Nurse Aide Training and Competency
Evaluation Program, 206
Nurse aides
career lattices, 224
current supply, 5
demand projections, 58
employment settings, 201
feeding assistance role, 225
medication administration
responsibility, 166, 225
quality of care, workload and,
213–214
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recommendations for training, 9,
218
role of, in older adult care, 201–202
supply challenges, 21
training requirements, 9, 22, 206–
207, 215, 217, 218, 232–233
See also Direct-care workers
Nurse Competence in Aging, 141–142
Nurse Education, Expansion, and
Development Act, 142–143, 170
Nurse practitioners, 3, 143
Nurse Reinvestment Act, 141–142
Nurses
emerging supply problems, 19
medication administration role, 166
obstacles to increasing supply, 140
projected demand, 58
projected supply, 140
scope of practice and job delegation
reforms, 165–166
support for doctorate level faculty,
175–176
See also Licensed practical nurses;
Nurse aides; Nurse practitioners;
Registered nurses
Nurses Improving Care for Health
System Elders, 154
Nursing Demand Model, 57
Nursing homes
age distribution of residents, 43–44
current utilization, 43–44
direct-care worker employment in,
201
emerging workforce supply
challenges, 21
Evercare program model of care,
85–86
Green House model of care, 81–83
health status of residents, 44
informal caregiver effects on entry,
254
Medication Regimen Review, 146
mental health problems among
residents, 45
nursing staff, 141
occupational injury risk, 212
older adult utilization, 3–4, 45, 48
oral-health care in, 144
per capita spending, 65
projected demand, 58
quality of care, staffing levels and,
213–214
racial/ethnic differences in
utilization, 50
screening guidelines, 157–158
shortcomings of Medicaid policies,
23
workforce turnover, 209–210
See also Long-term care
Nursing Reinvestment Act, 155
O
Obesity
prevalence projections, 59
service utilization projections and,
61
Omnibus Budget Reconciliation Act,
86, 206
Oncology, 57
Optometrists, 58, 152
Oregon, 90
Osteopathic medicine, 11, 138, 175
P
PACE. See Programs of All-Inclusive
Care for the Elderly
Palliative care. See End-of-life care
PAS Workforce Project, 232
Patient-centered care, 76
Patient role in health care
goals, 77–78
new models of care, 113
professional workforce needs and,
4–5
scope of, 241–243
self-management, 243–244
Personal- and home-care aides
income, 209
monitoring performance of, 203
on-the-job injury risk, 212
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recommendations, 9, 218
recruitment and retention
challenges, 209
role of, in older adult care, 202–203
training, 9, 207–208, 215, 218
workforce development programs,
232
See also Direct-care workers
Pharmacists
current certification in geriatrics, 5,
21, 125
education and training, 146–147
emerging supply problems, 19, 146
licensure, 147
in older adult health care, 146
reform of medication administration
roles, 166–167
reimbursement for advanced
services, 174
PHI, 224, 232
Physical therapy, 58, 151
Physician Aggregate Requirements
Model, 57
Physician assistants
current supply, 5, 21, 125, 148
education and training, 148
income, 171
in older adult health care, 147–148
older adult utilization, 5, 147
practice settings, 147, 148
scope of work, 147
Physicians
aging of population of, 20, 168
board certification, 137–138, 161
career satisfaction, 167
cost of geriatric training, 171
current medical school training,
129–133
current supply of geriatric
specialists, 124–125, 128–129
emerging supply problems, 19
income, 171, 172
postdoctoral training in geriatrics,
133–136
See also Physician assistants;
Professionals, health care;
Resident physicians
Podiatrists, 58, 152
Polk Community College, 164
Population trends and patterns
aging, 1, 15, 16, 45, 52–53
demographic features, 1, 4, 15–16,
52–55
demographic variations in health
care utilization, 49–52
geographic variation, 51
health care workforce aging, 20,
168–169
health status, 2–3
informal caregivers, 248–251
population diversity considerations
in new models of care, 109
potential sources for direct-care
worker labor pool, 227–229
projections for elderly population,
52–55
training for work with special
populations, 155–157
Practicing Physician Education Project,
154
Practicum Partnership Program, 150
Prayer, 49
Preventive care
goals for new models of care, 109
language proficiency and utilization
of, 51
Medication Regimen Review, 146
principles of delivery system reform,
76
provider training in, 157–158
racial/ethnic differences in
utilization, 50
shortcomings of current health care
delivery, 109
socioeconomic status and utilization
of, 51
Primary care
definition, 27
Medicare reimbursement policies,
23
Prisons, 54, 155
Private sector, new models of care,
79–84
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Professionals, health care, 31–32
current supply, 124
definition and scope, 27
educational enrollment patterns, 19
emerging supply problems, 19–20
financial aid for geriatric training in
exchange for service, 176–181
geographic distribution, 126–128
incomes, 171
National Institutes of Health
research grants to, 179
obstacles to geriatric training, 123
projected need, 58, 124
racial/ethnic diversity, 126
recommendations for recruitment
and retention, 10–11, 171–176
resident training in non-hospital
settings, 6–8, 23
See also Geriatric specialists;
Nurses; Physicians
Programs of All-Inclusive Care for the
Elderly (PACE), 84–85, 104–105
Q
Quality of care
current shortcomings, 14, 16, 75–76
direct-care workers, 213–214
efficiency of care, 56, 77
informal caregivers, 247
principles of delivery system reform,
12, 76–78
provider training and, 21, 216
recruitment and retention issues,
213–214
shortcomings of federal
reimbursement system, 22–23
transitions between care settings,
47–48
workplace environment and, 214
R
Race/ethnicity
direct-care workforce, 203, 204
diversity considerations in new
models of care, 109
health care professionals, 126
health status and utilization
patterns, 50–51
population projections, 52–54
principles of delivery system reform,
77
provider–patient relationship, 126
workforce diversity, 126
RAND Future Elderly Model,
58–61
Real Choice Systems Change Grants,
231
Recruitment and retention, 31–32
aging of workforce and, 168–169
direct-care workers. See Direct-care
worker recruitment and retention
education and training as factor in,
216
financial aid for geriatric training in
exchange for service, 176–181
financial incentives, 10, 171–181,
182
geriatric specialists, 10, 123
geriatrics faculty, 10–11, 153–155,
175–176
goals for new models of care,
109–110
negative stereotypes of geriatric
work, 169
nursing home workforce, 209–210
obstacles to, 123, 167–170,
181–182
quality of care and, 213–214
recommendations for improving,
10–11, 171–176
in rural areas, 127, 128
Regenstrief Institute, 80–81
Registered nurses
advanced practice training, 143–144
aging of population of, 20, 168
current certification in geriatrics, 5,
125
income, 171
job delegation skills, 165–166
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nursing home needs, 167
recruitment and retention, 168
training, 141–143
Reimbursement
billing code modifiers, 173
capitated payment systems, 97–98
coordination within federal system,
23
fee-for-service system, 96–97
mental health services, 46
for new models of care, 12, 98–101,
108
for patient self-management
interventions, 244
policy changes affecting demand
and utilization, 56
recommendations for, 10, 12, 108,
171–172
risk adjustment, 97, 100
shortcoming of current system,
22–23
strategies for enhancing recruitment
of health care professionals, 10,
171–175
for team care, 13
Remote monitoring technologies, 14,
77, 114–115, 245
Research
financial aid for geriatrics
researchers, 178–179
recommendations for new models of
care, 12–13, 108–110
Resident physicians
in dentistry, 145
geriatric training, 133–134, 155
Medicare graduate medical
education programs, 23, 136,
137
pharmacists, 147
racial/ethnic diversity, 126
recommendations for training, 8,
137
training in non-hospital settings,
6–8, 23, 136–137
Resources for Enhancing Alzheimer’s
Caregiver Health, 256
Respiratory disorders
mortality, 44
Rewarding Provider Performance, 114
Donald W. Reynolds Foundation, 129,
154
Risk adjusted payments, 97, 100
RTI International, 62–64
Rural population
diversity considerations in new
models of care, 109
health care professionals, 127–128
health status of older adults, 51,
127
recruitment and retention of health
care workers, 127, 128
S
Settings for care
demographic trends and, 54
direct-care workers, 201, 203
recommendations for training of
professionals in, 6–8, 137
transitions between settings, 47–48,
77
Skilled nursing facilities, 47
Smoking, service utilization projections
and, 61
Social HMOs, 86–87
Social workers
aging of population of, 168
competencies for work with older
adults, 149–150
current supply of geriatric
specialists, 5, 21, 125, 148–149
education and training, 149, 150
practice settings, 149
Practicum Partnership Program, 150
projected needs, 5, 148
roles for retired professionals, 169
Society of General Internal Medicine,
155
Socioeconomic status
care delivery models for low-income
older adults, 80–81
goals for new models of care, 109
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health care utilization and, 51
health status and, 50–51
preventive care utilization and, 51
South Carolina, 178
Special needs plans, 98–99
State governments
financial aid for geriatric training in
exchange for service, 176–178
recommendations for, 11, 218
scope of practice reforms, 166
Suicide, 44–45, 52
Sutter Visiting Nurse Association, 83
T
Team care
HELP delirium management model,
106
informal caregivers in, 256–258
new models of care, 7, 13, 113
PACE model of disability care, 85
patient role in, 4–5, 77–78, 113
training of medical professionals for,
159–160
U
United Health Care Corporation,
85–86
Urban Institute, 62–64
Utilization
chronic care-related, 42–43
consumer expectations for care and,
56
current patterns, 43–44, 45–49
demographic patterns, 49–52
determinants of, 4
models for projecting demand and,
57, 58–59, 61–62, 64–65
older adults, 3–4, 17, 39, 53
physician visits, 42, 45–46
projected demand, 4, 15, 17, 39,
55–56, 57–61, 62, 63–64,
66–67
reimbursement policies and, 56
V
Veterans, 52, 54
Veterans Administration, 134, 145,
159, 257
Veterans Health Administration, 48, 54
Volunteer workers, 229
W
Weill Cornell Medical College, 137
Wellspring nursing home, 223
Wisconsin, 91–92
Women’s health
insurance coverage for direct-care
workers, 210–211
utilization patterns, 49–50
Workforce, health care
adaptation to new models of care,
13, 111
aging of, 20, 168–169
barriers to recruitment and
retention, 5
coordination of care, 114
current capacity, 4–5
definition and scope, 27
demand for non-institutional
services, 200
future challenges, 1–2, 14, 15–17,
29–30
goals for improving, 2, 75–76
goals for new models of care,
109–110
job delegation reform, 110–111,
165–166
new professions, 165
new provider designations, 13, 112
older workers, 228–229
reform rationale, 67
roles and responsibilities in new
models of care, 111–113, 115
roles for retired professionals, 169
salient issues, 2, 25, 26–28, 29,
123–124
scope of practice reforms, 13, 77,
112, 165–167
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supply monitoring, 5, 6, 30
timely implementation of reforms,
2, 26, 31
volunteer workers, 229
See also Compensation for health
care workers; Education and
training of health care workers;
Professionals, health care
Workload
efficiency improvement, 77
quality of nursing care and,
213–214
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