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  • Compare to Florida (currently 18% over the age of 65) Older generation will be more heterogeneous. Changes in family structure (less children, divorce) have effects on the availability of informal caregivers.
  • While it is widely accepted that the current way of caring for older adults can be improved, there is little guidance available about which interventions are most effective. First, there is a general information gap – lack of complete evaluations. Second, evaluations may have conflicting results. Finally, evaluations lack information about key inputs, such as staffing or training.
  • Number of geriatricians are down from around 9,000 in the year 2000 and may continue to decrease due to many geriatricians choosing not to recertify, and few physicians choosing to enter the fields.
  • We need specialists to train the rest of the workforce, provide care to patients with the most complex needs, and perform research. Geriatricians stand to lose $7,000 annually for pursuing geriatrics (as opposed to general internists)
  • Turnover rate is an average – some institutions have even higher rates of turnover, even over 100% Job of food counter attendant is much less stressful.
  • Comparison of DCW hours to others is for state of California. Define informal caregivers as families and friends who provide unpaid care.
  • 31% of new nurses received baccalaureate degrees in 2005. 42% receive associate degrees
  • APRNs includes nurse practitioners, clinical nurse specialists, certified nurse anesthetists, and certified nurse midwives. First bullet is for patients aged 65+
  • Fellowhip position focuses on preparing pharmacist for academia and independent research. The one fellowship focuses on Alzheimer’s Disease.)
  • 32% of office visits to PA’s are by patients aged 65+.
  • In 1987, the NIA predicted the need for
  • EMT modules exist for pediatrics and obstetrics
  • Foundations came together – thought the issue was important, not being currently addressed. Warranted an IOM study.
  • Professionals refers to all types of health care professionals: Doctors, nurses, social workers, pharmacists, dentists, and others. Direct-care workers include nurse aides, home health aides, and personal and home care aides. Informal caregivers are the friends and families of older adults
  • Note that numbering of recommendations reflects their location in the report. Therefore, Recommendation 4.2 is the second recommendation in Chapter 4.
  • Current minimums for Certified Nursing Assistants and home health aides is 75 hours, although many states have increased these minimums. The 120 hours reflects the amount required by the top quartile of states. More hours may be needed as the competencies required by direct-care workers are more fully understood.
  • The value of the care provided by informal caregivers is estimated at over $300 billion annually, yet little is done to prepare them for their roles. Additionally, they are providing more and more complex services in community-based settings.
  • The value of the care provided by informal caregivers is estimated at over $300 billion annually, yet little is done to prepare them for their roles. Additionally, they are providing more and more complex services in community-based settings.
  • In 2007 Forbes magazine named personal and home care aides as one of the top 25 worst-paying jobs. On average, direct-care workers earn less than $10 per hour. 19% of female DCW have incomes below the poverty level and about ¼ of all DCW have no health insurance coverage.
  • Incentives to adopt these models should include enhanced payments for services provided under these models, provision of capital for infrastructure (e.g. HIT), streamlining of regulatory and administrative requirements, and elimination of impediments that may prevent older persons themselves from participating (e.g. higher co-payment for mental health services under Medicare).
  • Program for All-Inclusive Care of the Elderly - Modeled after On Lok program in San Francisco for Asian American older population CARE TEAM MINIMUM: primary care physician, registered nurse, social worker, physical therapist dietitian
  • These must be included at a minimum
  • Turnover rate MUCH lower than national averages. Capitated Medicare payments 42% lower than projected FFS expenditures, but capitated Medicaid payments about 86% higher than projected for FFS.
  • Barriers include the financing system, which often lack payment for important features such as care coordination, interdisciplinary teams, and patient education.
  • These new models of care for older adults should address areas where few models are currently being tested, such as prevention, long-term care, and palliative care Also, need to learn more about how to use the workforce more effectively within these models. All models should also consider appropriateness for special populations (ethnic, rural, etc.)
  • This includes JOB DELEGATION, whereby tasks are passed from more highly trained individuals to individuals with less specialized training. However, this delegation will require training of the professionals in supervisory skills and training of workers in new skills needed, along with the corresponding compensation. Need to recognize that patients and informal caregivers are important in this delegation of tasks.
  • Allow patients to become more independent and therefore less reliant on caregivers Increase efficient use of professional workforce (remote monitoring) Improve safety of care and caregiving (EHR to improve coordination; technologies that help lift/transfer patients may reduce on-the-job injury.
  • We need commitment from everyone: Feds, state, prof. orgs, foundations, local government, etc. This committee was not designed or charged to do full cost estimates. Acknowledge that improving care will certainly require more money, but the costs associated with continuing to provide care poorly may be even higher.
  • For informal caregivers, “When needed”- when your parent, spouse, etc. becomes demented, frail, etc.

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  • Retooling for an Aging America: Building the Health Care Workforce
  • Overview
    • Why is this important?
    • How did this study come about?
    • What are our findings?
    • Where do we go from here?
  • Why is this important?
    • Future increases in the population
    • Older persons use more services
    • Current care is not optimal
    • Inadequate workforce
  • 1. Future Increases
    • Increased longevity
    • Increase from 12% to 20% of population
    • Demographic trends
      • Racial and ethnic diversity
      • Family structure
  • Heterogeneous Needs
    • Special Populations
      • Ethnogeriatrics
      • Lesbian, gay, and bisexual persons
    • Continuum of Care
      • Health promotion/disease prevention
      • Palliative care
  • Palliative Care and Training
    • 80% of deaths occur over age 65
    • Almost all medical schools and 62% of pharmacy schools provide exposure
    • Medical students surveyed:
      • 20% received education
      • 39% unprepared to address patient fears
      • About half unprepared for their own feelings
  • Palliative Care and Residency
    • Many graduating residents feel unprepared to counsel patients:
      • 41% of family medicine residents
      • 43% of internal medicine residents
    • Only 2.7% of geriatric medicine fellows feel unprepared to care for dying patients
  • 2. Older Persons Use More Services
    • ~80% have a chronic disease
    • Geriatric syndromes
    • Current 12% of the population use:
      • 26% of physician office visits
      • 35% of hospital stays
      • 34% of prescriptions
      • 38% of EMS responses
  • Prevalence of Chronic Disease 36.6 26.2 10.9 Heart Disease 18.3 18.6 7.7 Diabetes 25.7 17.2 7.1 Any Cancer 53.8 52.9 22.9 Hypertension Age 75+ Age 65-74 Age 18+
  • Prevalence of Disability/Limitations 21.7 13.6 9.5 Vision limitations 29.4 22.8 8.0 Absence of all natural teeth 50.4 31.9 16.8 Trouble hearing Age 75+ Age 65-74 Age 18+
  • 3. Current Care is Not Optimal
    • Little guidance on effective interventions
    • Proportion of recommended care that is received declines with age
    • Models shown to be effective and efficient are not implemented widely
    • Lack of payment for interdisciplinary care, care coordination, patient education, and geriatric expertise.
  • 4. Inadequate Workforce
    • A. Not Enough Specialists
    • ~7,100 geriatricians and declining
    • ~1,600 geriatric psychiatrists
    • Less than 1% of nurses and pharmacists and less than 4% of social workers specialize in geriatrics
  • First-Year Geriatric Medicine Fellowship Positions 0 100 200 300 400 500 1997 1999 2001 2003 2005 2007 Available Filled
  • First-Year Geriatric Psychiatry Fellowship Positions 0 20 40 60 80 100 120 140 160 1997 1999 2001 2003 2005 2007 Available Filled
  • New Certifications in Geriatric Medicine, 1998-2004 Practice Pathway Eliminated Training Requirement Reduced to 1 Year
  • New Certifications in Geriatric Psychiatry, 1991-2004 Practice Pathway Eliminated Training Requirement Reduced to 1 Year
  • 4. Inadquate Workforce
    • B. Poor Recruitment of Specialists
    • Negative stereotypes of older adults
    • Lower incomes
    • High cost of training
    • Lack of opportunity for advanced training
  • 4. Inadequate Workforce
    • C. Poor Retention of Direct-Care Workers
    • 71% turnover of nurse aides
    • Money spent retraining
    • Personal and home care aides earn $8.54. Food counter attendants earn $7.76
    • Direct-care workers are more likely to lack health insurance and use food stamps
  • Direct-Care Worker Turnover
    • 40-60% of home health aides leave in one year; 80-90% in first 2 years
    • Assisted-living staff turnover: 21-135%
    • CNA turnover: 71% on average
    • Turnover costs employers $4.1 billion annually
  • 4. Inadequate Workforce
    • D. Not Enough General Training
    • Professionals receive little training in the common problems of older adults
    • Direct-care workers - federal training minimums have not changed in 20 years and may be lower than for dog groomers, cosmetologists, and crossing guards.
    • Informal caregivers receive little training
  • Registered Nurses
    • Less than 1% of RNs certified in geriatrics
    • 29% of baccalaureate programs have a certified faculty member
    • 1/3 of baccalaureate programs require exposure to geriatrics
    • Associate degree programs - unknown
  • Advanced Practice Registered Nurses
    • 23% of office visits and 47 of hospital outpatient visits
    • About 2.6% of APRNs certified in geriatrics
    • 300 geriatric APRNs graduate annually
  • Dentists
    • Geriatrics not recognized as a specialty for certification
    • 13 programs for academic geriatric dentistry
    • No residencies specific to geriatrics
    • Geriatrics not explicitly tested on board examinations
  • Pharmacists
    • Less than 1% certified in geriatrics
    • 10 residency programs in geriatric pharmacy (out of 351)
    • One fellowship position (Alzheimer’s Disease)
  • Physician Assistants
    • 32% of office visits
    • Less than 1% specialize in geriatrics
    • Accreditation requires exposure, but no minimum specified
    • No advanced training programs in geriatrics
  • Social Workers
    • In 1987, the NIA estimated a need for 70,000 geriatric social workers by 2020
    • Today, only 4% specialize (about 1/3 of that estimated need)
    • Between 1996 and 2001, the number of students specializing in aging decreased by 15.8%
  • Social Workers
    • 40% of schools lack faculty in aging
    • 80% of BSW programs have no coursework in aging
    • 29% of MSW programs offer aging focus
    • In the 1980s, almost half of MSW programs offered specialization in aging
  • Other Professions and Occupations
    • None of the following specialties has a subspecialty certificate in geriatrics
      • Dermatology
      • Emergency Medicine
      • Physical Medicine and Rehabilitation
      • Surgery
    • All have certificates in pediatrics
  • Other Professions and Occupations
    • EMT national curriculum does not have a module for geriatrics
    • 22% of undergraduate dietetics and nutrition programs offer courses in aging
    • Only 1 of 8 schools of podiatric medicine lists a course devoted to geriatrics
  • How Did This Study Come About?
    • • AARP
    • • Archstone Foundation
    • • Atlantic Philanthropies
    • • California Endowment
    • • Commonwealth Fund
    • • Fan Fox and Leslie R. Samuels Foundation
    • • John A. Hartford Foundation
    • • Josiah Macy, Jr. Foundation
    • • Retirement Research Foundation
    • • Robert Wood Johnson Foundation
  • Committee Members
    • • John W. Rowe - Chair, Columbia University
    • • Paula G. Allen-Meares , University of Michigan
    • • Stuart H. Altman , Brandeis University
    • • Marie A. Bernard , University of Oklahoma
    • • David Blumenthal , Massachusetts General Hospital
    • • Susan A. Chapman , University of California, San Francisco
    • • Terry T. Fulmer , New York University
    • • Tamara B. Harris , National Institute on Aging
    • • Miriam A. Mobley Smith , Chicago State University
    • • Carol Raphael , Visiting Nurse Service of New York
    • • David B. Reuben , University of California, Los Angeles
    • • Charles F. Reynolds III , University of Pittsburgh
    • • Joseph E. Scherger , University of California, San Diego
    • • Paul C. Tang , Palo Alto Medical Foundation
    • • Joshua M. Wiener , RTI International
  • Statement of Task
    • Future health status and utilization
    • Best use of the workforce
    • Education and training; recruitment and retention
    • Improving public programs to support the above
  • Committee Process
    • 15 month study
    • 4 in-person meetings
    • 6 commissioned papers
    • 2 public workshops with 18 speakers
    • 14 external reviewers
  • Three-Pronged Approach to Building Capacity
    • Enhance geriatric competence of general workforce in common problems
    • Increase recruitment and retention of geriatric specialists and caregivers
    • Implement innovative models of care
  • Enhancing Competence
    • Professionals
      • Doctors, nurses, social workers, pharmacists, etc.
    • Direct-Care Workers
      • Nurse aides, home health aides, personal and home care aides
    • Informal Caregivers
      • Families and friends
  • Professionals (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.
  • Professionals (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.
  • Direct-Care Workers (5.1)
    • States and the federal government should increase minimum training standards for all direct-care workers.
    • continued
  • Direct-Care Workers (5.1), continued
    • Federal requirements for the minimum training of CNAs and home health aides
      • raise to at least 120 hours
      • include demonstration of competence in the care of older adults as a criterion for certification.
    • continued
  • Direct-Care Workers (5.1)
    • States should also establish minimum training requirements for personal care aides.
  • Informal Caregivers (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 of Geriatric Specialists and Caregivers
    • Professionals
    • Direct-Care Workers
  • Professionals (4.3)
    • Public and private payers should provide financial incentives to increase the number of geriatric specialists in all health professions.
  • Professionals (4.3a)
    • Enhancement of reimbursement for clinical services delivered to older adults by practitioners with geriatric certification.
  • Internal Medicine Subspecialties $207K 96% Rheumatology $205K 93% Infectious Disease $358K 95% Hematology & Oncology $189K 92% Endocrinology $163K 54% Geriatric Medicine Median Compensation Fill Rate (1 st year) Subspecialty
  • Professionals (4.3b)
    • Enhancement of the Geriatric Academic Career Award (GACA) program to support junior geriatrics faculty in other health professions in addition to medicine.
  • Professionals (4.3c)
    • Loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists.
    • National Geriatric Service Corps
  • Direct-Care Workers (5.2)
    • State Medicaid programs should increase pay and fringe benefits for direct-care workers.
  • Median Hourly Wages, 2006 $7.76 $8.54 $9.34 $10.67 Food Counter Attendants Personal and Home Care Aides Home Health Aides Nurse Aides
  • Implementing Innovative Models of Care
    • Disseminating known models
    • Discovering newer models
    • Expanding individual roles
    • Improving capacity and safety
  • Principles for Redesigning Models 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.
  • Effective Features of New Models
    • Interdisciplinary team care
    • Care management
    • Chronic disease self-management
    • Caregiver education and support
    • Pharmaceutical management
    • Proactive rehabilitation
    • Preventive home visits
    • Transitional care
  • Disseminating Known Models (3.1)
    • Promote the dissemination of those models of care for older adults that have been shown to be effective and efficient.
  • PACE
    • Adults 55+ eligible for nursing home care
    • Combines Medicare and Medicaid funds plus individual contributions
    • Provide Medicare and Medicaid covered services
    • Also provide adult day care, nutritional counseling, recreational therapy, transportation, and personal care services
  • PACE Interdisciplinary Care Team
    • Primary care physician
    • Registered nurse
    • Social worker
    • Physical therapist
    • Pharmacist
    • PACE manager
    • Occupational therapist
    • Recreational therapist
    • Dietitian
    • Home-care coordinator
    • Personal care attendants
    • Drivers
  • PACE - Results
    • Higher satisfaction and quality of life
    • Improved health status & functioning
    • Increased # of days in community
    • Lower mortality
    • Among frailest, lower rates of hospital and nursing home utilization
    • continued
  • PACE – Results, continued
    • 12% annual turnover rate of aides
    • Payments ~10% higher
    • Savings for Medicare, higher costs for Medicaid
  • PACE – Dissemination
    • 1997 – permanent Medicare provider
    • By 2004, 180 PACE programs authorized, but today only 42 operating in 22 states
    • Only about 10,000 of 3 million eligible adults being served
    • continued
  • PACE – Barriers
    • Requires start-up funding for initial investment
    • Insufficient patient base – especially sparse rural populations
    • High costs for older adults not eligible for Medicaid
  • Why Aren’t Successful Models of Care Implemented Widely?
    • In general, innovative models of care for older persons are difficult to diffuse because of administrative and financial barriers
  • Discovering Newer Models (3.2)
    • Increase support for research and demonstration programs.
      • promote development of new models
      • promote effective use of the workforce
  • Expanding Individual Roles (3.3)
    • Expand the roles of individuals beyond the traditional scope of practice, such as through job delegation.
    • Development of an evidence base
    • Measurement of additional competence
    • Greater professional recognition and salary
  • Improving Capacity and Safety (6.1)
    • Support technological advancements that could enhance an individual’s capacity to provide care for older adults.
      • ADL technologies
      • Health information technologies, including remote technologies
  • Monitoring (1.1)
    • 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.
  • Next Steps
    • Need everyone
    • Cost implications
    • Need to act now
  • Summary
    • All providers (including family and friends) need to have the core competencies in caring for older persons
      • During general training
      • Lifelong
      • When needed
      • continued
  • Summary
    • Recruit and retain a cadre of geriatric specialists
      • Teach core competencies
      • Provide care for older persons with the most complex needs, and
      • Develop and test new models of care
      • continued
  • Summary
    • Redesign health care delivery to achieve the vision of care
      • New models
      • Changing roles, job delegation
      • Changing financing to support models
    • Retooling for an Aging America:
    • Building the Health Care Workforce
    • www.iom.edu/agingamerica