Retooling for an Aging America: Building the Health Care Workforce Joshua M' Wiener, Ph'D'

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Retooling for an Aging America Building the
Health Care WorkforceJoshua M. Wiener, Ph.D.
RTI International is a trade name of Research
Triangle Institute
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Institute of Medicine Study

• Chaired by Jack Rowe, former CEO of Mt. Sinai NYU
  Health and Aetna, Inc.
• Committee members included
• Carol Raphael, CEO of VNSNY
• Terry Fulmer, Dean of NYU School of Nursing
• Free PDF of the report available at
  http//books.nap.edu/catalog.php?record_id12089

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Funders of Institute of Medicine Study

• 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

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Introduction

• Is the current health care workforce adequate to
  provide high-quality care to older people?
• Will the future health care workforce be adequate
  to provide high-quality care to older people?
• Obvious concern to 35 million older people now
  and 87 million in 2050
• Older people are currently 12 of the population,
  but account for about 36 of physician,
  prescription drug and hospital use and 90 of
  nursing home use
• With aging of population, by 2030, older people
  will account for over 50 of total health
  expenditures

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What is the Problem?
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Special Issues of Older People

• Older people are not just young people with more
  birthdays.
• Multiple chronic illnesses 23 of Medicare
  beneficiaries with 5 or more chronic illnesses
  account for 68 of Medicare spending
• Significant proportion have disability
• 50 of 85 have ADL/IADL disability
• 50 of 75 have trouble hearing
• 22 of 75 have vision limitations
• 29 of 75 have lost all of their teeth
• 80 of all deaths among people over age 65

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Special Issues of Older People (cont.)

• Geriatric syndromes of
• Functional impairment
• Dementia
• Incontinence
• Osteoporosis
• Falls
• Decubitus ulcers

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Organization of the Delivery System

• What does this mean
• For the person with vision problems who takes 5
  different medications but cannot read the bottle
  label?
• For the person with dementia who has surgery in
  the hospital and is completely disoriented?
• For the person who has no teeth who is losing
  weight because they cant chew?

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Standard Acute Care Does Not Work

• Often not recover from illness emphasis on
  management of multiple chronic illnesses
• Care coordination/care management/interdisciplinar
  y teams
• Strictly medical model inadequate Long-term care
  and other social services are often needed
• Treating standard medical problems more complex
• Palliative and end-of-life care are often part of
  the mix

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Not Enough Geriatric Specialists

• About 1 of physicians are geriatricians and
  declining
• Geriatricians, who are more highly trained
  internists, make 7 less than general internists
• Fewer than 1 of RNs and 4 of social workers
  specialize in geriatrics

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Inadequate Training forGeneral Health Care
Workers

• 41 of graduating internal medicine residents say
  they are unprepared to counsel patients on
  palliative care
• Only 10 of board exam for internal medicine on
  geriatrics
• Only 33 of baccalaureate nursing programs
  require expose to geriatrics

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Direct Care Workers

• 71 annual turnover rate for certified nursing
  assistants in nursing homes
• Low levels of training
• In many states, little required training for
  personal care workers
• Federal government requires only 75 hours for
  certified nursing assistants and home health
  aides
• By comparison in CA manicurists (350 hours) and
  hair dressers/barbers (1500 hours)

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Long-Term Care Workers (cont.)

• Low wages of workers In 2006, personal and home
  care aides earn 8.54 per hour
• Lack of health insurance and other fringe
  benefits

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Long-Term Care Workforce (cont.)

• May adversely affect
• Continuity of care
• Staffing levels
• Quality of care
• Family caregivers receive little training and
  support, despite economic value of 350 billion

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Changes in the Size of the Elderly Population
Relative to the Potential Workforce, 1998 to 2050
Source Authors analysis of U.S. Census
Projections, 2003.
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Institute of Medicine Recommendations
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Increase Number of Geriatric Specialists

• Increase reimbursement for geriatric specialist
  services
• Establish loan forgiveness, scholarships, and
  direct financial incentives for geriatric
  specialists
• Providers should increase pay and fringe benefits
  for long-term care workers and Medicare and
  Medicaid should finance the increase

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Enhance General Competence

• Require more geriatric content in all licensure
  and certification for health care professionals
  and workers
• States and the federal government should increase
  the minimum training standards for CNAs and home
  health aides from 75 to 120 hours
• States should establish minimum training
  requirements for personal care aides not covered
  by federal rules

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Implement Innovative Models of Care

• Promote replication of comprehensive care models
  shown to be effective and efficient
• Include older persons and their family network as
  active partners in their care
• Chronic disease self-management
• Caregiver education and support

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Implement New Models of Care (cont.)

• Increase task delegation to nurses, physician
  assistants, and direct care workers to increase
  workforce capacity, career ladders and reduce
  costs
• Support development of new technologies, such as
  assistive devices for ADLs and health information
  technologies
• Increase funding for research and demonstration
  programs

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Summary Recommendations

• Recruit and retain a cadre of geriatric
  specialists
• Research and teaching
• Provide care for older people with most complex
  needs
• Develop and test new models of care
• Require all providers have core competencies in
  caring for older persons
• Redesign health care delivery to achieve new
  vision of care