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 co-morbidities. 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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