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 time-consuming 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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