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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 na- tion 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 appropri- ate 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 nationâs 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
16 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 millionâor almost double the nearly 37 million older adults alive in 2005. The number of the âoldest old,â 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 longev- ity 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 âan epidemic of chronic diseaseâ (Anderson and Horvath, 2004). The vast majority of older adults (80 percent) suffer from at least one chronic condition (e.g., demen- tia, 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 condi- tions may last for years, place limits on the activities of older adults, and require ongoing care (Anderson and Horvath, 2002). As a result, individu- als 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 Ameri- cans 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
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 profes- sionals, 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 chal- lenges 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 liv- ing (ADLs). 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). â Activities of daily living (ADLs) relate to personal care needs, including eating, bathing, using the toilet, dressing, and transferring from bed to chair.
18 RETOOLING FOR AN AGING AMERICA TABLE 1-1â Health and Home-Care Jobs Among the Top 30 Fastest- Growing Occupations in the United States, 2006 to 2016 Employment by Year (in Thousands) Percent Occupation 2006 2016 Increase (%) Personal- and home-care aides 767 1,156 50.6 Home health aides 787 1,171 48.7 Medical assistants 417 565 35.4 Physical therapist assistants 60 80 32.4 Pharmacy technicians 285 376 32.0 Dental hygienists 167 217 30.1 Mental health counselors 100 130 30.0 Mental health and substance abuse social workers 122 159 29.9 Dental assistants 280 362 29.2 Physical therapists 173 220 27.1 Physician assistants 66 83 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 care- givers) (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 di- vorce 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 grow- ing need for paid long-term care providers.
INTRODUCTION 19 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), pharma- cists (HRSA, 2000), dentists (Ryan, 2003), and many others are already apparent, particularly in non-urban areas (Box 1-1). Enrollment in medi- cal 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 geri- atric 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 â¢ Twenty-nine of 38 states surveyed indicate that a shortage of direct-care workers is currently a âseriousâ or âvery seriousâ issue (Harmuth and Dyson, 2005). â¢ There is currently a shortage of approximately 12,000 geriatricians; by 2030 the shortage will be about 28,000 (ADGAP, 2007a; Alliance for Aging Re- search, 2002). â¢ 2025 there is projected to be a shortage of 100,000 physicians (AAMC, By 2007a). â¢ The shortage of registered nurses overall is projected to be as high as 808,000 by 2020 (Auerbach et al., 2007; HRSA, 2002).
20 RETOOLING FOR AN AGING AMERICA Projected Number of Needed Geriatricians 40,000 Actual and Estimated Number of Geriatricians 35,000 Number of Geriatricians 30,000 25,000 20,000 15,000 10,000 5,000 0 1990 1995 2000 2005 2010 2020 2030 Year FIGURE 1-1â 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 as- sociated with attempting to predict specific numbers of future health care workforce supplies. Instead, the committee chose to present some previ- ously reported predictions of shortages in an attempt to highlight the rela- tive 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, but direct-care workers (i.e., nursing assistants, home health aides, and personal- and home-care aides) warrant at least equal consider- â For the purposes of this report, the term âprofessionalâ is meant to imply a professional in a health care field.
INTRODUCTION 21 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 per- cent (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 fre- quently 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 de- liver 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 Alzheimerâs disease (Alzheimerâs 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 fi- nancial support from both public and private organizations. Still, many
22 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 re- quirements exist for workers employed directly by consumers or by agencies that provide non-skilled home services, although many states do set mini- mum training levels. The limited training that does occur tends to focus on discrete clinical tasks instead of core competencies for interpersonal com- munication 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 caregiv- ers, 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 deliv- ery 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 an- other (Guterman, 2007; IOM, 2003; MedPAC, 2006). It also does not pay
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 deter- rent to the practice of primary care. The Medicare reimbursement system allocates more generous payments for procedures and specialist servicesâa policy that some have suggested discourages physicians from entering pri- mary 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 geriatri- ciansâ 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. Medicareâs 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 opportuni- ties 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 physi- cian 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 ex- pand 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 popula- tion. 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).
24 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 1-2â Intermediate Projections for the Medicare Program, 2007, 2016, and 2030 2007 2016 2030 Medicare enrollment 44 million 55 million 79 million Medicare expenditures $438 billion $863 billion NA HI trust fund assets $305 billion $221 billion $0 Medicare spending as a percentage of gross 3.2% 3.9% 6.5% domestic product (2015) Number of workers per Medicare beneficiary 3.9 3.2 2.4 (2006) (2015) NOTE: NA = Not Available; HI = Hospital Insurance. SOURCE: Federal HI and SMI Trust Funds Board of Trustees, 2007; Moon and Storeygard, 2002.
INTRODUCTION 25 pressures to control costs will surely increase while spending continues to rise faster than economic growth. The Congressional Budget Office re- ports 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 oc- cur. 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 clini- cally indicated services. In coming years the health care system as a whole will be faced with a number of pressing concerns, including childrenâs 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 grow- ing 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 work- shops. Staff and committee members also met with and received informa- tion from a variety of stakeholders and interested individuals. Support for the study was provided by 10 organizations: AARP, the Archstone Foun- dation, the Atlantic Philanthropies, the California Endowment, the Com- monwealth 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.
26 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 populationâ the rapidly growing and increasingly diverse population of Americans who are over 65 years of ageâthen 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 Ameri- cans 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 high- value 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 committeeâs goals by the year 2030, immediate action needs to be taken.
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 inte- grated, 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 fam- ily 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 pro- vide 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 set- tings. 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 encom- pass 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 signifi- cance 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 âneedâ 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
28 RETOOLING FOR AN AGING AMERICA reason that economists generally use the term âdemand,â which refers to the services an individual would be willing to pay for at a particular price. In economic terms, âneedâ and âdemandâ are quite different things. In the context of health care services for older adults, however, âneedâ is understood to be âclinical need,â which is what a medical or social ser- vices professional believes is appropriate care for an individual, given his or her medical condition. And since the public and private third-party pay- ment system uses âclinical needâ 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 âdemandâ 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 âsupply.â The committee rec- ognizes, for example, that the supply of health care workers available to take care of older adults will depend on the expected wages or compensa- tion 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 committeeâs recommendations to increase the âsupplyâ 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 IOMâs first report on the ge- riatric workforce, Aging and Medical Education (IOM, 1978), which raised national awareness of the challenges posed by the aging of the U.S. popula-
INTRODUCTION 29 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 Founda- tion 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 careâthat 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 IOMâs 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, eq- uitable, 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 areasâin 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
30 RETOOLING FOR AN AGING AMERICA adults if current patterns of care and of the training of providers continue. 2. 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. 3. Informal caregivers provide a large amount of long-term care ser- vices to families and friends, and will continue to be a significant part of the health care workforce. 4. The structure of public programs precludes both the effective de- livery of care to many older adults and the development of an ap- propriate workforce. 5. 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:â 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 accomplish- ments 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.
INTRODUCTION 31 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 nationâs 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 cur- rent 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 Medicareâs 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 par- ents. 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 com- mittee 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 ad- ditional 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
32 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, includ- ing assistance with ADLs and with instrumental activities of daily living (IADLs). 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 patientâs overall care team. The chapter discusses the need to promote the knowledge and skills of these caregivers in order to enhance their capa- bilities 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. REFERENCES AACN (American Association of Colleges of Nursing). 2006. Student enrollment rises in U.S. nursing colleges and universities for the 6th consecutive year. http://www.aacn.nche. edu/06Survey.htm (accessed July 9, 2007). AACP (American Association of Colleges of Pharmacy). 2006. Interest in pharmacy continues to rise as more students apply, enroll and graduate from schools of pharmacy. http:// www.aacp.org/site/tertiary.asp?TRACKID=&VID=2&CID=1257&DID=7613 (accessed July 9, 2007). AAHSA (American Association of Homes and Services for the Aging). 2007. Aging services: The facts. http://www.aahsa.org/aging_services/default.asp (accessed July 9, 2007). AAMC (Association of American Medical Colleges). 2007a. 2007 state physician workforce data book. Washington, DC: AAMC. AAMC. 2007b. U.S. medical school enrollment projected to increase by 17 percent. http:// www.aamc.org/newsroom/pressrel/2007/070212.htm (accessed July 9, 2007). AAPA (American Academy of Physician Assistants). 2007. 2007 AAPA physician assistant census report. Alexandria, VA: AAPA. â Instrumental activities of daily living (IADLs) refer to activities needed to remain inde- pendent, including shopping for groceries, preparing hot meals, using the telephone, and managing money.
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INTRODUCTION 37 Warshaw, G. A., and E. J. Bragg. 2003. The training of geriatricians in the United States: Three decades of progress. Journal of the American Geriatrics Society 51(7s):S338-S345. Warshaw, G. A., E. J. Bragg, R. W. Shaull, and C. J. Lindsell. 2002. Academic geriatric pro- grams in US allopathic and osteopathic medical schools. Journal of the American Medical Association 288(18):2313-2319. Wenger, N. S., D. H. Solomon, C. P. Roth, C. H. MacLean, D. Saliba, C. J. Kamberg, L. Z. Rubenstein, R. T. Young, E. M. Sloss, R. Louie, J. Adams, J. T. Chang, P. J. Venus, J. F. Schnelle, and P. G. Shekelle. 2003. The quality of medical care provided to vulnerable community-dwelling older patients. Annals of Internal Medicine 139(9):740-747. Wiener, J. M. 1996. Managed care and long-term care: The integration of financing and ser- vices. Generations 20(2):47-53. Wiener, J. M. 2007. Itâs not your grandmotherâs long-term care anymore! Public Policy & Aging Report 16(3):28-35. Wolf, D. A., and C. F. Longino, Jr. 2005. Our âincreasingly mobile societyâ? The curious persistence of a false belief. Gerontologist 45(1):5-11. Wolff, J. L., and J. D. Kasper. 2006. Caregivers of frail elders: Updating a national profile. Gerontologist 46(3):344-356. Wright, B. 2005. Direct care workers in long-term care. Washington, DC: AARP. Zabinski, D. 2007. Medicare in the 21st century: Changing beneficiary profile. Presentation at March 2007 Meeting of the Committee on the Future Health Care Workforce for Older Americans, Washington, DC.