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4 The Professional Health Care Workforce CHAPTER SUMMARY The need for health care professionals trained in geriatric principles is escalating, but even though opportunities for geriatric specialization ex- ist, few providers choose this career path. The education and training of professionals in the area of geriatrics is hampered by a scarcity of faculty, inadequate and variable academic curricula and clinical experiences, and a lack of opportunities for advanced training. Furthermore, the educa- tion and training of geriatric health care professionals is often limited in scope and needs to be expanded both to take into account the diversity of health care needs among older populations and to prepare professionals for the coming new models of care, many of which will require changed or expanded roles. The committee recommends that more be done to en- sure that all professionals have competence in geriatric principles. Finally, the recruitment and retention of geriatric professionals are hampered by several factors, including the persistent stereotypes of older populations, the aging of the workforce itself, and significant financial disincentives. The committee recommends that several types of financial incentives be offered to promote the recruitment and retention of clinical and academic geriatric specialists. In the coming decades demand is expected to increase markedly for all types of health care professionals in all settings of care for the elderly population. This chapter examines issues related to the education, training, recruitment, and retention of health care professionals in the care of older adults. This chapter begins with a brief overview of the supply of and de- 123
124 RETOOLING FOR AN AGING AMERICA mand for professionals who care for older patients. The overall pattern here is that older Americans account for a disproportionate share of professional health care services but, in spite of this demand, the number of geriatric specialists remains low. Next the chapter focuses on a few individual pro- fessions essential to the care of older adults. It goes on to examine over- arching themes in geriatric education and training. While improvements in the education and training of the health care workforce in geriatrics are evident, these efforts have failed to ensure that all providers who treat older adults have the necessary knowledge and skills to provide competent care. The chapter then considers future trends in education and training. Not only will there be a need for many more professionals working with older adults, but health care workers of the future will need to take on new and expanded roles. As discussed in Chapter 3, these changing responsibilities will affect the entire workforce, including the direct-care workforce, infor- mal caregivers, and patients themselves. (These populations are examined in more detail in Chapters 5 and 6.) Finally, the chapter concludes with strategies for recruiting and retaining professionals in geriatric specialties. These strategies largely depend on overcoming financial disincentives, such as relatively low salaries and the high cost of training. SUPPLY AND DISTRIBUTION The number of professional workers directly involved in the care of older adults is difficult to quantify, for a number of reasons: changes in em- ployment status, differing measures (e.g., licensed vs. active professionals), and the presence of ill-defined and overlapping titles for many occupations. Furthermore, many professionals treat older patients without being identi- fied as geriatric providers either by title or certification. Health care-related careers, including medical assistants, physician assistants, physical thera- pists, mental health counselors, pharmacy technicians, and dental hygien- ists, account for about half of the countryâs 30 fastest-growing occupations (BLS, 2007a). Despite the rapid growth, however, the supply of health care workers does not satisfy current demands and will certainly fall short of the increased demands expected in the future. In fact, the United States will need an additional 3.5 million health care providers by 2030 just to main- tain the current ratio of health care workers to population (Table 4-1). While the general need for professionals who care for older patients is high, the particular need for geriatric specialists is even greater. For ex- ample, geriatricians are the physicians who are specially trained in care â While a physician who has extensive experience with elderly patients may specialize in ge- riatrics, the term âgeriatricianâ refers to a physician who has been certified in the subspecialty of geriatric medicine, or received a certificate of added qualifications in geriatric medicine.
THE PROFESSIONAL HEALTH CARE WORKFORCE 125 TABLE 4-1â Number of Providers in 2005 and Projected Number Needed in 2030 to Maintain Current Provider-to-Population Ratios (in Thousands) 2005 2030 Difference Total health providers 9,994 13,522 3,528 Registered nurses 2,458 3,326 868 Nursing aides 2,009 2,719 709 Physicians 804 1,088 284 Licensed practical and vocational nurses 654 885 231 Pharmacists 236 319 83 Dentists 163 220 57 Other providers 3,670 4,965 1,295 NOTE: Numbers are for overall health care workforce and not limited to geriatric population. SOURCE: Mather, 2007. of the elderly population as a subspecialty of internal or family medicine. These specialists account for only a very small portion of the total physician workforceâjust 7,128 physicians are certified geriatricians, or one geriatri- cian for every 2,546 older Americans (ADGAP, 2007b). By 2030, assuming current rates of growth and attrition, one estimate shows that this number will increase to only 7,750 (one for every 4,254 older Americans), far short of the total predicted need of 36,000 (ADGAP, 2007b; Alliance for Aging Research, 2002). In fact, some argue that there could be a net decrease in geriatricians because of the decreasing number of physicians entering train- ing programs as well as the decreasing number of geriatricians who choose to recertify (Gawande, 2007). Geriatric psychiatry faces a similar shortage. Only 1,596 physicians are currently certified in geriatric psychiatry, or one for every 11,372 older Americans, and by 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b). Other professions have similarly low numbers of geriatric specialists. For example, just 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 registered nurses (Kovner et al., 2002) and pharmacists are certified in geriatrics. In short, dramatic increases in the number of geriatric special- ists are needed in all health professions. Even with tremendous effort, it is â Personal communication, T. Scott, American Society of Consultant Pharmacists, November 6, 2007.
126 RETOOLING FOR AN AGING AMERICA unlikely that we can completely fulfill the projected needs, but, still, much can be done to begin to close the gaps. Aside from concerns about the total numbers of health care workers with geriatric competencies, the composition and distribution of the health care workforce for older Americans should also be considered. This in- cludes racial and ethnic diversity as well as the geographic distribution of professionals trained to provide care to older adults. Racial and Ethnic Diversity The committee commissioned a paper on the increasing diversity of older populations (Yeo, 2007) and found that the diversity of the work- force is important for several reasons. First, minority patients often prefer to be treated by health care professionals of the same ethnic background (Acosta and Olsen, 2006; IOM, 2004; Mitchell and Lassiter, 2006; Tarn et al., 2005). Second, a provider from a patientâs own background may have better understanding of culturally appropriate demonstrations of respect for older populations and may also be more likely to speak the same lan- guage (in the case of bilingual providers). Finally, providers from minority populations often account for most of the services provided to underserved populations (HRSA, 2006a). For example, while only 3.4 percent of den- tists are black, they treat almost two-thirds (62 percent) of black patients (Mitchell and Lassiter, 2006). While older adults are more diverse than ever before, the younger gen- erations training to care for them are even more diverse (see Chapter 2). The pattern of this diversity, however, will not necessarily match up with the pattern of diversity among older Americans. Table 4-2 demonstrates, for example, that there is significant diversity among resident physicians in geriatrics, but the percentage of white residents (39 percent) is much lower than the percentage of whites in the elderly population, and the percentage of Asian residents (42 percent) is much higher that the percentage of Asians in the elderly population. Geographic Distribution The distribution of both professionals and older adults varies widely across the country. Since both of these populations may be unevenly dis- tributed across regions, states, and local communities, different areas may have different workforce needs. The committee commissioned a paper on state profiles of the U.S. health care workforce (Mather, 2007). This report showed there is an average of 443 dentists per 100,000 population aged 65 and older in the United States, but this ratio varies widely among the states. There are 759 dentists per 100,000 older adults in New Hampshire, but
THE PROFESSIONAL HEALTH CARE WORKFORCE 127 TABLE 4-2â Race and Ethnic Origin of Residents in Geriatric Medicine and Psychiatry, 2006 American Native Indian/ Hawaiian/ Alaskan Pacific Other/ Hispanic Black Native White Asian Islander Unknown Origina Total Geriatrics 4 0 22 15 1 2 5 44 (Family Medicine) Geriatrics 23 0 92 103 5 20 23 243 (Internal Medicine) Geriatric 7 0 25 32 1 7 8 72 Psychiatry Total 34 0 139 150 7 29 36 359 aHispanicorigin was determined separately from race, and so the categories are not mutu- ally exclusive. SOURCE: Brotherton and Etzel, 2007. only 104 dentists per 100,000 older adults in Kansas. This variance must be caused by a variety of factors, since these states do not have similar distri- butions in the numbers of other types of professionals. New Hampshire has a lower-than-average number of pharmacists per population of older adults, for example, while Kansas has a higher-than-average number of registered nurses. The need for health care workers with geriatric skills can also vary according to the distribution of older adults. For example, as discussed in Chapter 2, older adults make up 16.8 percent of Floridaâs total population, while they account for only 6.8 percent of Alaskaâs population (U.S. Census Bureau, 2008). Differences by community are likely to also vary widely. Therefore, the needed distribution of the health care workforce for older American can vary by both the state and the individual profession. The recruitment and retention of health care professionals in rural areas is especially challenging (IOM, 2005), and this is an important fac- tor when discussing the health care needs of the geriatric population, since older adults are disproportionately over-represented in rural areas (Hawes et al., 2005). Older adults that live in rural areas tend to be less healthy than those in urban areas and to have a higher rate of difficulty with ac- tivities of daily living (ADLs) (Brand, 2007; Magilvy and Congdon, 2000), while their access to health services is limited by the relatively small num- ber of providers (especially specialists) that choose to work in rural areas. Because of the relatively small number of specialists, physician assistants and nurse practitioners play significant roles in providing health services
128 RETOOLING FOR AN AGING AMERICA to the rural aging population (Henry and Hooker, 2007). Among the chal- lenges in recruiting any type of professional to rural areas are professional isolation, heavy call schedules, and few job opportunities for the spouses of the health care professionals. The best strategies for recruitment and retention may be those that focus on the training of existing rural provid- ers in geriatric skills via distance education in conjunction with the use of remote technologies to increase the availability of outside geriatric experts for rural elderly populations. THE CURRENT STATE OF GERIATRIC EDUCATION AND TRAINING For more than 30 years the IOM (IOM, 1978, 1993) and others (LaMascus et al., 2005; Olson et al., 2003) have called for improvements in the geriatric education and training of virtually all types of health care providers. While progress is evident, many formal training programs still do not include robust coursework in geriatrics (Berman et al., 2005; Eleazer et al., 2005; Linnebur et al., 2005; Scharlach et al., 2000). Among the barriers to increased education and training in geriatrics for all professions are the lack of faculty, lack of funding, lack of time in already-busy curricula, and the lack of recognition of the importance of geriatric training (Bragg et al., 2006; Hash et al., 2007; Hazzard, 2003; Rubin et al., 2003; Simon et al., 2003; Thomas et al., 2003; Warshaw et al., 2006). Furthermore, very little is known about the best methods to improve the knowledge and skills of professionals in caring for older adults (Gill, 2005). It is not possible to discuss every profession in detail, as virtually ev- ery professional cares for older patients to some degree. In the following section, several professions instrumental to the care of older adults are ex- amined. (See Table 4-3 for an overview.) Specifically, the status of geriatric education and training within each profession is discussed. While some professions are discussed more extensively than others, the committee does not intend for this to imply any conclusion about their importance to the care of older adults. Rather, this is a reflection of the amount of data avail- able and the extensiveness of the existing education and training programs in geriatrics. Overall, the breadth and depth of geriatric education and training remains inadequate to prepare all professionals for the health care needs of the future elderly population. Physicians Older Americans account for a disproportionate share of physician services, but a 2002 survey of primary care physicians showed that only half of these physicians believed that their colleagues could adequately treat
THE PROFESSIONAL HEALTH CARE WORKFORCE 129 geriatric conditions (Moore et al., 2004). This section examines the educa- tion and training of all physicians in the care of older adults, with a focus on the path for geriatricians. Geriatric Content The geriatric curricula in medical schools has had notable improve- ments. The percent of medical schools with requirements for âgeriatric exposureâ has increased from 82 percent in 1985-1986 to 98 percent in 1996-1997 (Eleazer et al., 2005). Still, much of this exposure is inadequate or occurs too late in the educational process to influence which speciali- ties the students select. As noted above, several major public and private initiatives support improvement in the geriatric education of physicians. In May 2001 the Donald W. Reynolds Foundation awarded $19.8 million in grants to 10 institutions in order to develop comprehensive training pro- grams in geriatrics (Donald W. Reynolds Foundation, 2007). Because of the success of this effort, the Donald W. Reynolds Foundation repeated the grants in 2003 and 2005, distributing almost $20 million in each round, and in October 2007 the Donald W. Reynolds Foundation issued a request for proposals for a fourth series of grants. In addition to this effort, the Donald W. Reynolds Foundation has established two departments of geri- atric medicine. The Health Resources and Services Administration (HRSA) distributes grants to support Geriatric Education Centers (GECs), which educate and train individuals in the care of older patients. These centers are often col- laborative efforts among several health-profession schools or health care facilities and have a special focus on interdisciplinary training. In July 2007 the John A. Hartford Foundation and the Association of American Medical Colleges (AAMC) hosted the National Consensus Con- ference on Geriatric Education. There the participants developed a set of minimum standards for the knowledge, skills, and attitudes of graduating medical students with respect to the care of older patients (Leipzig, 2007). The standards covered a number of domains, including â¢ cognitive and behavioral disorders; â¢ medication management; â¢ self-care capacity; â¢ falls, balance, gait disorders; â¢ atypical presentation of disease; â¢ palliative care; â¢ hospital care for older adults; and â¢ health care planning and promotion.
130 RETOOLING FOR AN AGING AMERICA TABLE 4-3â Overview of the Education and Training of Professionals in Geriatrics Nurses Oral-Health Workers Pharmacists Total jobs RNs: 2.5 millionb,2 Dentists: 161,000; 243,000 held (2006)a,1 LPNs: 749,000 (General dentists: 136,000) Dental hygienists: 167,000 Geriatric Less than 1% of RNs Unknown 1,297 certified (less than specialization and about 2.6% of 1%)4 or certification APRNs certified3,28 Academic 76% of baccalaureate 63% of dental schools 43% have two full-time leadership programs have at least have a geriatric faculty; most rely on one full-time âexpert,â director or chairman9 part-time faculty10 29% have a certified faculty member8 Exposure to One-third of 100% of dental and 43% have a discrete geriatrics in baccalaureate dental hygiene schools course; all schools schools programs require have identifiable provide opportunity for exposure; 94% of content; 18.8% advanced training in fundamental courses of dental hygiene geriatrics or long-term integrate geriatric schools have a discrete care10 content8 course14 Advanced Less than 100 13 programs for 10 residency programs; geriatric masterâs and post- geriatric dental one fellowship training masterâs programs; academic training; no program19 programs five programs in residencies specific to geropsychiatric geriatric dentistry18 nursing3 Number of Approximately 300 Unknown 13 resident slots; one advanced geriatric APRNs fellowship slot19 geriatric produced annually3 trainees Explicit Yes21 No22 No general certification; testing on national licensure non-geriatric exam organized by board approaches23 certification exams?c
THE PROFESSIONAL HEALTH CARE WORKFORCE 131 Physician Assistants Physicians Social Workers 66,000 633,000 595,000 Less than 1% specialize5 7,128 certified in geriatric About 4% of social workers medicine; 1,596 certified in specialize7 geriatric psychiatry6 27% of program Less than 1% of faculty 40% of schools have no faculty directors surveyed had specialize; all programs have knowledgeable in aging13 some form of geriatric an identifiable leader in training11 geriatrics12 Accreditation requires 98% of schools require some 80% of BSW students have no geriatric exposure, form of exposure16 coursework in aging17 including clinical experience in long-term care15 None Medicine: 29% of MSW programs offer 139 fellowship programs aging certificate, specialization, (468 1st-year positions)6 or concentration20 Psychiatry: DSW: unknown 58 fellowship programs (142 1st-year positions)6 Not Applicable Medicine: 253 in 1st year; Unknown 34 in 2nd year6 Psychiatry: 726 Yes24 Internal Medicine: 10% of No general certification; exam25 national licensure exam Family Medicine: optional organized by approaches28 module26 Psychiatry: yes27 continued
132 RETOOLING FOR AN AGING AMERICA TABLE 4-3â Continued Nurses Oral-Health Workers Pharmacists Geriatric American Nurse None Commission for certification Credentialing Center Certification in Geriatric Fellowship status body (ANCC) Pharmacy (CCGP) offered by American Society for Geriatric Dentistry (ASGD) and diplomate status offered by American Board of Special Care Dentistry (ABSCD) ABBREVIATIONS: Advanced Practice Registered Nurse (APRN); Bachelor of Social Work (BSW); Doctor of Social Work (DSW); Licensed Practical Nurse (LPN); Master of Social Work (MSW); Registered Nurse (RN). aNumber of jobs may be greater than number of practicing professionals, since some profes- sionals work in more than one position. bAs of 2004, there were 240,260 jobs held by APRNs. cRelies on description of exam content. The group then developed a total of 36 competencies based on these domains (AAMC/The John A. Hartford Foundation, 2007). The competen- cies included â¢ identification of medications to be avoided or used with caution in older adults; â¢ ability to define and distinguish delirium, depression, and dementia; â¢ assessment of ADLs and IADLs; â¢ identification of physiological changes due to aging; â¢ identification of psychological, social, and spiritual needs of pa- tients; and â¢ performance of examination to assess skin pressure ulcer status. While the coverage of geriatric issues at medical schools is increasing, students still express significant reservations about their abilities to treat older patients. The AAMCâs 2002 Medical School Graduate Questionnaire found 55 percent of graduates perceived inadequate coverage of geriatric issues in medical school; only 68 percent felt adequately prepared to care
THE PROFESSIONAL HEALTH CARE WORKFORCE 133 Physician Assistants Physicians Social Workers None American Board of Internal National Association of Social Medicine (ABIM), American Workers (NASW) Board of Family Medicine (ABFM), American Board of Psychiatry and Neurology (ABPN), American Osteopathic Board of Family Practice (AOBFP), American Osteopathic Board of Internal Medicine (AOBIM) SOURCES: 1BLS, 2008; 2HRSA, 2006; 3Kovner et al., 2002; 4Personal communication, T. Scott, American Society of Consultant Pharmacists, November 6, 2007; 5AAPA, 2007; 6ADGAP, 2007b; 7Center for Health Workforce Studies, 2006; 8Berman et al., 2005; 9Mohammad et al., 2003; 10Odegard et al., 2007; 11Olson et al., 2003; 12LaMascus et al., 2005; Warshaw et al., 2002; 13Scharlach et al., 2000; 14Mohammad et al., 2003; Tilliss et al., 1998; 15Brugna et al., 2007; 16Eleazer et al., 2005; 17Lubben et al., 1992; 18HRSA, 2005; 19ACCP, 2007; ASHP, 2007; 20Cummings and DeCoster, 2003; 21NCSBN, 2007; 22ABGD, 2007; 23NABP, 2008; 24NCCPA, 2008; 25ABIM, 2007; 26ABFM, 2007; 27ABPN, 2007c; ASWB, 2007; 28HRSA, 2006b. for older persons in acute-care settings, and only half felt prepared to care for them in long-term care settings (Eleazer et al., 2005). In spite of this, less than 3 percent of medical students take geriatric electives (Moore et al., 2004). Advanced Training Postdoctoral training of physicians occurs during both residency and fellowship programs. As of 2003, 27 types of medical residency programs (accounting for 70 percent of trainees) included Accreditation Council for Graduate Medical Education (ACGME) requirements for some form of ge- riatrics training, but the extent of such training is highly variable (Bragg and Warshaw, 2005; Bragg et al., 2006; Simon et al., 2003). One survey showed that only about half of graduating family-practice and internal-medicine residents (48 percent and 52 percent, respectively) felt very prepared to care for elderly patients (Blumenthal et al., 2001). Although a large majority of graduating psychiatry residents felt very prepared to diagnose and treat delirium (71 percent) and major depression (96 percent), only 56 percent felt very prepared to diagnose and treat dementia.
134 RETOOLING FOR AN AGING AMERICA Several specialties that treat large numbers of older patients, includ- ing ophthalmology, general surgery, and dermatology, do not include any requirements for geriatric training (Bragg and Warshaw, 2005). Since 1994 the John A. Hartford Foundation has funded the Geriatrics-for-Specialists Initiative, which aims to improve geriatric knowledge of surgical special- ists and related medical specialists. Their Geriatrics Education for Specialty Residents Program encourages interaction between directors of specialty residencies and the geriatricians within their facilities. After completion of a residency in internal medicine, family medicine, or general psychiatry, a physician can pursue a fellowship in geriatric medicine or geriatric psychiatry, which may last one or more years. Fellows may be graduates of allopathic or osteopathic schools of medicine, or they may be international medical graduates (IMGs). This finding is notable in that IMGs have become increasingly relied upon to provide primary care services and care to underserved populations in the United States (Hart et al., 2007). About half of geriatric-medicine and geriatric-psychiatry fellows (58.2 percent and 44.4 percent, respectively) are female, and about two-thirds of the two types of fellows (64.1 percent and 61.1 percent, respectively) are IMGs (Brotherton and Etzel, 2007). By comparison, across all specialties IMGs make up only 26.9 percent of the entire resident-physician popula- tion. As seen in Figures 4-1 and 4-2, while the number of positions available in geriatric-medicine and geriatric-psychiatry fellowship programs has been increasing, the percentage of positions filled has been decreasing. Very few fellows continue past the first year, possibly because of the decrease in the requirement for the length of training that is needed to pursue certification (discussed later in this section). The Veterans Administration (VA) plays an important role in the devel- opment of geriatric fellowships. In the 1970s, in anticipation of the wave of aging World War II veterans, the VA established Geriatric Research, Educa- tion and Clinical Care Centers (GRECCs) to improve geriatric knowledge (Goodwin and Morley, 1994; Warshaw and Bragg, 2003). These centers are still in operation and often educate and train multiple disciplines in geriatric care. At around the same time the VA first established fellowship programs in geriatric medicine and geriatric psychiatry, often in conjunction with a GRECC. Today, about 25 percent of geriatric-medicine fellowship positions and almost 50 percent of geriatric-psychiatry fellowship positions are sup- ported by the VA, and many other geriatric fellows will receive part of their training in VA facilities (VA, 2007a). The VA also funds four fellowships in geriatric neurology (VA, 2007b). Other branches of the federal government also support the geriatric education and training of physicians. HRSA administers the Title VII Ge- riatrics Health Professions Program. Although funding was eliminated for
THE PROFESSIONAL HEALTH CARE WORKFORCE 135 500 sitions ear Po ble First-Y Availa 400 ar Positions Filled First-Ye 300 200 100 0 97 98 99 00 01 02 03 04 05 06 07 19 19 19 20 20 20 20 20 20 20 20 Year FIGURE 4-1â First-year geriatric medicine fellowship positions, available and filled. SOURCE: ADGAP, 2007b. Figure 4-1 150 io ns Firs t-Year Posit Available 100 ar Positions Filled First-Ye 50 0 97 98 9 00 01 2 03 4 05 06 07 9 0 0 19 19 19 20 20 20 20 20 20 20 20 Year FIGURE 4-2â First-year geriatric psychiatry fellowship positions, available and filled. SOURCE: ADGAP, 2007b. Figure 4-2
136 RETOOLING FOR AN AGING AMERICA fiscal year 2006, it was restored for fiscal year 2007, with $31.5 million for the support of 48 GECs, 88 Geriatric Academic Career Awards (GACAs) for individuals, and 11 Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Professions Program awards given to institutions to prepare faculty for these professions (ADGAP, 2007c). In 2007 Congress approved a fiscal year 2008 Labor-Education-HHS appropriations bill that included continuation of the Title VII geriatrics programs at the same funding level as for fiscal year 2007, but President Bush vetoed the bill on November 13, 2007, and the House of Representatives failed to override the veto on November 15, 2007. Finally, CMS is the major financial supporter of the residency training of all physicians. In fiscal year 2004 it paid $7.9 billion for graduate medi- cal education (GME) (GAO, 2006). Medicare pays for a portion of the cost of GME for physician residents and fellows through direct and indirect medical-education payments. Direct medical education (DME) payments support hospitalsâ direct cost of operating a GME program, especially salary support for residents; indirect medical education (IME) payments cover a portion of the added patient care costs associated with teaching hospital settings (MedPAC, 2003). Through GME, Medicare has specifi- cally supported advanced training in geriatrics by counting geriatric fellows as full-time equivalent (FTE) residents, while all other subspecialty fellows count only as one-half of a full-time equivalent. Thus hospitals that train geriatricians receive more GME funding than hospitals that train other types of subspecialists (MedPAC, 2003). Furthermore, when GME updates were frozen in the 1990s, geriatric programs were exempt. Sites of Training The training of medical students and residents tends to occur in discrete episodes of care, within single disciplines, and usually only in the hospital or ambulatory setting, which means that residents generally do not have the opportunity to follow patients longitudinally over time and across set- tings of care. Thus many students and residents lack exposure to alternative sites of care of importance to the geriatric patientânamely, home-care set- tings, nursing homes, and assisted-living facilities. Deterrents to increasing student clinical experiences in these sites include the need for an on-site supervisor of the same discipline, the need for collaboration with site staff, a lack of student interest, and a lack of time in already crowded programs (Leipzig et al., 2002; Warshaw et al., 2006). In one national survey, only 27 percent of graduating family-practice â Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2008. HR 3043. 110th Congress. July 13, 2007.
THE PROFESSIONAL HEALTH CARE WORKFORCE 137 residents and only 13 percent of graduating internal-medicine residents felt very prepared to care for nursing-home patients (Blumenthal et al., 2001). Still, clinical experiences in alternative sites of care have increased some- what from past years (Cheeti and Schor, 2002; Matter et al., 2003). For example, Weill Cornell Medical College implemented a clerkship in which third- and fourth-year medical students accompanied a geriatrics team on home visits to patients living with chronic illness; when interviewed about the experience, 84 percent of recent graduates felt that it had had a positive effect on their delivery of care (Yuen et al., 2006). Among the obstacles to expanding training sites is a lack of funding to cover the expenses of residents while in non-hospital settings. As described above, Medicare distributes GME funds, primarily to hospitals, to support the training of residents. However, the Balanced Budget Amendment of 1997 allows for other providers, including federally qualified health cen- ters, rural health clinics, and managed care organizations to receive GME funds directly (AAMC, 2007c). Furthermore, since 1987 hospitals have been allowed to count the time that residents spend in settings outside the hospital, such as nursing homes and physician offices, subject to certain agreed-upon conditions between the hospital and the outside entity. Still, this does not happen often enough. Since most care of older patients occurs in non-hospital settings, more needs to be done to ensure that professionals are fully trained in how to care for patients in these settings. The committee concluded that comprehensive care of older patients should include training in non-hospital settings. Recommendation 4-1:â The committee recommends that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patientsâ homes. Residency program directors need to ensure that their residentsâ sched- ules include adequate time rotating through these alternative settings, and the directors and hospital administrators need to be willing to collabo- rate with the outside entities to reach mutually agreeable conditions for partnership. Board Certification Physicians may pursue voluntary national board certification in many major specialties and then become certified in the subspecialties of geriatric medicine or geriatric psychiatry. It was in 1988 that the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine
138 RETOOLING FOR AN AGING AMERICA (ABIM) first offered a 10-year certificate of added qualifications (CAQ) in the subspecialty of geriatric medicine. Originally CAQs were available only to physicians with at least 2 years of specialty geriatric training or to those who had substantial clinical experience (the âpractice pathwayâ). In 1994 the ABIM and ABFM phased out the practice-pathway option, and in 1998 they lowered the training requirement to only 1 year, resulting in a slight upward trend in the recruitment of geriatric fellows. As seen in Figure 4-3, the number of physicians certified annually surged and then sharply decreased when the practice-pathway option was eliminated; only 13.4 percent of all new certifications occurred after the practice-pathway option ended. Osteopathic physicians may pursue CAQs from the ABIM or ABFM and also from the American Osteopathic Board of Family Physicians (AOBFP) or the American Osteopathic Board of Internal Medicine (AOBIM), which have offered certification since 1991. The AOBIM ended the practice-pathway option in 1994, and the AOBFP ended it in 2002. The American Board of Psychiatry and Neurology (ABPN) recognized geriatric psychiatry as a subspecialty in 1989 and first awarded 10-year CAQs in 1991 (ABPN, 2007a). In 1996 the ABPN phased out the practice- pathway option and subsequently reduced post-graduate training require- ments from 2 years to 1 year. Figure 4-4 shows a similar surge and then a drop in certification related to these events. Only 13 percent of all geriatric psychiatrists ever certified became certified after the practice pathway was phased out. As the geriatric certifications expire, many physicians do not pursue recertification; most of these physicians were certified via the practice path- way. Reasons for not recertifying are multifactorial, including retirement, the burden of the process, and the lack of perceived benefit. Table 4-4 shows that only about half of all physicians certified in geriatric medicine or geriatric psychiatry before 1994 have been recertified (ADGAP, 2005). By comparison, 89 percent of physicians who received specialty certificates in other disciplines from the ABIM between 1990 and 1995 enrolled in the maintenance of certification process; of those, 81 percent completed the process (ABIM, 2005). The comparable rate of recertification in geriatrics among other health professions is unknown. â In 2006, the ABIM recognized geriatric medicine as a subspecialty of internal medicine instead of as a CAQ (ABIM, 2006). â The ABPN dropped the term âof added qualificationsâ in 1997 (ABPN, 2007b). â Excluding clinical cardiac electrophysiology, critical care medicine, and geriatric medicine.
THE PROFESSIONAL HEALTH CARE WORKFORCE 139 3000 Practice Pathway 2500 Eliminated 2000 1500 Training Requirement 1000 Reduced to 1 Year 500 0 1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 Year FIGURE 4-3â Numbers of physicians newly certified in geriatric medicine, 1988-2004. 4-3.eps SOURCE: ADGAP, 2005. 800 Practice Pathway 700 Eliminated 600 500 400 300 Training Requirement Reduced to 1 Year 200 100 0 1991 1992 1994 1995 1996 1998 2000 2002 2004 Year FIGURE 4-4â Numbers of physicians newly certified in geriatric psychiatry, 1991-2004. SOURCE: ADGAP, 2005. 4-4.eps
140 RETOOLING FOR AN AGING AMERICA TABLE 4-4â Number of Physicians Certified and Recertified in Geriatrics Family Medicine Internal Medicine Psychiatry Yeara Certified Recertified Certified Recertified Certified Recertified 1988 752 477 1,654 801 NA NA 1990 473 313 1,204 524 NA NA 1991 NA NA NA NA 490 323 1992 597 359 1,254 605 359 236 1994 771 371 1,568 585 422 154 TOTAL 2,593 1,520 5,679 2,515 1,271 713 (58.6%) (44.3%) (56.1%) NOTE: NA = not applicable. aCertification examinations by each body were not available in every calendar year. SOURCE: ADGAP, 2005. Nurses Professional nurses represent the largest sector of the health care workforce responsible for patient care in most health care settings. The pro- fessional nurse workforce consists of registered nurses (RNs) and advanced practice registered nurses (APRNs), who are RNs prepared in masterâs degree programs. With few exceptions, almost all professional nurses are involved in the care of older adults. In addition to direct care, professional nurses supervise licensed practical nurses (LPNs) and certified nurse aides (CNAs) (discussed in Chapter 5). While the current and impending nursing shortage has received much attention, there have been some improvements; enrollment in baccalaureate programs increased by 5 percent from 2005 to 2006, and the number of graduates increased by 18 percent (AACN, 2006). However, this upswing is tempered by the fact that more than 32,000 qualified applicants to nursing programs (baccalaureate level or higher) were not accepted; about half the schools identified lack of faculty as the main barrier to admitting more students (AACN, 2006; Anderson, 2007). Additionally, men remain underrepresented in the nursing profession and need to be considered for recruitment efforts to allay workforce shortages (see Chapter 5). Licensed Practical Nurses LPNs have a more limited scope of practice than RNs, but this scope can vary widely among states, especially in light of the nursing shortage. â this report, âprofessional nursesâ refers to nurses who have graduated from an approved In baccalaureate, associate degree, or diploma nursing program and who have passed a national licensing examination, the NCLEX-RNs. â some states, this level of nurse is referred to as a licensed vocational nurse (LVN). In
THE PROFESSIONAL HEALTH CARE WORKFORCE 141 With about 26 percent of all LPNs working in nursing homes, LPNs are especially important to the care of older adults in long-term care settings (BLS, 2007b). LPNs often provide more hours of care per nursing home resident per day than do RNs (Harrington et al., 2006). LPNs receive about 1 year of training through technical or vocational schools or through junior or community colleges. With experience and training, LPNs may supervise nurse aides. For example, the Institute for the Future of Aging Services is developing a leadership training program to teach LVNs the necessary skills and competencies to be more effective supervisors (IFAS, 2008). Some of the elements of this training include communication, critical thinking, con- flict resolution, and cultural competency. Little is known about the geriatric training of LPNs. Registered Nurses As with other professions, nurses generally receive little or no prepara- tion in the principles that underlie geriatric nursing in their basic nursing education. In 2005, 31 percent of new RNs received baccalaureate degrees, but only one-third of the baccalaureate programs required a course focused on geriatrics. Almost all baccalaureate programs include some geriatric content, but the extent of this content is unknown (Berman et al., 2005). While 42 percent of RNs receive their initial education through associate degree nursing programs (HRSA, 2006b), the degree of integration of geri- atrics into these programs is also unknown. Given the paucity of geriatric content in programs preparing nurses, it is appropriate to assume that most practicing RNs have little formal preparation in geriatrics. There exist a number of efforts aimed at ensuring nursing competency in geriatric care. In 2000, for example, the American Association of Col- leges of Nursing (AACN) developed guidelines for geriatric competencies in baccalaureate programs. The National Council of State Boards of Nursing (NCSBN) mapped those guidelines against the National Council Licensure Examination (NCLEX), which is required for licensure of all nurses, to ensure adequate testing on geriatric issues (Wendt, 2003). Still, more needs to be done to analyze the depth of this content (Bednash et al., 2003). As with other professions, there exist various public and private efforts aimed at increasing the geriatric content of nursing programs and develop- ing geriatric nursing leaders. Since 1996 the John A. Hartford Foundation has invested $60 million in the Hartford Geriatric Nursing Initiative, which includes the Institute for Geriatric Nursing and the Centers of Geriatric Nursing Excellence. These programs foster the development of academic leaders and increase geriatric content in the education and training of nurses. In 2002 the Atlantic Philanthropies funded a 5-year initiative to improve nursing competence in treating older adults (Box 4-1). Under the
142 RETOOLING FOR AN AGING AMERICA BOX 4-1 Nurse Competence in Aging Initiative âNurse Competence in Aging (NCA) is an initiative to improve the quality of health care older adults receive by enhancing the geriatric competenceâthe knowledge, skills and attitudesâof the 400,000 nurses who are professionally identified as members of approximately 57 specialty nursing associations. Nurse Competence in Aging is committed to: âEnhancing Geriatric Activities of National Specialty Nursing Associations Associa- tions apply for grant funding and receive technical assistance to move forward with geriatric best practice initiatives. Funded associations are designated ANA- SNAPGs, or American Nurses Association-Specialty Nursing Association Partners in Geriatrics. âPromoting Gerontological Nursing Certification to encourage specialty nurses to obtain dual certification and validate their geriatric competence along with their specialty expertise. Scholarships available! âProviding a Web-based Comprehensive Geriatric Nursing Resource Center GeroNurseOnline is a comprehensive website providing current best practice information on care of older adults. We invite you to explore GeroNurseOnline and become a Gero Smart Nurse! âNurse Competence in Aging was a 5-year initiative funded by The Atlantic Philan- thropies (USA) Inc., awarded to the American Nurses Association (ANA) through the American Nurses Foundation (ANF), and represented a strategic alliance among ANA, the American Nurses Credentialing Center (ANCC) and the John A. Hartford Foundation Institute for Geriatric Nursing, New York University.â SOURCE: ANA, 2007. Nurse Reinvestment Act, the Comprehensive Geriatric Education Program provides funds for clinical training of nurses in geriatrics, the development and dissemination of geriatric nursing curricula, and the preparation of nursing faculty to teach geriatrics. Funding for this program has remained at around $3.4 million annually since fiscal year 2004 (HRSA, 2007b). The Nurse Education, Expansion, and Development Act of 200710 proposes to â Nurse Reinvestment Act. Public Law 107-205. 107th Congress. August 1, 2002. 10â Nurse Education, Expansion, and Development Act of 2007. S 446. 110th Congress, 1st session. January 31, 2007.
THE PROFESSIONAL HEALTH CARE WORKFORCE 143 offer grants to nursing schools to increase the integration of geriatrics into their core curricula. Similar initiatives have also been developed to support education and training in geropsychiatric nursing. For example, in 2007 the John A. Hartford Foundation awarded $1.2 million to establish the Geropsychiatric Nursing Collaborative. This group will establish a core set of geropsychi- atric competencies in order to develop basic curricula for all levels of nurse training (The John A. Hartford Foundation, 2007). Advanced Practice Registered Nurses An RN may become an APRN by obtaining a masterâs degree and may become certified either through a national certifying examination or through state certification mechanisms. An APRN functions as an inde- pendent health care provider, addressing the full range of a patientâs health problems and needs within an area of specialization. There are a number of different types of APRNs, including: nurse practitioners (NPs), who provide primary care; clinical nurse specialists, who typically specialize in a medical or surgical specialty; certified nurse anesthetists; and certified nurse mid- wives. The pipeline for producing APRNs with a specialization in geriatrics is inadequate to meet the need. As with other types of nurses, the John A. Hartford Foundation has been a key supporter in the development of the geriatric APRN workforce. In particular, the Building Academic Geriatric Nursing Capacity Scholars and Fellows Awards Program targets doctoral and post-doctoral nurses and APRNs who want to redirect their careers toward geriatrics (Fagin et al., 2006). NPs represent a particularly important component of the workforce car- ing for older adults because of their ability to provide primary care as well as care for patients prior to, during, and following an acute care hospitalization and also to care for residents in institutional long-term care settings. NPs treat a disproportionate number of older adultsâ23 percent of office visits and 47 percent of hospital outpatient visits with NPs are made by people 65 and older (Center for Health Workforce Studies, 2005). Furthermore, NPs care for a higher proportion of elderly poor adults than do physicians or physician assistants (Cipher et al., 2006). Finally, NPs have been shown to provide high-quality care and be cost-effective (Hooker et al., 2005; Melin and Bygren, 1992; Mezey et al., 2005). While APRNs care for large numbers of older adults in ambulatory care, hospitals, and institutional long-term care settings, APRN education programs lack specific geriatric requirements. The AACN publishes a set of competencies called Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care (AACN, 2004), but it does not require
144 RETOOLING FOR AN AGING AMERICA that these competencies be incorporated into educational programs. Some of these competencies include â¢ ability to distinguish between illness and normal aging; â¢ assessment of geriatric syndromes; â¢ identification of changes in mental status; â¢ education of patients and their families about prevention and end- of-life care; â¢ assessment of cultural and spiritual concerns; and â¢ collaboration with other health care professionals. Little is known about on-the-job opportunities for APRNs to gain knowledge and skill in geriatric nursing care. Oral-Health Care Workers The oral health needs of older adults are significantly different from the needs of younger people, and older adults face a variety of challenges in meeting these needs. One of the barriers facing older adults who need oral-health services is lack of access to care. This lack of access is often due to the lack of coverage under Medicare for routine services, but it is also the case that many oral-health professionals are reluctant to travel to alternative sites of care (such as community-based settings) or to man- age the complicated social and medical challenges associated with older patients. Even though the delivery of basic oral-health services to nursing home patients is supported by government regulation, less than 20 percent of residents of government-certified institutions received dental services in 1997 (MacEntee et al., 2005). In 1987 the National Institute on Aging (NIA) predicted a need for 1,500 geriatric dental academicians and 7,500 dental practitioners with training in geriatric dentistry by the year 2000 (NIA, 1987). By the mid-1990s, however, only about 100 dentists in total had completed advanced training in geriatrics (HRSA, 1995), and little has changed since then. The availability of geriatric training for dentists has improved over the past few decades. In 1976, only 5 percent of dental schools offered courses in geriatric dentistry and, at that time, more than half of the programs (52 percent) did not foresee geriatric dentistry as part of their future curricula (Mohammad et al., 2003). However, by 1981 about half of all schools had developed geriatric dentistry programs, and an additional 25 percent planned to add geriatric curricula in the near future. As of 2001, all dental schools reported having some curricula related to geriatric dentistry, and almost one-third operated a geriatric clinic (Mohammad et al., 2003). The geriatric content varies greatly among schools. A school may offer
THE PROFESSIONAL HEALTH CARE WORKFORCE 145 only a single elective course, for example, or material information may be imparted via guest lecturers. Additionally, exposure to clinical experiences is lagging behind the didactic requirements. Of the students graduating in 2001, almost 20 percent did not feel prepared to care for the elderly popu- lation, and 25 percent felt the geriatric dental curriculum was inadequate (Mohammad et al., 2003). The American Dental Association currently does not recognize geriatric dentistry as a separate specialty, and none of the 509 residencies recognized by the American Dental Education Association are specifically devoted to the care of geriatric patients; in contrast, specialty recognition and 71 resi- dencies exist for pediatric dentistry. In fiscal year 2005, HRSA supported seven residency programs in pediatric or general dentistry; one program specifically requested funds to improve clinical and didactic curriculum in geriatric dentistry, but the residency is not focused on geriatrics (HRSA, 2005b). The VAâs Advanced Fellowship in Geriatrics program allows den- tists (and other health care professionals) to pursue advanced research in geriatrics at one of 16 GRECCs (VA, 2007a). Previous VA fellowships in geriatric dentistry are no longer available. As mentioned previously, HRSA administers the Title VII Geriatrics Health Professions Program, which includes awards to institutions to prepare geriatrics faculty in dentistry, medicine, and behavioral/mental health. The American Board of General Dentistry (ABGD) offers board cer- tification in general dentistry following completion of a post-graduate residency; exam content does not explicitly require questions on geriatric care or on special-care dentistry, but it does explicitly require knowledge of pediatric dentistry (ABGD, 2007). Also, while the ABGDâs general dentistry certification process has minimum requirements for continuing dental edu- cation in several areas (e.g., periodontics, orthodontics, and pediatric den- tistry), it has no minimum requirements for âspecial patient care,â although it is a listed category. The American Society for Geriatric Dentistry (ASGD), part of the Special Care Dentistry Association, offers fellowship status to ASGD members who meet requirements for post-graduate and continuing education and who pass an oral examination. The American Board of Spe- cial Care Dentistry further offers diplomate status to ASGD fellows based on time in practice and membership in the SCDA. The American Dental Association, however, does not recognize this specialty board. Less is known about the geriatric education and training of dental hy- gienists, although dental hygienists are increasingly important in providing care to special populations, especially those in rural areas and long-term care settings. Dental hygienists usually earn associate degrees, but some programs grant up to a masterâs level degree. Dental hygienists are licensed by individual states, must pass written and clinical examinations, and have variable requirements for continuing education. While all schools have in-
146 RETOOLING FOR AN AGING AMERICA tegrated geriatric content, about half (49.5 percent) consider their geriatric curricula to be inadequate (Tilliss et al., 1998). Pharmacists There is currently a significant national shortage of pharmacists in the United States, which is due to a number of factors, including increased use of prescription medications, increased workloads, changing sites of service, demographic changes in the workforce, and expanding scopes of work (HRSA, 2000). While the absolute number of pharmacists has grown, sup- ply has not kept up with demand, and wide variations in the numbers of pharmacists per capita exist from state to state (Walton et al., 2007). The current shortage causes problems for older adults, who tend to be heavy users of prescription drugs and to rely on pharmacists for counseling on the proper use of medications and on the monitoring of medication-related problems, such as interactions, duplications, adverse events, and adherence irregularities (Cooksey et al., 2002). The role of pharmacists in the interdisciplinary care of older patients was reinforced in 1974 when Medicare first mandated drug regimen re- views (now called a Medication Regimen Review) in nursing homes by consultant pharmacists (Levenson and Saffel, 2007). In this setting, the role of the consultant pharmacist includes the provision information and recom- mendations to physicians regarding medications, identification of improper use of medications or the prescription of incompatible medications, and collaboration with the medical director and other staff to develop proper protocols for response to adverse events. This role has increased importance with the escalation of the number of medications given to the most frail and chronically ill patients. Additionally, with the advent of Medicare Part D, pharmacists potentially have a role in the education of older adults on their plan options and associated implications. The doctor of pharmacy (PharmD) degree requires 4 years of pharmacy education. The Accreditation Standards and Guidelines for the Profes- sional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, adopted in 2006, implies that geriatrics should be a part of the pharmacy curriculum but does not explicitly require its inclusion. However, the sci- ence foundation of programs must consider populations that have altered pharmacological needs because of physiology or other reasons; this may include geriatric patients. Some of the competencies needed for the care of older patients include knowledge of the influence of aging on drug therapy, provision of medication and wellness counseling, and knowledge of geriat- ric syndromes (Odegard et al., 2007). The American Society of Health-System Pharmacists (ASHP) accredits 1-year residencies in pharmacy, community pharmacy, or managed care
THE PROFESSIONAL HEALTH CARE WORKFORCE 147 pharmacy, which are referred to as PGY-1, for Post Graduate Year 1. Phar- macists may pursue a second year of residency training (PGY-2) in a focused area, including geriatric pharmacy. The ASHP currently accredits (or pre- accredits) 351 PGY-2 programs (ASHP, 2007). There are eight accredited programs in geriatric pharmacy, and two other programs are pre-candidates for accreditation. The American College of Clinical Pharmacy offers one fellowship position in geriatrics to prepare pharmacists for academia and independent research; this 2-year fellowship focuses on Alzheimerâs Dis- ease (ACCP, 2007). Viability of these programs has been hindered by inconsistent funding; with the exception of GECs, there are few federal or private-foundation-funded programs or initiatives that support pharmacist education and research training in geriatrics. Pharmacist licensure, which is performed by individual states and ju- risdictions, depends on passing a national examination, and 46 jurisdic- tions require an additional examination on federal law and state-specific regulations (CCP, 2006). Some states also require laboratory and oral examinations. Re-licensure requires a minimum of continuing education credits. Currently, neither continuing education in geriatrics nor demon- strated geriatric competency is required for pharmacist re-licensure in any state. However, a 2005 survey of state pharmacy laws found that one state requires all pharmacists to participate in 2 hours of continuing education in end-of-life care every 2 years, and two states require all pharmacists working as long-term care consultants to have at least a portion of their continuing education activities focused on the care of older adults (Lin- nebur et al., 2005). Physician Assistants Physician assistants (PAs) represent an important part of the work- force for the elderly population (Olshansky et al., 2005). PAs work under the supervision of a physician, but they can often work apart from the physicianâs direct presence and can prescribe medications and bill for health care services. Unlike some of the other professions described above, the PA workforce tends to be younger and is growing rapidly. About half of PAs work in family medicine or general medicine (Brugna et al., 2007; Hooker and Berlin, 2002). The 65-and-older population accounts for about 32 per- cent of office visits to PAs (Hachmuth and Hootman, 2001), and 78 percent of PAs report treating at least some patients over the age of 85 (Center for Health Workforce Studies, 2005). PAs are an especially important source of care in underserved areas, where they often act as the principal care provider in clinics, with physi- cians attending on an intermittent basis. In this vein, they are a potential source of care to meet the increased need that is projected for long-term
148 RETOOLING FOR AN AGING AMERICA care settings. Their use may be a particularly attractive strategy since, as with NPs, the use of PAs has been shown to be cost-effective (Ackermann and Kemle, 1998; Brugna et al., 2007). On the other hand, according to a survey of more than 23,000 PAs, only 5 percent of respondents reported spending any time in a nursing home or other long-term care facility, and less than 1 percent identified their primary practice as geriatrics (AAPA, 2007). Of those respondents who specialize in geriatrics, 67 percent re- ported working primarily in a nursing home or long-term care facility, and 75 percent reported spending at least some time in those settings. Almost 18 percent of PAs who specialize in geriatrics spend some time caring for patients at home, compared to 1.3 percent of all other types of PAs. And almost 22 percent of PAs specializing in geriatrics are employed by the government, primarily by the VA, while only 9 percent of all other types of PAs work for the government. The overwhelming majority of the 136 accredited PA programs are located within universities and colleges, but a few exist within hospi- tals, community colleges, and military institutions (BLS, 2007c). Most of these programs offer a masterâs level degree, while others offer bachelorâs and associate-level degrees. Virtually all students in these programsâ99 percentâpursue primary-care tracks. Most programs follow traditional curricula of medical schools (Hooker and Berlin, 2002), and while some PAs receive advanced training, the bulk of the advanced programs focus on surgical and emergency care (APPAP, 2008). Accreditation standards require training in geriatrics but do not specify a minimum workload (BLS, 2007c). As is the case with other professions, there have been many calls for increased education and training of PAs in geriatrics (Brugna et al., 2007; Olson et al., 2003; Segal-Gidan, 2002; Woolsey, 2005). Unfortunately, very little has been done to examine the quality and quantity of current geriatric education and training among PA programs. In one survey, PA program ad- ministrators who were asked which areas of the curricula needed increased emphasis said that geriatric issues related to pharmacology and mental health deserved the highest priority (Olson et al., 2003). Social Workers The need for geriatric social workers has been recognized for decades (NIA, 1987; Saltz, 1997). In 1987 the NIA estimated that there would be a need for 70,000 social workers prepared in geriatrics by 2020, or a 43 percent increase over the needs at that point in time. In spite of this urgency, the number of social workers trained in geriatrics has not kept pace with the need. While 73 percent of social workers report that they work with adults aged 55 and over, and between 7.6 and 9.4 percent of social work-
THE PROFESSIONAL HEALTH CARE WORKFORCE 149 ers are employed in long-term care settings, only about 4 percent actually specialize in geriatrics (ASPE, 2006; Center for Health Workforce Studies, 2006). Between 1996 and 2001 the number of students specializing in aging decreased by 15.8 percent (ASPE, 2006). On the other hand, many social workers begin to specialize in the care of older persons after graduation and do so without formal training in geriatrics (Cummings and DeCoster, 2003). Social workers receive training through either bachelors-level (BSW) or masters-level (MSW) programs, which may be accredited by the Council on Social Work Education. As of 2006, the Council accredited 458 BSW pro- grams and 181 MSW programs; there were also 74 doctoral programs in social work (DSW or PhD) at the time (BLS, 2007d). Combined, BSW and MSW programs graduate about 31,000 students annually (ASPE, 2006). Social workers with BSW degrees are more likely to work in long-term care settings than those with MSW degrees. A 1995 survey showed that 11.5 percent of BSW social workers worked in nursing homes or hospices, compared to 1 percent of MSW holders, and 16.5 percent identified aging services as their primary practice, compared to 3.7 percent of MSW holders (ASPE, 2006). In spite of the long-recognized need for social workers trained in aging issues, most social work programs contain little or no geriatric content in their curricula. In fact, the proportion of programs offering specialization in aging is decreasing. In the early 1980s almost half of MSW programs offered an aging specialization; by the early 1990s this had dropped to about one-third of programs, and as of 2003 only about 29 percent of MSW programs offered an aging concentration, specialization, or certificate program (Cummings and DeCoster, 2003; Scharlach et al., 2000). Existing aging curricula often have limited content, rarely offering more than one or two elective courses. In 1988 the vast majority of BSW programsâabout 80 percentâdid not offer specific instruction on aging issues (Lubben et al., 1992). The inadequacy of curricula is compounded by the fact that social- work students show low levels of interest in taking courses on aging and have persistent negative attitudes about working with older people (Hash et al., 2007; Lubben et al., 1992). In 2000 the Council on Social Work Education, in conjunction with Strengthening Aging and Gerontology Education for Social Work (SAGE-SW), surveyed social workers about the competencies that geriatric social workers and other types of social workers need in order to care for older patients effectively (Rosen et al., 2000). Sixty-five competencies were identified, of which 35 were described by the respondents as being needed by all types of social workers. These competencies included
150 RETOOLING FOR AN AGING AMERICA â¢ knowledge of the physical, social, and psychological changes of aging; â¢ knowledge of the diversity of attitudes about aging; â¢ use of case management skills to get access to needed resources; â¢ collaboration with other health professionals; â¢ identification of oneâs own biases toward aging; and â¢ respect of diverse cultural and ethnic needs. Several initiatives aim to promote education and training in geriatric social work: â¢ The Social Work Leadership Institute at the New York Academy of Medicine, funded by the Atlantic Philanthropies and the John A. Hartford Foundation, coordinates the Practicum Partnership Program, an innovative educational model to train masters level social workers in their field work (Box 4-2). â¢ The Atlantic Philanthropies established the Institute for Geriatric Social Work, which, in partnership with the American Society on Aging and other groups, promotes the training of practicing social workers in issues related to the elderly population (IGSW, 2007). â¢ In 2000-2004 the John A. Hartford Foundation supported the Geriatric Enrichment Program (GeroRich) to increase geriatric con- tent in basic social work courses at both the BSW and MSW levels (Hash et al., 2007). â¢ The John A. Hartford Foundation also supports the Council on Social Work Education Gero-Ed Center, which serves as a resource for both faculty and students to become competent in geriatric issues. Very few social-work trainees do advanced training or field work in aging, and of those who do, most are students in MSW programs. This lack of training is primarily due to a lack of funding for program support or stipends (ASPE, 2006; Scharlach et al., 2000). In partnership with the Social Work Leadership Institute, the John A. Hartford Foundation sup- ports 60 MSW programs in an effort to increase the quality and content of field experiences in aging. The effort aims to increase the numbers of MSW students who go on to specialize in geriatrics. In 1998 the National Association of Social Workers (NASW), the vol- untary professional organization of social workers, created a new specialty section on aging. Recently the NASW has developed three specialty certifi- cations in gerontology available to its members (NASW, 2007).
THE PROFESSIONAL HEALTH CARE WORKFORCE 151 BOX 4-2 The Practicum Partnership Program âThe Practicum Partnership Program sponsored by the New York Academy of Medicine and the Hartford Foundation is in its eighth year. It has trained more than 1,000 social workers to work with older adults using a specialized field edu- cation model for students at masters-level social work programs. PPPs across the country form a strong educational foundation to grow the ranks of leaders with aging specializations. âThe PPP differs from traditional MSW field education models. Based on innova- tive partnerships between universities and community-based agencies, the PPP provides students with wide-ranging, hands-on experience in older adult care. Over the course of either one or two years, students rotate through multiple field settings, gaining exposure to different care systems and a broad spectrum of life phases. âEvaluations of the program have already demonstrated promising results: in our pilot study, 80 percent of PPP graduates have gone on to pursue careers in the field of aging. Since 1999, with support from the John A. Hartford Foundation, 45 PPPs have been established at colleges and universities nationwide.â SOURCE: SWLI, 2007. Allied Health and Other Professions and Occupations Many other professionals also provide essential health services to older Americans. These professionals are pressed to meet the needs of the grow- ing older population because of shortages of supply, increases in demand, and deficiencies in geriatric education and training that are similar to those already discussed. For example, â¢ HRSAâs 1995 report on the status of geriatric education showed only 17 percent to 19 percent of physical therapy programs had at least 75 percent of their students complete a geriatric internship even though 39 percent of the physical therapy patients were over 65 (HRSA, 1995). â¢ The Emergency Medical TechnicianâBasic: National Standard Curriculum, developed by the National Highway Traffic Safety Ad- ministration, includes modules dedicated to the care of obstetrics and pediatric patients, but none are dedicated to the older adult patient (NHTSA, 1994).
152 RETOOLING FOR AN AGING AMERICA â¢ While 84 percent of optometry schools and colleges reported a required geriatrics course, the content of these courses was variable. â¢ Only one of the eight schools of podiatric medicine has a dis- crete course devoted to the care of geriatric patients, while six list courses specific to the care of pediatric patients (AACPM, 2007). â¢ In a 2004 survey of dietetics and nutrition programs, 22 percent of the undergraduate programs and 44 percent of the graduate pro- grams offered courses in aging (Rhee et al., 2004). In comparison, maternal and child health courses were offered in 31 and 51 per- cent of the programs, respectively. Thirty-seven percent of graduate programs had no faculty in geriatrics. â¢ None of the following specialties with high volumes of older pa- tients has a subspecialty certificate available in geriatrics: derma- tology, emergency medicine, physical medicine and rehabilitation, or surgery. By contrast, all have certification in pediatrics (ABMS, 2007). Of particular importance are the many occupations that fall under the broad category of âallied health care workers.â This term is ill-defined, and the many definitions that have been developed are often contradictory (Lecca et al., 2003). In general, allied health care workers represent nearly 200 different occupations, including various types of technologists, techni- cians, therapists, and health-information professionals. Many of the allied health occupations are currently experiencing shortages and are projected to be among the fastest-growing occupations in the United States (BLS, 2007a). These groups face significant increases in need for their services in all care settings (Chapman et al., 2004). The geriatric education and training of the allied health care workforce is highly variable and is usually structured according to the standards of the appropriate accrediting body. Other Issues in Geriatric Education and Training In addition to the particular professional concerns discussed in the pre- vious section, there are a number of other overarching issues that all pro- fessions face in the geriatric education and training of their practitioners. First, the education and training of all types of professionals depends on the availability of qualified faculty. Second, practitioners should be aware of the unique health care needs of several special elderly populations; these populations include various racial and ethnic groups as well as the growing number of lesbian, gay, and bisexual older adults.11 Third, all practitioners 11â There are insufficient data on transgendered older adults to include in this section.
THE PROFESSIONAL HEALTH CARE WORKFORCE 153 who care for older adults should be educated and trained in the full spec- trum of health care needs, from health promotion to palliative care. Finally, as discussed in Chapter 3, interdisciplinary care of older adults shows promise, so students in all professions should be trained on how to be an effective member of an interdisciplinary team. Leadership A well-recognized barrier to geriatric education and training of all health care providers is the inadequate number of available and qualified academic faculty (Berkman et al., 2000; Berman et al., 2005; Cavalieri et al., 1999; Graber et al., 1999; Hazzard, 2003; Kovner et al., 2002; Rhee et al., 2004; Rubin et al., 2003; Simon et al., 2003; Warshaw et al., 2006). Any effort to increase geriatric education will find itself limited by the availability of trained faculty. Furthermore, beyond the need for a greater number of geriatric faculty, all geriatric fields need strong expert leaders to develop new knowledge and recruit new students. It is a controversial question whether advanced geriatric training pro- grams should be designed to train geriatric specialists for clinical practice or to train them for academic research and leadership. Some argue that, for the sake of the efficient use of scarce resources, geriatric specialists should concentrate on their roles of performing research and training the future health care workforce and should act as clinical consultants in only the most complex cases. Beyond academics and clinical care, geriatric leaders need to learn the skills to manage staff, promote quality, and create a healthy work environment. For example, the relationship between nursing supervisors and nurse aides plays a significant role in the development of a hospitable work environment that leads to increased job satisfaction (see Chapter 5 for more on job satisfaction and turnover among direct-care workers) (Tellis-Nayak, 2007). In addition, certain management principles, such as providing rewards to nurse aide staff, have been associated with improved patient outcomes (Barry et al., 2005). This relationship will also have increased importance as direct-care workers assume more patient respon- sibility in the cascading mechanism of job delegation (discussed more later in this chapter). To increase the number of geriatric leaders, a number of public and private entities have developed programs to promote research and teaching capacities in geriatrics. Examples include the following: â¢ The Hartford Geriatric Social Work Faculty Scholars Program, funded by the John A. Hartford Foundation, aims to develop lead- ers in geriatric social work through research support, mentoring,
154 RETOOLING FOR AN AGING AMERICA skills-based workshops, and nurturing of professional relationships (GSWI, 2007; Maramaldi et al., 2004). â¢ HRSAâs Geriatric Training for Physicians, Dentists, and Behavioral/ Mental Health Professions Program is the countryâs sole source of postgraduate training for preparing dentists to teach geriatrics (HRSA, 2005a). In fiscal year 2005 HRSA funded 13 programs with a total of $6.3 million in grants. It is unknown, however, whether all of these programs filled their available dental positions. â¢ The Atlantic Philanthropies and the John A. Hartford Foundation support the Dennis W. Jahnigen Career Development Scholars Awards to develop geriatric academic leaders in surgical and re- lated specialties, such as anesthesiology, ophthalmology, and emer- gency medicine. The two foundations are also responsible for the establishment and continuation of the T. Frank Williams Research Scholars Award, which supports research by medical subspecialists in geriatrics or aging. â¢ In July 2004 the Donald W. Reynolds Foundation awarded a total of $12 million in grants to four academic health centers for them to train their medical faculty in geriatrics (Donald W. Reynolds Foundation, 2007). â¢ HRSA grants GACAs (Geriatric Academic Career Awards) directly to junior faculty at allopathic and osteopathic medical schools to support teaching (HRSA, 2005a). â¢ The John A. Hartford Foundationâs Centers of Excellence in geriat- ric medicine, psychiatry, and nursing help to train larger numbers of competent geriatric academicians and also allow specialists to devote time to geriatric research in addition to their work training future clinicians. Recognizing the scarcity of geriatric leaders, several institutions have developed innovative approaches to spread knowledge of geriatric prin- ciples. For example, â¢ In 1997 the Practicing Physician Education Project used geriatric experts to train non-geriatrician physician leaders to educate their peers on various geriatric syndromes (Levine et al., 2007). â¢ Since 1992, the Nurses Improving Care for Health System Elders (NICHE) program has worked with nurses in hospital settings to implement models and protocols that improve the care of ge- riatric patients. In the Geriatric Resource Nurse (GRN) model, a geriatric APRN trains a staff nurse to be the clinical resource on geriatric issues for other nurses (NICHE, 2008).
THE PROFESSIONAL HEALTH CARE WORKFORCE 155 â¢ The Boston University Medical Center developed the Chief Resi- dent Immersion Training (CRIT) Program in the Care of Older Adults to improve understanding and teaching of geriatric prin- ciples among residents in non-geriatric fields (ADGAP, 2007a). The program is being disseminated nationally. â¢ In 2003-2004 the Society of General Internal Medicine and the John A. Hartford Foundation worked in Collaborative Centers for Research and Education in the Care of Older Adults to enhance the ability of general internists to teach geriatrics (Williams et al., 2007). â¢ HRSA administers the National Advisory Council on Nurse Educa- tion and Practice, which, in response to the Nursing Reinvestment Act, provided grants for the geriatric education and training of registered nurses so that they can act as leaders and trainers for CNAs and LPNs (HRSA, 2003). â¢ Geriatric experts have tried to infuse geriatrics into training pro- grams for personnel who might not normally gain exposure to geriatric principles. Faculty at Northern Michigan University de- veloped a training program for correctional workers that focused on the needs of the aging prison population (Cianciolo and Zupan, 2004). Special Populations Ethnogeriatricsâ As discussed in Chapter 2, the elderly population of the future will be more diverse than todayâs older adults. Thus increased knowl- edge of different cultural belief systems will be important to the develop- ment of comprehensive and effective plans of action. For example, older Asian adults may not disclose their non-Western health beliefs, including the use of herbal medications or alternative health procedures, unless di- rectly asked (McBride et al., 1996). These concerns are especially important considering the potential mismatch between the diversity of the health care workforce and the diversity of the older adult population. For example, the high proportion of IMGs among fellows in geriatric medicine and geriatric psychiatry was demonstrated earlier in this chapter. However, concerns ex- ist for issues of communication and cultural competency in particular when IMGs care for older adults (Howard et al., 2006; Kales et al., 2006). Several efforts have been started to improve upon the ethnogeriatric ed- ucation and training of the health care workforce in settings where provid- ers are responsible for taking care of diverse populations. For example, the Collaborative for Ethnogeriatric Education produced a five-module Core Curriculum in Ethnogeriatrics and 11 Ethnic Specific Modules which can be
156 RETOOLING FOR AN AGING AMERICA BOX 4-3 Knowledge and Skills Needed in Ethnogeriatrics Knowledge: â¢ Differential health risks â¢ Diverse cultural health beliefs and practice systems â¢ Historic experiences that cohorts of older adults are likely to have experienced â¢ Palliative care Skills: â¢ Showing culturally appropriate respect to older adults â¢ Performing culturally appropriate assessments â¢ Eliciting eldersâ explanatory models of their conditions â¢ Working with older adultsâ families from different cultures â¢ Identifying cultural guidesa aCultural guides are often individuals from the local community who help patients navigate the health care system, keeping cultural preferences in mind. SOURCE: Yeo, 2007. used as resources in different geographic areas to provide content on local populations (www.stanford.edu/group/ethnoger). Box 4-3 lists some of the knowledge and skills needed to properly care for diverse populations. Lesbian, gay, and bisexual personsâ Approximately 1 million to 3 million adults ages 65 and older are gay, lesbian, or bisexual (GLB), and by 2030 that number is expected to rise to 4 million (Cahill et al., 2000). The few existing studies on the health care needs of older GLB patients report simi- larities to the health care needs of heterosexual older adults, with a few important differences. Many GLB patients do not feel comfortable disclos- ing their sexual orientation to their health care providers. Surveys reveal that discrimination based on sexual orientation is widespread in health care and other social-service settings, and it often causes GLB persons to avoid seeking health care (Cahill et al., 2000; Ryan and Futterman, 1998; Schatz and OâHanlan, 1994). The discomfort of revealing sexual orientation to health care providers is heightened for older adults who came of age at a
THE PROFESSIONAL HEALTH CARE WORKFORCE 157 time when society was even less accepting of homosexuality (Brotman et al., 2003). Knowledge of a patientâs sexuality can be critical to high-quality patient care. A recent study estimated that approximately 100,000 adults ages 50 and older are HIV positive (ASA, 2007). Older adults with HIV/AIDS may be misdiagnosed because health care providers do not perceive HIV/AIDS to be a risk among older adults and because older adults often do not disclose the nature of their sexual activity to health care providers (AIDS InfoNet, 2007; NAHOF, 2007). Additionally, GLB older adults often do not have the same family support systems as heterosexual older adults, particularly since GLB older adults are less likely to have children and are more likely to live alone (Cahill et al., 2000). The Continuum of Care Geriatric education is highly variable in its level of comprehensiveness, and it often fails to address the health care needs of older adults across the continuum of care, ranging from preventive to palliative care. Health care professionals should be aware that older adults have a vast range of health care needs. Many students still are not taught about or exposed to older populations at either end of the continuum of care. Health promotion/disease preventionâ Health promotion is beneficial for people of all ages and all health conditions, but it may be especially impor- tant to the growing cohort of healthy older adultsâthat is, the 20 percent of older Americans who have no chronic disease and who require only preventive and episodic care. Traditionally, the training of professionals in the care of older adults has focused only on the treatment of disease and has given little attention to the promotion of health. For example, poor nutrition is prevalent among seniors (IOM, 2000), but most profession- als are still not trained in the nutritional needs of older adults (Bonnel, 2003; Rhee et al., 2004). Government agencies and professional societies have developed guidelines for health promotion and disease prevention in elderly populations which include goals typically promoted for other populations, including increased physical activity, smoking cessation, and weight management (Fields and Nicastri, 2004). These guidelines are based on research that shows the benefits of health promotion and disease pre- vention in elderly populations. For example, studies have shown that older persons who practice tai chi experience fewer falls (Li et al., 2002, 2005; Wolf et al., 1996). Screening guidelines are important in nursing homes for the early detec- tion of depression and pressure ulcers (McElhone et al., 2005). Unfortu- nately, prevention and screening guidelines often lump all elderly persons
158 RETOOLING FOR AN AGING AMERICA into one group (65 years and older), and recommendations are often based on studies performed in younger age groups (Nicastri and Fields, 2004). More research is needed on preventive services for older adults, especially for the âoldest old,â and health care professionals need to be aware of the value of these services for all of their older patients. The activities of professional groups today reflect a growing awareness of the importance of health promotion and disease prevention for older patients. For example, the Geriatrics Section of the American Physical Therapy Association has an interest group on âHealth Promotion & Well- nessâ that aims to improve the education, clinical practice, and research of physical therapists in health and wellness among older adults (APTA, 2007). The American Geriatrics Society lists âhealth promotion and dis- ease prevention strategiesâ among the areas of knowledge needed for the successful preparation of internal medicine physicians who care for older adults (AGS, 2004). The American Dietetic Association includes the provi- sion of nutrition care across the lifespan, âinfants through geriatrics,â as one of the core competencies for entry-level dietitians and dietetic techni- cians (ADA, 2008). Palliative careâ Within geriatric education and training programs, pal- liative care skills are especially important since 80 percent of American deaths occur among those over age 65 (Ersek and Ferrell, 2005). Skills that are particularly important include identification and relief of physi- cal and emotional stress, effective communication, interdisciplinary team work, recognition of the signs and symptoms of imminent death, and sup- port of the bereavement process (National Consensus Project for Quality Palliative Care, 2004). The opportunities for exposure to these topics has improved greatly in recent years; almost all medical schools offer some form of end-of-life care education, and 62 percent of pharmacy schools surveyed reported didactic training in end-of-life care (Billings and Block, 1997; Herndon et al., 2003). Despite such improvements, however, the overall education and train- ing of the health care workforce in palliative care is deficient (Billings and Block, 1997; Ersek and Ferrell, 2005; Holley et al., 2003; IOM, 1997; Paice et al., 2006; Walsh-Burke and Csikai, 2005). In one survey of medi- cal students, residents, and faculty, less than 20 percent reported that they received formal education in end-of-life care, 39 percent felt unprepared to address patient fears, and almost half felt unprepared to deal with their own feelings about death (Sullivan et al., 2003). Another survey showed that less than half of graduating family medicine and internal medicine residents (41 percent and 43 percent, respectively) felt very prepared to counsel patients on end-of-life issues (Blumenthal et al., 2001). In contrast, a 2005 study showed 70 percent of geriatric medicine fellows reported completing rota-
THE PROFESSIONAL HEALTH CARE WORKFORCE 159 tions in palliative care, end-of-life care, or hospice, and only 2.7 percent felt unprepared to care for dying patients (Pan et al., 2005). In October 2006 the American Board of Medical Specialties (ABMS) announced Hospice and Palliative Medicine as a new subspecialty for ten different specialty boards (ABMS, 2006). The first certifying exams will be administered in October 2008. Interdisciplinary Team Training One element common to many models described in Chapter 3 is the use of interdisciplinary teams. The value of interdisciplinary teams for the care of older adults with complex care needs has been increasingly ac- knowledged in recent years (Dyer et al., 2003; Howe and Sherman, 2006; Inouye et al., 2000; Maurer et al., 2006; Wheeler et al., 2007; Williams et al., 2006). The term âinterdisciplinary teamâ implies an interaction and an interdependence among practitioners with different areas of expertise who are working together to treat a single patient. Still, health care professionals are typically trained separately by discipline, which fosters ideas of hier- archy and responsibility for individual decision making (Hall and Weaver, 2001). As a result, providers may gain little understanding of or apprecia- tion for the expertise of other providers or the skills needed to effectively participate in an interdisciplinary team. However, most health care profes- sions identify interdisciplinary team practice as a necessary competency in the care of older adults. The field of geriatrics led the movement toward team training in health services. In the 1970s the VA developed the Interdisciplinary Team Train- ing in Geriatrics (ITTG) Program, and in the 1980s HRSA began awarding grants for GECs to teach collaboration and teamwork to health care profes- sionals working in geriatrics (Heinemann and Zeiss, 2002). In 1997 the John A. Hartford Foundation funded eight national pro- grams to develop geriatric interdisciplinary team training (GITT) programs for students in nursing, social work, and medicine in order to foster the skills needed for effective team care. These programs often included other professionals, such as pharmacists, dentists, and rehabilitation therapists. GITT seeks to train health professionals to work more effectively on geri- atric care teams. The announced goals included the creation of a national model to forge partnerships between geriatric care providers and institu- tions of education, the development of educational curricula for interdisci- plinary team training, training health care professionals in team skills, and the testing of new models of training for practicing professionals (Flaherty et al., 2003). To evaluate this training, several measures have been developed to as- sess traineesâ knowledge of interdisciplinary geriatric-care planning, their
160 RETOOLING FOR AN AGING AMERICA knowledge of team dynamics, their attitudes toward geriatrics and teams, and their skills in team care (Flaherty et al., 2003). One evaluation showed that the most improvement came on measures of attitudes, especially self- reported measures of team skills; no changes were seen in care planning, and few changes were seen in team dynamics, depending on the question and the discipline (Fulmer et al., 2005). Obstacles identified for interdis- ciplinary training within the GITT programs included differing lengths of rotation among the disciplines, differing levels of experience among the participants, and the inability of clinicians to supervise students from other disciplines (Reuben et al., 2003, 2004). Physicians were the least experi- enced with and the most averse to sharing responsibilities of patient care. Similar results have been documented in studies of other similar models (Fitzgerald et al., 2006; Leipzig et al., 2002; Williams et al., 2006). HRSA has been a strong supporter of interdisciplinary training in geri- atrics and has stated that interdisciplinary geriatric education should be a core requirement for every health profession (HRSA, 1995). As mentioned above, GECs provide interdisciplinary training of faculty, students, and practitioners in the diagnosis, treatment, and prevention of disease, disabil- ity, and other health problems of older adults (HRSA, 2007c). While more and more professionals are gaining experience in interdisciplinary training, little evidence exists to determine which methods are best for imparting the knowledge and skills necessary to work as a team member or to show how such training affects patterns of practice (Cooper et al., 2001; Hall and Weaver, 2001; Remington et al., 2006). Conclusions The education and training of professionals in geriatrics has improved because of the expansion of school-based opportunities, increased efforts in interdisciplinary training, and the development of alternative pathways to gaining geriatric knowledge and skills (discussed in more detail later in this chapter). Professional groups, private foundations, and public agencies all support and promote multiple efforts. Even so, the committee concludes that in the education and training of the health care workforce, geriatric principles are still too often insuf- ficiently represented in the curricula, and clinical experiences are not robust. This is true in general for all the relevant professions. Very few pro- fessions have robust advanced training programs in geriatrics; of those professionals that do have options for advanced training, few individuals take advantage of these opportunities. One barrier to the development of
THE PROFESSIONAL HEALTH CARE WORKFORCE 161 more opportunities for advanced training in geriatrics is a lack of funding (discussed later in this chapter). Professionals may also learn about the care of older adults through continuing-education activities. Most licensed professionals have state- based requirements that they must complete a specific number of continuing- education approved hours in order to maintain their licenses. Requirements vary widely among states, both in the number of hours required and regard- ing the content of those activities. Continuing-education requirements may also depend on requirements for board certification or for membership in professional societies. The content of the continuing education required of professionals is usually not specified. Many professionals fail to receive adequate education and training in geriatric issues while in school, and of those who do receive such education and training, some fail to keep up to date with this knowledge. Since almost all professionals find themselves caring for older adults to some degree, they need to have a minimum level of competence in geri- atrics. The general competence of health care professionals is ensured via mechanisms of state- or jurisdiction-based licensure and national board cer- tification, both of which may require completion of a verbal examination, a written examination, or minimum amounts of annual education and train- ing. Professional licensure provides the primary and most comprehensive route to ensure that practitioners are competent in the principles of geriatric care, since virtually all health care professionals must be licensed in order to provide care. Board certification, a voluntary process, is a secondary mechanism to ensure geriatric competency of professionals. Often neither licensure nor certification examinations have explicit geriatric content, or, if they do, the content is inadequate to ensure competency. By comparison, many of these examinations have explicit content concerning other patient populations, most notably pediatric populations. The committee considered many mechanisms for facilitating the im- provement of competence in geriatrics, including requiring schools to im- prove curricula as a basis of accreditation or requiring a certain percentage of continuing education hours to be spent on geriatric issues. Ultimately, the committee concluded that the most comprehensive way to facilitate this change would be through the explicit inclusion of geriatrics content on examinations for licensure and certification. Recommendation 4-2:â 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. For many professionals, education and training programs are devised to prepare students for licensure and certification examinations, and so the
162 RETOOLING FOR AN AGING AMERICA inclusion of geriatrics in standardized examinations may encourage schools to increase the levels of geriatric education in their curricula. Exceptions may be made where appropriate (i.e., certain pediatric specialists and ob- stetricians). More will need to be done to improve the tools that evaluate this competence, such as ensuring the breadth and depth of questions on examinations are adequate to prove competence. In addition, educators, professional organizations, board examiners, and state licensing boards will need to work together to determine the best methods for assuring that the educational and training curricula for each discipline are devised to impart the competencies (i.e., knowledge, skills, and abilities) that these examina- tions will assess. TRENDS AFFECTING THE FUTURE OF EDUCATION AND TRAINING Developing an effective health care workforce for older Americans will require taking a number of factors into account, including the demands of the future elderly population and changes that may affect the education and training of professionals. Furthermore, needs may develop for new types of workers and new skill sets, especially in light of new models of care and the emergence of new technologies. This section describes alternatives to traditional education, including the greater use of distance education and community colleges. Distance education is an efficient way to spread geriatric knowledge held by a small number of experts to large numbers of professionals, while community colleges can train certain types of new and existing workers, providing a source of education for some profession- als who might have previously received only on-the-job training and also offering a way to standardize training. Finally, the section examines how emerging technologies and models of care may create needs for new types of workers or skill sets. This includes the possibility of having current workers take on different jobs so as to create a more flexible workforce that uses all individuals efficiently (to their maximum levels of competence). Internet-Based Education In recent years there has been a significant increase in the use of Internet-based education for the initial and continuing education and train- ing of professionals in geriatrics (Gainor et al., 2004; Supiano et al., 2002; Swagerty et al., 2000). This is one way to achieve wider dissemination of geriatric knowledge, especially to thoseâsuch as health care providers in rural areasâwho are unable to attend courses because of geographic, finan- cial, and time-based constraints (Murphy-Southwick and McBride, 2006).
THE PROFESSIONAL HEALTH CARE WORKFORCE 163 Internet-based education is also a useful tool for dealing with the lack of available leaders to teach the various courses. Educators recognize that distance education has a number of valuable attributes, such as improved access to geriatric materials for non-traditional students, increased access to experts, and an increased ability to share in- formation among disciplines. A survey of members of the Association for Gerontology in Higher Education found that 35 percent of the member institutions used distance education, with most of them (79 percent) having been using the modality for less than 5 years (Johnson, 2004). A survey of various medical education programs found that 79 percent used the Internet for geriatric education, and 56 percent reported that they were currently developing Internet-based products (Hajjar et al., 2007). There is also evi- dence, however, that some Internet-based geriatric information is of poor or inadequate quality (Hajjar et al., 2005). Community Colleges Innovative community college programs have great potential for play- ing a role in both the initial and the continuing geriatric education of certain professionals. Indeed, community colleges have already been in- strumental in the education and training of large parts of the health care workforce for older patients. For example, community colleges educate a large number of the nurses who receive associate degrees (Mahaffey, 2002), and they provide refresher courses to those nurses already in the workforce (Sussman, 2006). Community colleges may provide career ladder programs for entry-level workers and partner with nursing homes and home health agencies to develop programs for continuing education. Community colleges have also been essential in the development of many new certificate programs and education courses. Community colleges have the advantage of being able to tailor programs to local needs and state- based requirements and to use approaches that will be most acceptable to workers in that community. Recognizing this, the Allied and Auxiliary Health Care Workforce Project, sponsored by the California HealthCare Foundation and the California Endowment, funded seven model programs at community colleges to create new courses and credentialing processes for health care workers (Chapman et al., 2004). Mt. San Antonio College, one recipient of the funding created a new certificate program for entry-level mental health workers. City College of San Francisco and Jewish Vocational Services created a âGateway to Health Careers Programâ to introduce lo- cal residents to health care careers and to provide basic skills training for college readiness. Community college programs offer one approach to stan- dardizing curricula for new types of workers who care for older patients and to ensuring the competency of those workers.
164 RETOOLING FOR AN AGING AMERICA The federal government supports the use of community colleges to train new health workers. For example, the Employment and Training Admin- istration within the U.S. Department of Labor supports Community-Based Job Training Grants that increase the capacity of community colleges to provide training in high-demand industries. Examples include a $2 mil- lion grant to Polk Community College in Florida to address the shortage of cardiovascular technologists and technicians to meet the demand from older patients and a $2.1 million grant to Manchester Community College in Connecticut to produce a larger number of graduates in nursing and al- lied health (DOL, 2006). Technology New technologies will affect how health care is delivered. These tech- nologies may require providers to acquire new skills, such as how to oper- ate new devices or to monitor patients from a distance via telemedicine, and that may change which types of providers are used to perform certain functions (Mullan, 2002). For example, imaging clinicians may need to ex- pand their skill sets by learning how to operate and interpret a number of different imaging modalities, or new sub-specialty jobs may be created for people with expertise in a single specific imaging modality. The technologies most likely to affect the health care workforce in terms of types of workers and the necessary skill sets include â¢ technologies that may alter clinical practice, such as new forms of imaging and minimally invasive surgery; â¢ technologies that may use the workforce more efficiently, such as remote monitoring; â¢ technologies that may improve access to information, such as elec- tronic health records; and â¢ technologies that may improve ergonomics, such as assistive de- vices for patient mobility and transport, and that may help prevent injury to workers (Health Technology Center, 2007). As new technologies emerge, current workers will have to adapt to their use by acquiring new skills, or new types of workers may appear. While some technologies may impose new responsibilities on the health care work- force, others may relieve workers of their current duties or replace them altogether. One class of technologies that will be of particular importance to the health care workforce in light of current and future shortages are those technologies that will help older adults in the performance of activities of daily living (ADLs) and thus reduce the need for health care workers in this area. These technologies are discussed in more depth in Chapter 6.
THE PROFESSIONAL HEALTH CARE WORKFORCE 165 New Professions The health care workforce has a history of creating new professions in response to need, often as a result of the emergence of new technologies or the development of new models of care. At other times, new professions arise because of a serious shortage of providers. The profession of physician assistants, for example, was created in the 1960s to meet the urgent need for providers of primary care. In the same way, new professions may arise in response to the demand for services from older populations. One type of new worker that has recently emerged in the care of older adults is the geriatric care manager. This new role stems from the develop- ment of a formal title for a care coordinator, a job which currently is often undertaken by a variety of providers without formal recognition. In most states, anyone can use this title without any requirement of training or cer- tification (Stone et al., 2002), although many geriatric care managers are certified in other professions, most often in either social work or nursing. Recently, however, the number of certification programs for care managers has surged; one survey found more than 40 different certification designa- tions that might be appropriate for care managers, such as âcertified family life educatorâ and âcertified case managerâ (Reinhardt, 2003). As more people become aware of the importance of care coordination, especially for the older, frail elderly population, it can be expected that there will be increased need for health care workers who can fill this role. At the same time, the competencies needed to be an effective care manager will need to be developed, a task that will be made more difficult by the fact that no one profession âownsâ this position. Expanding Roles To compensate for the serious shortages of providers that will charac- terize the coming decades, workers will need to be used more efficiently. More specifically, health care providers of all levels of education and train- ing will need to assume additional responsibilitiesâor relinquish some responsibilities that they already haveâto help ensure that all members of the health care workforce are used at their highest level of competence. Some professionals will likely need to increase their skills in order to be competent in more areas of care, while higher-level professionals may need to delegate some duties in order to be able to devote more of their time to providing the complex services that only they can provide. (See Chapters 3 and 5 for more on job delegation.) However, professionals are often not prepared for the role of delegator. For example, while RNs are increas- ingly responsible for supervision and delegation of care tasks to assistive personnel, they often are not taught the necessary decision-making skills
166 RETOOLING FOR AN AGING AMERICA associated with this role (Parsons, 1999). One survey of newly graduated baccalaureate nurses pointed to lack of education as the single most im- portant barrier to effective delegation and that skills were generally learned through trial and error (Thomas and Hume, 1998). Formal efforts to help nurses learn these skills are increasing, often through continuing education (Kleinman and Saccomano, 2006). States can play a role in changing the structure of the health care workforce by passing laws that recognize scopes of practice for new types of providers and that expand the legal scope of work for existing providers, although this may be controversial among professional groups (Carson- Smith and Minarik, 2007; RCHWS, 2003; Rossi, 2003; Wing et al., 2004). For example, there has been a great deal of debate in the United States over the use of advanced dental hygienistsâknown as dental therapists in other countriesâto provide some basic dental services to underserved patients (Mertz and OâNeil, 2002; Ryan, 2003). And, as has been seen with team- based training, physicians are often reluctant to delegate responsibilities for care to other workers (Reuben et al., 2004). Among nurses, the delegation of medication administration duties from RNs to CNAs or unlicensed per- sonnel has received much attention (Reinhard et al., 2003). First, there is extreme variation and ambiguity in state laws regarding which tasks may be delegated, ranging from the ability to merely remind patients to take their medications to physical administration of the medication. Confusion about these tasks has led to concern for liability among nursing supervi- sors. Second, there have been some concerns for patient safety. However, little research has been performed to examine the impact of using CNAs or unlicensed personnel for medication administration on patient care, such as comparison of medication error rates between RNs and unlicensed staff. But, some RNs argue that these workers have fewer distractions, leading to more accurate delivery of medications (Reinhard et al., 2003). There is good deal of precedent for the idea of expanding scopes of work or delegating responsibilities in response to workforce needs. Both the physician assistant and the advanced nurse practitioner professions, for instance, have undergone expansions of their legal scopes of practice, most notably in the state-based regulations regarding prescription author- ity. There has also been an expansion of work roles among many types of allied workers. For example, some physicians have trained their medical assistants to teach self-management skills to patients (Bodenheimer, 2007). And pharmacy technicians have assumed increased responsibility for tasks not requiring professional clinical judgment (Muenzen et al., 2005). While pharmacy technicians most often dispense medications and maintain inven- tory, they have increasingly become involved in more skilled areas, such as in supervising processes of quality assurance (e.g., medication order entry and separating similar-looking or similar-sounding medications). In
THE PROFESSIONAL HEALTH CARE WORKFORCE 167 response, many state boards of pharmacy have allowed a broadening of pharmacy technician responsibilities. As new or enhanced scopes of practice are developed, effort will be needed to avoid policies that impede the flexible and effective use of these personnel. While a detailed discussion of state scope-of-practice laws is be- yond the scope of this report, the issue is central to improving the capacity of the health care workforce for older Americans. RECRUITMENT AND RETENTION Health care providers who care for older patients serve a complex, challenging population, and evidence shows that working with geriatric patients is highly satisfying. One study showed, for example, that geriatric medicine has the highest percentage of âvery satisfiedâ specialists among physicians surveyed in the 1996-1997 Community Tracking Physician Sur- vey (Leigh et al., 2002). Another study found that 79 percent of geriatri- cians surveyed felt their geriatric fellowship had a positive effect on their career satisfaction level, and almost 90 percent said they would recommend a geriatric fellowship to others (Shah et al., 2006). In spite of this, many geriatric fellowship positions remain unfilled. Among professionals who have a choice, most do not choose geriatric specialties or choose to work in long-term care settings. Among high school students considering a nursing career almost half have no interest in specializing in geriatrics, whereas 87 percent report having an interest in pediatric nursing (Evercare, 2007). In 2002, 15 percent of the RN positions and 13 percent of the LPN positions at nursing homes were vacant (National Commission on Nursing Work- force for Long-Term Care, 2005). This section describes the barriers to recruitment and retention of pro- fessionals in geriatric fields, with a particular emphasis on the recruitment technique of offering financial support in exchange for service commit- ments. Many of these barriers are not unique to the health care profession- als who care for older patients, but this section will focus specifically on these issues as they relate to the health care professionals who care for older patients or who work primarily in long-term care settings. Barriers The barriers to recruiting and retaining health care professionals in the geriatric field include negative stereotypes of working with older patients, the complexity of geriatric cases, a lack of mentors, the availability of more attractive opportunities in non-health care professions, and also vari- ous financial disincentives. It is particularly difficult to retain and recruit care providers into institutional long-term care because of the stressful
168 RETOOLING FOR AN AGING AMERICA and physically demanding working conditions, relatively low salaries, and low job satisfaction. Turnover of health care professionals in these settings contributes to poorer patient outcomes and increased turnover of other workers. For example, increased turnover of RNs has been associated with decreased quality of care (Castle and Engberg, 2005); high rates of turnover among nursing home administrators and managers has been associated with both poorer patient outcomes and increased turnover of RNs and LPNs (Castle, 2001, 2005). This section highlights some of the challenges to the recruitment and retention of health care providers to care for older patients. The first chal- lenge discussed is that the workforce itself is aging. Large groups of work- ers are expected to retire in the coming decades, and they will have to be replaced, which will only heighten the need for health care providers. The second challenge is that stereotypes persist about caring for older patients; many assume that the work is depressing and that most older patients are extremely sick, frail, or demented. Next is the lack of opportunity for pro- viders to receive advanced training in geriatrics; if no training opportunities exist, health care professionals will be unable or unwilling to specialize in geriatric care. The last challenges discussed are the financial ones. Because of the costs of extra training and the failure of payment systems to compen- sate geriatric specialists properly, financial disincentives are probably the greatest obstacles to the recruitment and retention of more geriatric-specific health care professionals. The section concludes with an examination of the use of programs that offer financial support in exchange for service commitments. Aging of the Health Care Workforce One challenge to the health care workforce in general is the aging of its members. As of January 2007, 23.3 percent of all active physicians were 60 or older (AAMC, 2007a). In 2001, 81 percent of all dentists were over age 45, and the number of dentists expected to retire by 2020 is larger than the number of new dentists expected to enter the workforce by that time (Center for Health Workforce Studies, 2005). By 2020 almost half of all registered nurses will be over age 50 (AHA, 2007; Buerhaus et al., 2000), and about one-third of all currently practicing social workers will soon be of retirement age (National Commission for Quality Long-Term Care, 2007). More needs to be done to retain some of these older workers, recog- nizing their importance as on-the-job mentors, most likely by the develop- ment of less physically demanding roles or more flexible work schedules (Rosenfeld, 2007). Their roles could be made less physically demand-
THE PROFESSIONAL HEALTH CARE WORKFORCE 169 ing, for instance, by the development of technologies that perform the more labor-intensive of their duties. Another retention strategy would be to recruit older workers into leadership roles (Rosenfeld, 2007). Retired geriatric-health professionals have invaluable knowledge and expertise, and they could become academic leaders in the training of future generations. This would be of great value, especially considering the scarcity of faculty described above. Retired generalists, with additional training, could also re-enter their fields as geriatric experts. The social work profession has embraced this concept with the development of the Retired Social Workers Project, which uses both distance and in-person education to train retired social workers in geriatric concepts so that they might return to the work- force to assist older patients (IGSW, 2007). Negative Stereotypes While the current elderly population is healthier and more educated and has higher rates of volunteerism than previous generations of the same age, negative stereotypes of older adults persist, including that they are typically physically disabled, senile, and disconnected from social activities (Krout and McKernan, 2007; Wood and Mulligan, 2000). In spite of the job satisfaction that has been documented among geriatric providers, stu- dents still see working with these populations as depressing, which may be one of the reasons that when students are asked about their specialization preferences, they continue to rank geriatrics near the bottom (Anderson and Wiscott, 2004; Cummings and Galambos, 2002). Early exposures to a broad range of geriatric patientsâand especially to healthier older adultsâhas a positive effect on interest in geriatric fields (Bernard et al., 2003; Cummings et al., 2003, 2005; Linn and Zeppa, 1987; Medina-Walpole et al., 2002; Reuben et al., 1995; Woolsey, 2007). One particularly effective strategy for providing students with this sort of positive experience is pairing them with older patients who act as mentors (Corwin et al., 2006; Stewart and Alford, 2006; Waldrop et al., 2006). In such a mentoring program a student will typically meet regularly with a healthy older adult over a certain period of time, often to complete specific assignments; the older patient acts to sensitize the student to the positive aspects of aging, to dispel myths, and to create empathy for the frustra- tions faced by seniors. A second strategy whose effectiveness is supported by evidence is to expose students to professional role models or mentors who reinforce the positive aspects of geriatric care and, by doing so, inspire students to enter geriatric fields themselves (Hazzard, 1999; Johnson and Valle, 1996; Maas et al., 2006; Mackin et al., 2006; Medina-Walpole et al., 2002).
170 RETOOLING FOR AN AGING AMERICA Lack of Opportunity The recruitment of health care professionals to become geriatric spe- cialists is often hindered by a simple lack of opportunity. As discussed previ- ously, many professionals have neither adequate introduction to geriatrics nor opportunities for advanced training in the field. While GME supports the general training of physicians in geriatrics, workers in other professions often lack the opportunity for advanced training in geriatrics, usually be- cause there is not enough funding for the programs or not enough funding for salary support. Indeed, this is part of a pattern that extends far beyond geriatrics. Generally speaking, with the exception of physicians, few professionals have significant support for advanced training. In response, some efforts have arisen in recent years to increase the training opportunities for these professionals. The Medicare program, for example, not only supports the training of residents but has made some payments to hospitals for its share of the direct costs of nursing and allied health training programs. In 2001 Congress introduced the All Payer Graduate Medical Education Act,12 which would collect additional GME funds through a 1 percent tax on private health plans. Part of this revenue was directed toward the gradu- ate education of ânon-physician health professionalsâ (AAMC, 2007b). The Nurse Education, Expansion, and Development Act13 proposes to provide grants to nursing schools, in part, to develop âpost-baccalaureate residency programs to prepare nurses for practice in specialty areas where nursing shortages are more severe.â These measures are for the training of professionals in general, however, and do not necessarily support advanced geriatric training. In the area of geriatrics, advanced training programs for professionals other than physicians often must look to private foundations for support, or else it falls to the individual students to pay for the programs without any source of subsidy. For example, in 2007 the John A. Hartford Founda- tion awarded a $5 million renewal grant to the Gerontological Society of America for the purpose of preparing doctoral students in geriatric social work (The John A. Hartford Foundation, 2007). Financial Concerns Financial burdens create great challenges in the recruitment and reten- tion of all types of professionals. 12â All Payer Graduate Medical Education Act of 2001. HR 2178. 107th Congress. June 14, 2001. 13â Nurse Education, Expansion, and Development Act of 2007. S 446. 110th Congress, 1st session. January 31, 2007.
THE PROFESSIONAL HEALTH CARE WORKFORCE 171 Recommendation 4-3:â Public and private payers should provide fi- nancial incentives to increase the number of geriatric specialists in all health professions. Specific types of financial incentives will be recommended throughout the rest of this chapter. Medicare and Medicaid policies will be especially important in the implementation of financial incentives due both to their role in the financing of health care services for older adults as well as the influence of their policies on other payers. The costs associated with extra years of geriatric training do not trans- late into additional income, and geriatric specialists tend to earn signifi- cantly less income than specialists in other areas and often less than the generalists within their own fields. In fact, the additional training needed to become a geriatric specialist has been shown to have a negative effect on fu- ture earnings. In 1999 a physician who pursued a 1-year geriatric medicine fellowship stood to lose $7,016 annually, and the completion of a 2-year fellowship translated into a net annual loss of $8,592 (Weeks and Wallace, 2004). In 2005 a geriatricianâs median salary was only 93 percent of the median salary for a general internist (ADGAP, 2007b). Similar disparities exist for other professions. For instance, compared with nurses in hospital settings, full-time RNs who work in nursing homes or other extended-care facilities receive lower annual earnings on average, even though they work more hours per week, incur more hours of overtime, and have a larger percentage of overtime hours that are mandatory (HRSA, 2006b). PAs who specialize in geriatrics have lower salaries than other types of PAs (AAPA, 2007). One survey of recent MSW graduates showed that while 70 percent strongly agreed that geriatric care is an important part of social work, only 36 percent strongly agreed that geriatric social work offered good career opportunities (Cummings et al., 2003). In part this income disparity is due to the fact that a larger proportion of a geriatric specialistâs reimbursement tends to come from Medicare and Medicaid. Additionally, as the population ages, many non-geriatric special- ists will experience similar difficulties. Rates of reimbursement are low for primary care codes in general, especially as compared with the procedural codes typically used by other specialists. Medicare and Medicaid reimburse- ments do not take into account the fact that the care of frail older adults with complex care needs is very time-consuming, a situation that causes geriatric specialists to have fewer patient encounters and fewer billings (MedPAC, 2003). Recommendation 4-3a:â All payers should include a specific enhance- ment of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics.
172 RETOOLING FOR AN AGING AMERICA This enhancement should apply to all types of professionals certified in geriatric care. Several mechanisms can and should be used to facilitate this enhancement due to the variety of providers and mechanisms for delivery of compensation. Whatever the mechanism, this enhancement should raise salaries enough to create greater appeal to entering geriatric fields. As one example, in 2005, the net clinical compensation of a geriatrician was about $163,000, while that of a general internal medicine physician was about $175,000 (ADGAP, 2007d). However, the disparities between geriatric medicine and other subspecialties of internal or family medicine are even greater. Table 4-5 shows that other non-procedure driven subspe- cialties of internal medicine have markedly higher fill rates for advanced training programs, as well as substantially higher salaries. In this example, to raise salaries for the existing geriatricians from $163,000 to $200,000 (to be in accordance with other similar subspecial- ties) for each of the existing 7,128 geriatricians would cost about $263 million. However, the committee supports creating incentives to markedly increase the number of providers. The committee presents two hypothetical examples of estimates for extra annual costs (due to payment enhancements) under assumptions associated with two different goals for the growth in number of certified geriatricians. Under the first scenario (Table 4-6), the goal is to double the number of geriatricians over 10 years; this goal requires a 20 percent increase in the number of geriatric fellows graduating annually. Under the second scenario (Table 4-7), the goal is to triple the number of geriatricians over 20 years; this goal requires a 10 percent annual increase in the number of fellows graduating annually. The committee recognizes both of these goals are ambitious and beyond the capacity of the current system to produce these numbers of graduates unless significant changes are made. These differing scenarios, however, serve to provide two different TABLE 4-5â Fill Rate for Subspecialty Training in Internal Medicine Programs and Median Compensation Number of Total Number Program of Program Median Year 1 Positions Year 1 Positions Fill Compensation Filled (as of Available (as of Rate (in Thousands) Subspecialty 12/31/2006) 12/31/2006) (%) (2005) Geriatric medicinea 253 468 54% $163 Endocrinology 232 252 92% $189 Hematology and oncology 410 432 95% $358 Infectious disease 324 348 93% $205 Rheumatology 176 184 96% $207 aIncludes fellowships as a subspecialty of either internal medicine or family medicine.
THE PROFESSIONAL HEALTH CARE WORKFORCE 173 TABLE 4-6â Timeline for Extra Costs Associated with Geriatrician Salary Increase Assuming Doubling of Numbers Over 10 Years Extra Annual Costs Annual Number of Graduates Total Number (in Millions, Year (Assuming 20% Annual Increase) of Geriatricians 2008 Dollars) 2008 253a 7,381 $273.1 2009 304 7,685 $284.3 2010 365 8,050 $297.8 2011 438 8,488 $314.1 2012 526 9,014 $333.5 2013 631 9,645 $356.9 2014 757 10,402 $384.9 2015 908 11,310 $418.5 2016 1,090 12,400 $458.8 2017 1,308 13,708 $507.2 2018 1,570 15,278 $565.3 NOTE: These estimations calculate growth in the number of geriatricians based on an assump- tion of growth in the number of fellows and do not include estimations of attrition. Costs were estimated assuming $37,000 in extra annual costs for each of the geriatricians practicing in that year, and have not been adjusted for cost-of-living increases or inflation. aThe initial number of graduates is based on the current number of first-year fellows in geriatrics. strategies that highlight the amount of effort that will be needed to close the gap between the numbers of current supply and the numbers needed in the future. Ultimately, the chosen strategy will depend on the ability of the current system to increase its capacity, the development of an increased interest in geriatrics among providers, and the availability of immediate and future funding sources. While the committee recognizes the current high level of attrition among these providers, it also contends that attrition will likely decrease if greater financial incentives exist. Estimates do not take attrition into account. One mechanism to increase salaries would be to develop a special fee schedule for services provided by geriatric specialists that increased the rela- tive value of the provider. Another option would be to create a new modifier that allows for increased payment. Modifiers are added to billing codes to indicate special circumstances surrounding the delivery of a service. For example, the â22â modifier recognizes that âFor any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentationâ (CMS, 2007). This modifier is currently only available for surgical procedures and involves much docu- mentation to justify its use, but it serves as an example of how a modifier could be developed for use by geriatric specialists for billing purposes.
174 RETOOLING FOR AN AGING AMERICA TABLE 4-7â Timeline for Extra Costs Associated with Geriatrician Salary Increase Assuming Tripling of Numbers Over 20 Years Extra Annual Costs Annual Number of Graduates Total Number (in Millions, Year (Assuming 10% Annual Increase) of Geriatricians 2008 Dollars) 2008 253a 7,381 $273.1 2009 278 7,659 $283.4 2010 306 7,965 $294.7 2011 337 8,302 $307.2 2012 371 8,673 $320.9 2013 408 9,081 $336.0 2014 449 9,530 $352.6 2015 494 10,024 $370.9 2016 543 10,567 $391.0 2017 597 11,164 $413.1 2018 657 11,821 $437.4 2019 723 12,544 $464.1 2020 795 13,339 $493.5 2021 875 14,214 $525.9 2022 963 15,177 $561.5 2023 1,059 16,236 $600.7 2024 1,165 17,401 $643.8 2025 1,281 18,682 $691.2 2026 1,409 20,091 $743.4 2027 1,550 21,641 $800.7 2028 1,705 23,346 $863.8 NOTE: These estimations calculate growth in the number of geriatricians based on an assump- tion of growth in the number of fellows and do not include estimations of attrition. Costs were estimated assuming $37,000 in extra annual costs for each of the geriatricians practicing in that year, and have not been adjusted for cost-of-living increases or inflation. aThe initial number of graduates is based on the current number of first-year fellows in geriatrics. Other aspects of reimbursement policies can create financial disincen- tives to geriatric specialization. For instance, Medicare and Medicaid often lack codes for care coordination and other advance services; by support- ing these types of advanced services through the development of âmedical homes,â Medicare could realize savings of as much as $194 billion over 10 years (Commonwealth Fund, 2007). And insurers often allow only for a pharmacist dispensing fee, failing to reimburse for advanced pharmacist services, including those activities shown to improve patient outcomes or lower health care costs. In response to these concerns, the 2006 implemen- tation of the Medicare Modernization Act of 2003 established a mecha- nism by which pharmacists are eligible to receive payment for providing medication-therapy management services as a benefit of the Part D program (CMS, 2005). Psychiatrists thinking of specializing in geriatrics may be
THE PROFESSIONAL HEALTH CARE WORKFORCE 175 pushed toward other areas since Medicare requires a 50 percent copayment for outpatient mental health services, compared to 20 percent for most other medical services (ADGAP, 2007a). Furthermore, Medicare does not cover any routine oral-health services. Financial burdens affect the recruitment and retention of clinical and academic geriatric experts. A 2004 survey of second-year MSW stu- dents found that over 60 percent expressed interest in an aging-related internshipâif a stipend were available for this activity (Cummings et al., 2005). Junior faculty in geriatrics have lower compensation than those in family or internal medicine (ADGAP, 2004). At higher faculty positions the median dollars paid to those in geriatrics become similar to those paid for other specialties, but the pay of geriatrics specialists still lags behind that of the higher-paid procedural specialties. Between 2002 and 2003 salaries for geriatric physician faculty decreased by 3 percent; during this time pe- riod, family medicine salaries increased by 1.5 percent, and general internal medicine salaries remained the same. GACAs have been instrumental in the development of academic geri- atricians. These awards are especially appealing since the grants directly support teaching services during the life of the award. Recommendation 4-3b:â Congress should authorize and fund an en- hancement of the Geriatric Academic Career Award (GACA) program to support junior geriatrics faculty in other health professions in addi- tion to allopathic and osteopathic medicine. The committee supports the extension of GACAs to all doctorate-level health care professionals. As has been discussed, many of the geriatric spe- cialties are limited by the availability of faculty and mentors. The creation of GACAs for other doctoral-level health care professions would help to promote not only the geriatric professions, but would enable educational programs to better educate all professionals in the care of older adults. Recognizing the lag time between the initial training of professionals until the time they are available to become faculty, these training opportunities should begin now. In June 2007, Senator Bingaman introduced a bill14 that would provide GACAs to doctorate level nurses certified in geriatrics or geropsychiatry. This bill proposed a funding level of $1.875 million per fiscal year (plus administrative costs) to allow for a total of 125 5-year awards for $75,000 in total between 2008 and 2015. A loftier goal could be to have one GACA at every institution that prepares advanced practice professionals. For ex- 14â Nurse faculty and physical therapist education act of 2007. S 1628. 110th Congress, 1st session. June 14, 2007.
176 RETOOLING FOR AN AGING AMERICA ample, about 81 programs exist to prepare geriatric nurse practitioners. The availability of a $75,000 GACA for each of these 81 faculty positions would amount to about $6.1 million annually (plus administrative costs) for the nursing profession alone. (Similar efforts should be made for other professions.) The committee recognizes that geriatric educators are also needed at institutions that do not have specific programs in geriatrics, as all professionals need to be trained in geriatric principles. However, the avail- ability of these awards at advanced programs is an achievable first step. To avoid some of the pitfalls experienced by the GACA program for physicians, the committee supports making the GACA an institutional award (instead of an individual award). Additionally, as the number of professionals entering the different disciplines increases, the number of GACAs needs to proportionately increase. Linking Financial Support to Service Most efforts to recruit and retain professionals for in-need populations seek to relieve professionals of at least part of the financial burden associ- ated with their education and training. These recruitment efforts usually consist of offering some type of financial supportâgenerally scholarships or loan forgiveness, or bothâin exchange for the professional promising to serve a certain number of years with a population in need. Programs exist at both the state and national levels, and many programs entail a collabora- tion between the two. Five general types of programs link financial support and service (Table 4-8). Scholarships and loan repayments are by far the most common types of programs. However, very few studies have assessed the effect of these programs on completion of service or retention of practitioners (Pathman et al., 2000). These programs also change frequently without any evidence of immediate or lasting effectiveness. Since they are the most common, the rest of this section will focus on scholarship and loan-repayment programs. State Efforts Many states attempt to recruit needed members to the health care workforce with programs that offer financial support in exchange for future service. Such programs date back to the 1940s. In 1987 HRSA created the State Loan Repayment Program (SLRP), which authorizes the National Health Service Corps (discussed below) to provide matching funds to states that develop educational loan-repayment programs. These funds are specifi- cally designated for primary care physicians in exchange for service in a so-called health-professions shortage area, or HPSA. Some state-level programs operate with federal support, while others
TABLE 4-8â Classification of Support-for-Service Programs Program Type Eligibility Servicea Use of Funds Typical Design Impact in State-Based Programsb Scholarship Students Required Up-front Funds to students for tuition, fees, books, On average, 66.5% complete service training costs and living expenses, with service expected obligations; 27.2% repay loans instead of after training providing service Second shortest retention; least likely to repeat the process Loan Students Optional Up-front Loans to students for tuition, fees, books, On average, 44.7% complete service training costs and living expenses; loan is repaid after obligations; 49.2% repay loan rather than training either financially or by providing provide service service Resident Junior Required Variable Unrestricted funds for junior and, On average, 93% complete service support residents occasionally, senior residents, with service obligations (combined with next two groups) expected after training Combined with next 2 groups, only 2.3% repay loans instead of providing service Shortest retention Loan Senior Required Repayment of Funds to repay outstanding educational See âResident Support Programsâ repayment residents and educational loans of graduating residents and Longest retention practitioners loans practitioners in exchange for service Direct Senior Required Unrestricted Unrestricted funds for graduating See âResident Support Programsâ financial residents and residents and practitioners in exchange incentive practitioners for service aWhile service is ârequiredâ for some types of programs, many have buyout options (with associated penalties). bBased on one study (Pathman et al., 2004). SOURCE: Pathman et al., 2000, 2004. Copyright 2000, American Medical Association. All rights reserved. 177
178 RETOOLING FOR AN AGING AMERICA operate without. A 1996 survey found that 82 programs in 41 states sup- ported almost 1,700 professionals (Pathman et al., 2000). Most of these programs (84 percent) supported medical students, residents, and practicing physicians; about half (44 percent) were available to PAs and APRNs, and about 20 percent were available to other professionals, such as dentists and podiatrists. The programs offered support amounts that ranged from $3,000 to $38,000 annually, and they had service commitments ranging from 1 to 60 months. When Pathman and colleagues sought to evaluate the effectiveness of state-level support-for-service programs, they found that participants in such programs practiced in needier areas and cared for more Medicaid and uninsured patients than non-participants (Pathman et al., 2004). Retention was also slightly higher for participants in the program than it was for non- participants. Overall, loan repayment and direct financial incentives proved to be the most successful methods. Scholarships and other student-focused programs were challenged by the administrative burden of keeping track of these students over the course of their educational paths. Some state-level loan-repayment programs focus specifically on geri- atricians. For example, in May 2005 South Carolina introduced the Geri- atric Loan Forgiveness Program, which forgives $35,000 of medical school debt for each year of fellowship training in geriatric medicine or geriatric psychiatry; loan forgiveness is dependent on the physician practicing in the state of South Carolina for at least 5 years (Lt. Governorâs Office on Aging, 2005). Indian Health Service The Indian Health Service (IHS) Loan Repayment Program repays up to $20,000 in education loans per year (plus additional tax benefits) for practitioners in certain health professions who commit to practicing for at least 2 years in an IHS facility or other approved program (IHS, 2007). While all professionals are eligible for this program, physicians and nurses usually get highest priority. National Institutes of Health Loan Repayment Program The National Institutes of Health (NIH) offers loan repayment to doctoral-level researchers in exchange for commitments to perform re- search. For a 2-year commitment the NIH pays off up to $35,000 per year of educational debt, plus additional tax benefits. Individuals may perform the research at any nonprofit organization, university, or government orga- nization. Loan repayment is currently available for researchers in
THE PROFESSIONAL HEALTH CARE WORKFORCE 179 â¢ clinical research; â¢ pediatric research; â¢ health-disparities research; â¢ clinical research for individuals from disadvantaged backgrounds; and â¢ contraception and infertility research (NIH, 2007g). Repayment for researchers in clinical research comprises more than half of the NIH repayment programâs contracts and funds. For fiscal year 2006, 38 percent of the 1,044 new applications and 71 percent of the 777 renewal applications for clinical research were accepted (NIH, 2007a). More than half of the contracts for clinical research were made with medi- cal doctors; other clinicians given contracts included optometrists, dentists, psychologists, pharmacists, doctors of naturopathic medicine, and doctors of osteopathic medicine (NIH, 2007d). Contracts for clinical research to- taled almost $40 million (for 945 contracts), and contracts for pediatric research totaled $18.8 million (for 403 contracts). Contracts for all five ar- eas of research together added up to approximately $70 million (for 1,651 contracts) (NIH, 2007b,c,d,e,f). National Health Service Corps Perhaps the best known program offering health professionals financial support for educational and training expenses in exchange for service is the National Health Service Corps (NHSC). The NHSC, which was established in 1972 in an amendment to the Emergency Health Personnel Act, operates as part of the Public Health Service and places health care practitioners in HPSAs. Under the loan-forgiveness program, practitioners receive up to $25,000 per year of service for the first 2 years of service. After completing that 2-year minimum, commitments may be extended annually, and prac- titioners who extend their service in the HPSA beyond the first 2 years can receive as much as $35,000 in loan forgiveness per year in the succeeding years. Reviews of the effectiveness of the NHSC have been mixed, mostly because of questions about its ability to retain practitioners over the long term (Mullan, 1999; Pathman et al., 2006). The fiscal year 2006 budget for the NHSC was about $125.4 million, of which $85.2 million was used for the loan-repayment and scholarship programs (HRSA, 2007a). Over its entire history, more than 27,000 professionals have served with the NHSC, and currently about 4,000 are in service (HRSA, 2007d). The NHSC re- cruits the following types of professionals: â¢ Primary care physicians â¢ Nurse practitioners
180 RETOOLING FOR AN AGING AMERICA â¢ Dentists â¢ Mental and behavioral health professionals â¢ Physician assistants â¢ Certified nurse-midwives â¢ Dental hygienists In addition to loan forgiveness for the various types of professionals, the NHSC offers scholarships for students in â¢ allopathic medical schools; â¢ osteopathic medical schools; â¢ family nurse practitioner and nurse-midwifery programs; â¢ physician assistant programs; and â¢ dental schools. These scholarships pay for up to 4 years of education, including tuition and related educational expenses plus a stipend. Students commit to 1 year of service in a shortage area for each year of financial support (with a 2- year minimum). Little has been done to evaluate the impact and effectiveness of the NHSC. However, a 1995 report found that, as is the case with in-state programs, NHSC scholarship programs have worse outcomes (in terms of service completion, satisfaction, and retention) and higher administra- tive costs than loan-repayment programs (GAO, 1995). Indeed, the report showed that loan-repayment participants end up costing the government one-half to one-third less than scholarship recipients. Recently, members of Congress proposed the use of NHSC to improve the recruitment and retention of geriatricians. The most recent attempt was the Geriatricians Loan Forgiveness Act of 2007,15 which called for fellowship years in either geriatric medicine or geriatric psychiatry to be recognized as a period of service to an underserved population. Similar bills have been introduced in both the House and Senate multiple times, so far without success. The committee concluded that programs that link financial support to service have been effective in increasing the numbers of health care professionals that serve in underserved areas of the country and that they serve as good models for the development of similar programs to address shortages of geriatric providers. 15â Geriatricians Loan Forgiveness Act of 2007. HR 2502. 110th Congress, 1st session. May 24, 2007.
THE PROFESSIONAL HEALTH CARE WORKFORCE 181 For example, as discussed above, some geriatric professions have exist- ing opportunities for advanced training, but practitioners do not pursue the positions (e.g., only 54 percent of available first-year positions in geriatric medicine were filled in 2006-2007). If financial support was available, it might encourage professionals to pursue such advanced training. The avail- ability of scholarships could also get students interested in geriatrics earlier in their careers, which in turn would create a need for the development of more robust geriatric curricula and more advanced training options. Recommendation 4-3c:â States and the federal government should in- stitute programs for loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists. One such mechanism should include the development of a National Geriatric Service Corps, modeled after the National Health Service Corps. One mechanism to create incentives for students to enter geriatric specialties is a National Geriatric Health Service Corps which would offer loan repayment for newly graduating professionals in geriatrics. There are many mechanisms for achieving this increased recruitment and retention; loan repayment is one example. For example, the committee estimated the costs required to institute loan repayment for graduating fellows of geriatric medicine. As in Tables 4-6 and 4-7, the committee presents costs for a loan repayment program associated with two hypothetical goals: to either double the number of geriatricians over 10 years, or to triple their numbers over 20 years. Under these scenarios, the costs for loan repayment for physicians is estimated at $35,000 per year for 4 years (or $140,000 per physician). Tables 4-9 and 4-10 demonstrate rough estimates for loan repayment to graduating fellows of geriatric medicine based on 2008 dollars assuming, as in Tables 4-6 and 4-7, either a 20 percent or 10 percent annual increase in the number of geriatric fellows. CONCLUSION This chapter addressed the education, training, recruitment, and re- tention of the professional health care workforce. Overall, there is an inadequate supply of professionals in general for meeting the health care needs of the future older adults and also an inadequate number of geriatric specialists both to care for these patients and to teach other professionals about geriatric care. Although the situation is improving, most professional education programs still do not have sufficient geriatric content in their curricula or adequate experiences in clinical settings. When the opportunity exists, most professionals are not choosing to receive specialized training in geriatrics, and some professions lack the opportunity for advanced geriatric
182 RETOOLING FOR AN AGING AMERICA TABLE 4-9â Timeline for Costs Associated with Geriatrician Loan Repayment Assuming Doubling of Numbers Over 10 Years Annual Costs for Annual Number of Graduates Total Number Loan Repayment Year (Assuming 20% Annual Increase) of Geriatricians (in Millions, 2008 Dollars) 2008 253a 7,381 $35.4 2009 304 7,685 $42.6 2010 365 8,050 $51.1 2011 438 8,488 $61.3 2012 526 9,014 $73.6 2013 631 9,645 $88.3 2014 757 10,402 $106.0 2015 908 11,310 $127.1 2016 1,090 12,400 $152.6 2017 1,308 13,708 $183.1 2018 1,570 15,278 $219.8 NOTE: These estimations calculate growth in the number of geriatricians based on an assump- tion of growth in the number of fellows and do not include estimations of attrition. Annual costs were estimated assuming $140,000 in loan repayments for each of the fellows graduating in that year, and have not been adjusted for cost-of-living increases or inflation. Administrative costs have also not been included in these estimates. aThe initial number of graduates is based on the current number of first-year fellows in geriatrics. training. Distance-education programs and community colleges are provid- ing viable alternatives for the education and training of many professionals in geriatric principles. The future workforce will likely need to fulfill new roles, be more flexible, and possess new skills. The committee recommends that more be done to increase the breadth of geriatric experiences among health care professionals and to ensure the geriatric competence of all providers. Barriers to recruitment and retention include the aging of the workforce itself and negative stereotypes about working with older adults. Financial disincentives include disparities in the reimbursement system, such as lack of payment for care coordination, and the high costs associated with ad- vanced training. The committee recommends that financial incentives be implemented in order to encourage more professionals to become geriatric specialists; such incentives should include the enhancement of payments to geriatric specialists, an expansion of the GACA program, and the institu- tion of loan forgiveness, scholarships, or direct financial incentives to assist with the high costs of tuition among all types of health care professionals who care for older adults. While all of these areas have shown improve- ment, much more needs to be done to educate, train, recruit, and retain a competent and ample professional workforce to care for the older popula- tion in 2030.
THE PROFESSIONAL HEALTH CARE WORKFORCE 183 TABLE 4-10â Timeline for Costs Associated with Geriatrician Loan Repayment Assuming Tripling of Numbers Over 20 Years Annual Costs for Annual Number of Graduates Total Number Loan Repayment Year (Assuming 10% Annual Increase) of Geriatricians (in Millions, 2008 Dollars) 2008 253a 7,381 $35.4 2009 278 7,659 $42.1 2010 306 7,965 $42.8 2011 337 8,302 $47.2 2012 371 8,673 $51.9 2013 408 9,081 $57.1 2014 449 9,530 $62.9 2015 494 10,024 $69.2 2016 543 10,567 $76.0 2017 597 11,164 $83.6 2018 657 11,821 $92.0 2019 723 12,544 $101.2 2020 795 13,339 $111.3 2021 875 14,214 $122.5 2022 963 15,177 $134.8 2023 1,059 16,236 $148.3 2024 1,165 17,401 $163.1 2025 1,281 18,682 $179.3 2026 1,409 20,091 $197.3 2027 1,550 21,641 $217.0 2028 1,705 23,346 $238.7 NOTE: These estimations calculate growth in the number of geriatricians based on an assump- tion of growth in the number of fellows and do not include estimations of attrition. Annual costs were estimated assuming $140,000 in loan repayments for each of the fellows graduating in that year, and have not been adjusted for cost-of-living increases or inflation. Administrative costs have also not been included in these estimates. aThe initial number of graduates is based on the current number of first-year fellows in geriatrics. REFERENCES AACN (American Association of Colleges of Nursing). 2004. Nurse practitioner and clinical nurse specialist competencies for older adult care. http://www.hartfordign.org/case_study/ Geriatric%20Competencies%20for%20non-GNPs.pdf (accessed February 1, 2008). AACN. 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). AACPM (American Association of Colleges of Podiatric Medicine). 2007. American As- sociation of Colleges of Podiatric Medicine: School links. http://www.aacpm.org/html/ collegelinks/cl_schools.asp (accessed August 22, 2007). AAMC (Association of American Medical Colleges). 2007a. 2007 state physician workforce data book. http://med.ucmerced.edu/docs/AAMC2007StateDataWorkbook.pdf (accessed January 29, 2008).
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