retooling for an aging america: building the health care ...

1. Retooling for an Aging America: Building the Health Care WorkforceJoshua M. Wiener, Ph.D. 1

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3. Funders of Institute of Medicine Study AARP Archstone Foundation Atlantic Philanthropies California Endowment Commonwealth Fund Fan Fox and Leslie R. Samuels Foundation John A. Hartford Foundation Josiah Macy, Jr., Foundation Retirement Research Foundation Robert Wood Johnson Foundation 3

4. Introduction Is the current health care workforce adequate to provide high-quality care to older people? Will the future health care workforce be adequate to provide high-quality care to older people? Obvious concern to 35 million older people now and 87 million in 2050 Older people are currently 12% of the population, but account for about 36% of physician, prescription drug and hospital use and 90% of nursing home use With aging of population, by 2030, older people will account for over 50% of total health expenditures 4

5. What is the Problem? 5

6. Special Issues of Older People Older people are not just young people with more birthdays. Multiple chronic illnesses: 23% of Medicare beneficiaries with 5 or more chronic illnesses account for 68% of Medicare spending Significant proportion have disability 50% of 85+ have ADL/IADL disability 50% of 75+ have trouble hearing 22% of 75+ have vision limitations 29% of 75+ have lost all of their teeth 80% of all deaths among people over age 65 6

7. Special Issues of Older People (cont.) Geriatric syndromes of Functional impairment Dementia Incontinence Osteoporosis Falls Decubitus ulcers 7

8. Organization of the Delivery System What does this mean For the person with vision problems who takes 5 different medications but cannot read the bottle label? For the person with dementia who has surgery in the hospital and is completely disoriented? For the person who has no teeth who is losing weight because they can�t chew? 8

9. Standard Acute Care Does Not Work Often not recover from illness: emphasis on management of multiple chronic illnesses Care coordination/care management/interdisciplinary teams Strictly medical model inadequate: Long-term care and other social services are often needed Treating standard medical problems more complex Palliative and end-of-life care are often part of the mix

10. Not Enough Geriatric Specialists About 1% of physicians are geriatricians and declining Geriatricians, who are more highly trained internists, make 7% less than general internists Fewer than 1% of RNs and 4% of social workers specialize in geriatrics 10

11. Inadequate Training forGeneral Health Care Workers 41% of graduating internal medicine residents say they are unprepared to counsel patients on palliative care Only 10% of board exam for internal medicine on geriatrics Only 33% of baccalaureate nursing programs require expose to geriatrics 11

12. Direct Care Workers 71% annual turnover rate for certified nursing assistants in nursing homes Low levels of training In many states, little required training for personal care workers Federal government requires only 75 hours for certified nursing assistants and home health aides By comparison in CA: manicurists (350 hours) and hair dressers/barbers (1500 hours) 12

13. Long-Term Care Workers (cont.) Low wages of workers: In 2006, personal and home care aides earn $8.54 per hour Lack of health insurance and other fringe benefits 13

14. Long-Term Care Workforce (cont.) May adversely affect Continuity of care Staffing levels Quality of care Family caregivers receive little training and support, despite economic value of $350 billion 14

15. Changes in the Size of the Elderly Population Relative to the Potential Workforce, 1998 to 2050 15

16. Institute of Medicine Recommendations 16

17. Increase Number of Geriatric Specialists Increase reimbursement for geriatric specialist services Establish loan forgiveness, scholarships, and direct financial incentives for geriatric specialists Providers should increase pay and fringe benefits for long-term care workers and Medicare and Medicaid should finance the increase 17

18. Enhance General Competence Require more geriatric content in all licensure and certification for health care professionals and workers States and the federal government should increase the minimum training standards for CNAs and home health aides from 75 to 120 hours States should establish minimum training requirements for personal care aides not covered by federal rules 18

19. Implement Innovative Models of Care Promote replication of comprehensive care models shown to be effective and efficient Include older persons and their family network as active partners in their care Chronic disease self-management Caregiver education and support 19

20. Implement New Models of Care (cont.) Increase task delegation to nurses, physician assistants, and direct care workers to increase workforce capacity, career ladders and reduce costs Support development of new technologies, such as assistive devices for ADLs and health information technologies Increase funding for research and demonstration programs 20

21. Summary Recommendations Recruit and retain a cadre of geriatric specialists Research and teaching Provide care for older people with most complex needs Develop and test new models of care Require all providers have core competencies in caring for older persons Redesign health care delivery to achieve new vision of care 21