Improving the Health Care of America’s Older Adults Through Social Work

1. Improving the Health Care of America’s Older Adults Through Social Work Corinne H. Rieder Executive Director and Treasurer The John A. Hartford Foundation The Leadership Academy in Aging NYAM/NADD Partnership Saturday, June 18, 2011

2. Overview • What are Key Challenges to Overcome in Meeting the Health Care Needs of Older Adults? • What Steps can Social Work Educators & Practitioners Take to Improve the Health Care of Older People? • The Hartford Foundation: What is it? Why Aging? • The Foundation’s Social Work Initiatives: What are they? What has been Accomplished?

3. I. 7 Key Challenges to Overcome in Meeting the Health Care Needs of Older Adults • Demographic changes • Chronic diseases • Use & cost of health & support services • Inadequate & poorly prepared health care workforce • Failure to deliver care cost-effectively • Discrimination & ageism • Important financial, ideological & ethical issues 3

4. First, the Demographics • The growth of older Americans is dramatic. - Today there are 40 M people 65 & older. By 2050 there will be 85 M. • The increase in the number of people 85 & older is especially large. - They will increase from 1.5% in 2000 to 5% of the population by 2050. - Those 100 & older are projected to grow from 50,000 to 800,000. 4

5. US Population Pyramids 5

6. Increases in the Oldest Old U.S. Population Aged 85+ (in millions) Sources of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005; U.S. Census Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004. 6

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8. 60% 55% 49% 50% 37% 40% Heart Disease 31% Hypertension 27% 30% Cancers 24% 19% 20% 13% 8% 7% 10% 4% 2% 0% 18-44 45-64 65-74 75+ Age in Years Second, the Prevalence of Chronic Diseases Increases with Age 8

10. Third, the Use & Cost of Health & Social Services Increases with Age • 1. Older adults represent 13% of the population, yet account for: • 26% of physician office visits • 50% of specialty ambulatory care visits • 46% of patients in critical care • 50% of hospital days • 32% of prescriptions • 70% of home health services • 90% of residents in nursing facilities 10

11. Third, the Use & Cost of Health & Social Services Increases with Age (Continued) 2. Medicare beneficiaries with 5 or more conditions: • See more than 3X as many physicians (14 different physicians per year) • Visit physicians more than 4X as often • Receive almost 5X the number of prescriptions (on average, 49 per year, including refills)

12. Third, the Use & Cost of Health & Social Services Increases with Age (Continued) • Health Care Spending • About 95% of all health care spending is for the chronically ill. • 64% of all Medicare spending goes to the 10% of beneficiaries with 5 or more chronic conditions. More attention to the 10%. • Estimates are that about ¼ of Medicare’s budget goes to patients in their final year of life. 40% of that is in the last 30 days. It is interesting to note that the cost of people age 85 & over is 1/3 lower than for people 65 to 75 in their final year.

13. Third, the Use & Cost of Health Care Services Increase with Technology (Continued) 4. The development & use of technology in health care increases health care costs, i.e., medical technology • Medical technology refers to procedures, equipment, and processes by which medical care is delivered. • New medical & surgical procedures & Units (angioplasty, joint replacements, ACE units) • New medical devices (defibrillators) • New support systems (electronic medical records & transmission of information, telemedicine) • New therapies & drugs (statins, beta-blockers)

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15. Fourth, an Inadequate & Poorly Prepared Health Care Workforce • NIA estimates a need for 60,000--70,000 geriatric social workers by 2020. In 2000, there were only 13,500 geriatric social workers with a median age of 50 years. • Of the 240,000 advanced practice nurses only3,500are geriatric nurse practitioners. Overall, the projected shortages in nursing range from 340,000 to 1 M nurses by 2030. 15

16. Fourth, an Inadequate & Poorly Prepared Health Care Workforce (Continued) • By 2030 there will be fewer than 8000 geriatricians against a projected need for 30,000 geriatricians. • Half of all geriatric fellowship positions go unfilled & half of those filled go to physicians from other countries who may not be committed to geriatrics. • By 2030 there will be only 1,700 geriatric psychiatrists (1 per 5,700 older Americans with a mental illness).

17. Fourth, an Inadequate & Poorly Prepared Health Care Workforce (Continued) • There are 43.5 M unpaid caregivers who provide care to a person 50 or older. Many of them are unprepared to deal with chronic diseases & the geriatric syndromes of old age. This unpaid care totaled approximately $375 billion in 2007. • 1 M more direct-care workers will be needed by 2018, according to the latest employment projections. They are required to receive very little education, often less than dog groomers & people that shampoo your hair in salons.

18. Fifth, the Failure to Deliver Care Cost-Effectively Increasing the numbers & skills of geriatrics-trained workers will not be sufficient, as it will not fix the deficiencies in the way care is delivered or address inefficiencies. • The health care system remains focused on acute care rather than on chronic diseases. • Specialist care is favored over primary care & prevention • The fragmented system challenges communication between & among providers & care coordination is infrequent. 18

19. Fifth, the Failure to Deliver Care Cost-Effectively (Continued) • Payment policies (fee-for-service) encourage service volume rather than quality. Capitated & bundled care is essential to better integrate health delivery & social services. • Patients & their caregivers need to be active partners in their care. • Health care & social supports need to take account of patients’ cultural & geographic diversity.

20. Fifth, the Failure to Deliver Care Cost-Effective (Continued) • Errors (for the general population between 44,000 & 98,000 deaths per year) • Hospital infections (for the general population 100,000 deaths per year) • Unsafe prescribing (1.3 million for the general population) • High rates of hospital readmission (20% within 30 days at a cost of $17 B/Y) • 45% of people in nursing homes have no advanced directives & 75% of older people will not be able to make some or all of their end-of-life decisions.

21. Fifth, the Failure to Deliver Care Cost-Effectively (Continued) • There is poor adherence to guidelines (33% for geriatric conditions) • Too many health care expenditures that are of little value (estimates range from 25 to 30% of all expenditures) • A 2005 report by the NAE & the IOM found that 30 to 40% of every $ spent on health care was associated with overuse, misuses, duplication, system failures, unnecessary repetition, poor communication & inefficiency.

22. Sixth, the Prevalence of Discrimination & Ageism Discrimination & ageism negatively impact: • The quality of care that older people receive. • Recruitment of students into geriatric health professions. • The educational & training environment, i.e., poor care becomes standard care. • There are large numbers of older adults that are abused (physically, psychologically, financially) &/or suffer from self-neglect.

23. Finally, there are Important Financial, Ideological & Ethical Issues • Medicare expenditures were $524B in fiscal year 2010, representing 15% of federal outlays, 17.6% of GDP & $14,000/year per Medicare beneficiary). • + $100B in out of pocket, retiree & supplemental • A growing concern about the mismatch between projected costs of health & the ability of the economy & younger generations to pay for them. • Ethical issues abound. • Competing ideological viewpoints, particularly on the role of government versus that of the private sector.

24. II. Next Steps to Improve the Health Care of Older People What is Hartford’s vision? What is the Foundation doing to achieve that vision? What steps can the social work profession take to improve & integrate health & supportive services for older people? I will offer 4 recommendations & what I will call 4 “inconvenient truths.”

25. Hartford’s Vision • Older adults receive quality health care from sufficient numbers of well-trained health professionals. • Care for older adults is integrated, patient-centered& coordinated. • Health professionals are trained to & work in interdisciplinary/inter-professional teams & our country’s financing & delivery systems support them. • Our health care system takes account of the increasing social, demographic & geographic diversityof older adults. • Health care is seamless across various delivery sites& all clinicians have immediate access to patients’ health information & communicate with one another.

26. Hartford’s Vision (Continued) • Older people & their families are active partners in their care & greater attention is paid to & financing of disease prevention, the adoption of healthy life styles & the preservation of function. • Movement away from fee-for-service payment of physicians toward innovative provider payment & delivery system reforms, e.g., accountable care organizations, bundled acute & post-acute care payment, & patient centered medical homes.

27. Hartford’s Work to Achieve this Vision • Maintain the Foundation’s national scope even with reduced assets. • Maintain a narrow & consistent focus in one area. • Maintain our commitment to be strategic in our grantmaking with clear goals, objectives, strategies & self-evaluation. • Increase partnerships & advocacy efforts with grantees, other foundations & government entities with the same goals.

28. Recommendation #1 The Work Site • Every practicing social worker is prepared to provide quality care to older adults through innovative partnerships with academic institutions &/or on-the-job education & training. • Work sites provide high quality clinical training & education for students. • Social workers advocate for patients & clients & teach patients & families to advocate for themselves.

29. Recommendation #2 Education & Training • More faculty members are expert in geriatrics. • Geriatrics is infused into & across the curriculum. • Students have more, better & a greater variety of clinical experiences with older people & the institutions that serve them. Field experience is elevated within academic programs. • Schools of Social Work move closer to becoming more like such professional schools as medicine & nursing, rather than arts & sciences adjuncts. SW Schools & their faculty bring together social work’s unique expertise at the individual & community level with a greater knowledge base in health care systems & service delivery.

30. Recommendation #2 Education & Training(Continued) • Barriers to interprofessional training, such as scheduling, accreditation requirements & financial impediments need to be removed. Training together will enable students to see the value of & work better together in interdisciplinary teams after graduation.

31. Recommendation #3Team Care • Team care for older adults with chronic & complex health & social needs are instituted: teams have a common purpose, specialization of function, defined roles & processes for coordinating their efforts. • Clinicians work at the top of their training & the edge of their license. Team members are empowered to perform tasks according to scope of practice, experience & education. Teams find ways to incorporate & coordinate the supports already existing. Patients, families & communities are also part of the team.* * Who Will Provide Primary Care & How Will They be Trained? Josiah Macy, Jr. Foundation, 2010

32. Recommendation #4Partnerships • Improving the health care of older people needs both interdisciplinary/inter-professional & community partnerships. Are there silos or turf battles that need to be addressed in your organization &/or community? Have you utilized the resources of other professions & your community to advance social work?

33. The Inconvenient Truths: Truth #1 • ARE YOU AT THE TABLE OR ON THE MENU?* Social workers have to be advocates & leaders for change even without the money to do it. • You cannot wait for others—politicians, bureaucrats or academic colleagues in other professions—to “allow” or “invite you” to join the debate & revitalize & reshape the health care system & the profession, e.g., join your local or state Alzheimer’s Association, meet & work with your local & state elected officials. • One heartening development is the collaborative work nationally of 6 healthcare regulatory organizations (Med, SW, Nursing, Pharmacy, PT & OT) to guide regulatory decision making with regard to scopes of practice. *Diane Meier “Be at the Table or Be on the Menu”

34. The Inconvenient Truths: Truth #1(Continued) • What are the dangers & opportunities for social workers & other health professions with implementation of the Patient Protection & Affordable Care Act (PPACA or ACA)? The tools of policymakers are very blunt—changes in payment & regulatory incentives give great scope to professionals & institutions to decide how to implement. Take advantage of these funding opportunities and new delivery & funding structures. - Hospital Readmission - ACA programs, e.g., ACOs, Innovation monies - Reducing health care costs - Coordination & integration of service delivery - Disease prevention - Caring for patients with multiple chronic diseases - Patient-centered medical homes – how will they be implemented? Roles for social workers?

35. The Inconvenient Truths: Truth #2 • You don’t need to re-invent the wheel. In education & service delivery there is an abundance of ideas & materials, & numerous models waiting to be adopted in your institution or community.* * For example, see the IOM Report, Retooling for an Aging America: Building the Health Care Workforce (2008) which identifies many evidence-based service models.

36. The Inconvenient Truths: Truth #3 • Social workers need to better define who they are, what they do, & they need to make a business case with evidence of their cost-effectiveness. The general public & other health professionals are not fully aware of social work’s real & potential contributions to improving the health care of older people.

37. The Inconvenient Truths: Truth #4 • The social work profession is sometimes hurt by its fragmentation. Who speaks for social work nationally? The field is fragmented by its multiple national associations. This situation reduces its impact & dilutes the potentially pivotal role played by its leaders.

38. III. The Hartford Foundation • 82 year old, $500 million mission-driven foundation; 30 year history of improving the health of older people • National in scope; premium on projects that can be sustained & have a multiplier effect; avoid duplicating the focus of others; place importance on partnering with grantees & other funders • Strategic in grantmaking; grants are made competitively; rarely fund unsolicited proposals • Our narrow & consistent focus is unique for a foundation our size; peers have multiple foci & shorter term commitments to a funding area • Committed $430 million to 200 organizations over the past 30 years • Hartford is one of the largest funders of social work & nursing outside of state & federal governments

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42. The bequest from John A. Hartford, which established the Foundation, directed future Hartford trustees “to do the greatest good for the greatest number.” And…”to carve from the whole vast spectrum of human needs one small band that the heart and mind together tell you is the area in which you can make your best contribution.”

43. The Foundation’s Choice & Its Importance to Social Work Given Mr. Hartford’s wishes, what led the Foundation to choose improving the health care of older adults as its goal? 1. Respect for Mr. Hartford’s desire to target a limited area to achieve maximum impact. 2. The demographics. 3. No other foundation had that area as a major focus. 43

44. IV. Hartford’s Social Work Initiative Goal All social workers are prepared to care for older adults 44

45. Hartford’s Objectives 1. Prepare a geriatrically competent workforce. 2. Infuse geriatrics in the education programs of all schools of social work in the country. 3. Ensure that there are sufficient geriatrics faculty members. • Develop, test & disseminate innovative, cost-effective models of care that improve services to older adults. • Draw national attention to the importance of social work in improving the health care of older people. 6. Communicate the idea that older adults are “a core business” of health care & its professions. 45

46. Hartford’s Strategies The Foundation pursues two major strategies in its social work initiative: • Faculty & Leadership Development • Curricular Change

47. Hartford’s Intermediate Indicators of Impact Social Work • 50% of MSW programs require coursework in aging (currently about 25%) • 75% of MSW programs adopt the Hartford Partnership Program for Aging Education (HPPAE) model (currently about 50%) • 60% of programs have more than 2 faculty members specialized in geriatrics (currently about 45%). 47

48. Hartford’s Financial Commitments to Social Work to Achieve these Objectives 1999-2010 Social Work • $70 Million authorized • 36 Major grants approved 48

49. The Foundation’s Specific Accomplishments in Social Work in the Past Decade • Faculty development • Faculty Scholars Program --106 scholars in 11 cohorts • Doctoral Fellows Program--88 doctoral fellows • Pre-dissertation Awards--80 awardees • The Leadership Academy in Aging--24 deans • Curriculum • Grants resulted in new aging curricula being disseminated & adapted by over 180 schools • Gero-Ed is a model for the development of additional competencies (CSWE EPAS) • Aging-content increased in social work text books. • Providing real-world training for social work students. • Hartford Partnership Program for Aging Education (HPPAE, formerly PPP) adopted in 72 schools in 32 states. • Three important books by Barbara Berkman & Nancy Hooyman. 49

50. Hartford’s Leveraging: 2001-2009