Retooling for an Aging America: Building the Health Care Workforce

REPORT BRIEF
The number of older adults in the United States will almost double between 2005 and 2030, and the nation is not prepared to meet their social and health care needs. The baby boomer generation starts to turn 65 in 2011, which will create multiple challenges for the health care system. For one, the majority of older adults suffer from at least one chronic condition and rely on health care services far more than other segments of the population. Additionally, this generation of older adults will be the most diverse the nation has ever seen with more education, increased longevity, more widely dispersed families, and more racial and ethnic diversity, making their needs much different than previous generations. Another problem is the dramatic shortage of all types of health care workers, especially those in long-term care settings. Finally, the overall health care workforce is inadequately trained to care for older adults.

In 2007, the Institute of Medicine (IOM) charged the ad hoc Committee on the Future Health Care Workforce for Older Americans to determine the health care needs of Americans over 65 years of age and to assess those needs through an analysis of the forces that shape the health care workforce, including education and training, models of care, and public and private programs. The committee concludes that the definition of the health care workforce must be expanded to include everyone involved in a patient’s care: health care professionals, direct-care workers, informal caregivers (usually family and friends), and patients themselves. All of these individuals must have the essential data, knowledge, and tools to provide high-quality health care. The committee proposes a concurrent three-prong approach:

• Enhance the geriatric competence of the entire workforce
• Increase the recruitment and retention of geriatric specialists and caregivers
• Improve the way care is delivered

ENHANCING GERIATRIC COMPETENCE
In general, the health care workforce receives very little geriatric training and is not prepared to deliver the best possible care to older patients. Since virtually all health professionals care for older adults to some degree, geriatric competence needs to be improved through significant enhancements in educational curricula and training programs. The committee recommends that health care professionals should be required to demonstrate their competence in the care of older adults as a criterion of licensure and certification.

Direct-care workers (nurse aides, home health aides, and personal care aides) are the primary providers of paid hands-on care to older adults, yet they are inadequately trained in geriatric care. The committee also recommends that training standards for these workers should be strengthened by increasing existing federal training requirements and establishing state-based standards.

Finally, both patients and informal caregivers need to be better integrated into the health care team. By learning self-management skills, patients can improve their health and reduce their need for formal care. In addition, informal caregivers play a large role in the delivery of increasingly complex health care services to older adults.

The committee recommends that public, private, and community organizations provide funding and ensure that training opportunities are available for informal caregivers.

INCREASING RECRUITMENT AND RETENTION
Geriatric specialists are needed in all professions not only for their clinical expertise, but also because they will be responsible to train the entire workforce in geriatric principles. However only a small percentage of professional health care providers specialize in geriatrics, in part due to the high cost associated with the extra years of training as well as the relatively low pay. The committee recommends that financial incentives be provided to increase the number of geriatric specialists in every health profession. These incentives should include an increase in payments for their clinical services, the development of awards to increase the number of faculty in geriatrics, and the establishment of programs that would provide loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists.

Direct-care workers typically have high levels of turnover and job dissatisfaction due to low pay, poor working conditions, high rates of on-the-job injury, and few opportunities for advancement. To help improve the quality of these jobs, more needs to be done to improve job desirability, including improved supervisory relationships and greater opportunities for career growth. To overcome huge financial disincentives, the committee recommends that state Medicaid programs increase pay for direct care workers and provide access to fringe benefits.

IMPROVING MODELS OF CARE
The health care system today often fails to provide high-quality care to older adults, and services are often delivered by many different providers without coordination. The committee envisions the following key principles for the care of older adults in the future:

• The health needs of the older population need to be addressed comprehensively.
• Services need to be provided efficiently.
• Older persons need to be encouraged to be active partners in their own care.

Many innovative models of care show promise to improve the quality of care delivered to older adults or to reduce costs. However the diffusion of these models has been minimal, often due to the fact that current financing systems do not provide payment for features such as patient education, care coordination, and interdisciplinary care. The committee recommends that more be done to improve the dissemination of models of care that have been shown to be effective and efficient for older adults. Since no single model of care will be sufficient to meet the needs of all older adults, the committee also recommends that Congress and public and private foundations significantly increase support for research and programs that promote the development of new models of care in areas where few models are currently being tested, such as preventive and palliative care.

More research is also needed regarding the effective use of the workforce to care for older persons—that is, how to increase both the size and the capabilities of the existing workforce and how those strategies might affect patient outcomes. In part, this will require an expansion of the roles of many members of the health care work- force, including technicians, direct-care workers, informal caregivers, and the patients themselves. As individual roles are broadened, the following elements need to be considered:

• Development of an evidence base regarding new provider designations
• Measurement of additional competence to attain these designations
• Greater professional recognition and salary, commensurate with these responsibilities.

Finally, the committee recommends that federal agencies provide support for the development of technological advancements that could enhance individuals’ capacity to provide care for older patients. This includes the use of assistive technologies that may reduce the need for formal care and improve the safety of care and caregiving. Health information technologies and remote monitoring technologies improve communication among all caregivers and enable health professionals to be more efficient.

CONCLUSION
This report serves as a call for fundamental reform in the way the workforce is trained and used to care for older adults. In order to deliver high-quality care to older adults, the development of a health care workforce that is sufficient in both size and skill is essential. While the impending demands on the health care system have been recognized for decades, little has been done to prepare for the years ahead. The nation needs to move quickly and efficiently to make certain that the health care workforce increases in size and has the proper education and training to handle the needs of a new generation of older Americans.

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