3

Enabling Community Participation Through Workforce Training, Education, and Development

Even when people are able to live in their own homes within their community, engaging with the community outside of the home can remain a challenge. How to accomplish the latter through workforce training, education, and development was the subject of the workshop’s first panel, which featured presentations from four speakers. The panelists described the approach that a multi-site provider of both skilled home health and personal care services is using to develop its workforce, the importance of training from the perspectives of family caregivers and of individuals with disabilities, and what the Health Resources and Services Administration (HRSA) is doing to build workforce capacity and infrastructure.

WORKFORCE DEVELOPMENT ACROSS THE SPECTRUM OF CARE

Michael Johnson
Practice Leader, Home Health
BAYADA Home Health Care

BAYADA Home Health Care is a family-owned home health care organization that provides both long-term and hourly services—home health aide services and skilled nursing services—to pediatric and adult clients (approximately 70 percent of the organization’s business) and also Medicare-certified home health and hospice services. Each line of service

is organized into one of eight specialty practices, said Michael Johnson of BAYADA Home Health Care. The Home Health practice, led by Johnson, employs 2,800 clinical staff who provide care for nearly 12,000 clients weekly across 16 states. BAYADA’s 2,800 clinical staff in Home Health, both professional and paraprofessional, have the opportunity to do a lot of good in the communities they serve, Johnson said. In addition, the 700 office staff, including directors, clinical managers, and client services managers, might not provide services directly, but they play an equally important role in the delivery of care.

When thinking about how to promote community health, well-being, and participation, it is important to first think about quality, said Johnson. The Institute of Medicine defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM, 1990, p. 4). Johnson said he considers the goal of “desired health outcomes” in the larger quality framework proposed by Donebedian, which identifies structure and process as two main determinants of quality (Donabedian, 1988). Structure refers to the attributes of settings where care is delivered, whereas process refers to which health practices are followed. Johnson and his colleagues have been working to develop measures to assess process. Johnson said that while many do not want to take the time to consider process, it is important. “The outcome is the ultimate goal, but what our clinicians and [staff] need to understand is the habits that you develop are what are likely to create the [desired] outcomes. So you can’t ignore [structure or process],” he explained.

In addition to considering the quality issues that affect whether the desired health outcomes are achieved, health itself should also be considered, said Johnson. A principle stated in the constitution of the World Health Organization defines health as “A state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 2016). BAYADA uses this principle when training its clinicians, who have mostly thought about physical and perhaps mental well-being in their work but who, like many providers aside from medical social workers, spend little time thinking about how to integrate social well-being into their work.

Combined, this larger framework for achieving quality—both in health and in well-being—requires accountability by providers, which is best achieved using a community-based system that supports the coordination and integration of services with an appropriate model of care delivery that is centered on the individual client living in the community, Johnson said. In this connected ecosystem, which Johnson referred to as the patient-centered health and well-being neighborhood, family and caregivers are key drivers for needed services, and a plethora of community-based services help keep the individual safe at home and

participating in his or her community. This “neighborhood” serves as the larger ecosystem in which to find the patient-centered medical home, which is a physician-led model of care designed to coordinate primary care services and better manage population health. Johnson cautioned, however, that the mere existence of the many components of this ecosystem does not mean that they necessarily work well together. Thus, connectedness is important.

BAYADA’s framework for training, education, and ongoing development has three parts, Johnson said: (1) clinical competence, (2) community resource awareness, and (3) leadership competence. Clinical competence training, he explained, aims to enhance the expertise of BAYADA’s clinicians so that they can improve the physical and mental health outcomes of their clients. Community resource awareness training ensures that clinicians have access to those resources that enhance integration, participation, and social well-being. Leadership competence training, which Johnson said is often talked about but then overlooked at the time of execution in most organizations, is intended to expand the capacity to support and sustain the change needed to make the most efficient use of financial resources and the available workforce. Leadership is also required to create the “connectedness” that is essential for improving community-based systems of care, Johnson said.

Although leadership competence is a key driver to help realize the organization’s mission, which is known as “The BAYADA Way,” the ability to follow is also important, Johnson said. “When we are training our workforce, everyone needs to have leadership capacity, but everyone also has to have followership capacity,” said Johnson, describing “followership” as the ability to listen, recognize another’s good ideas, and pitch in to help bring them to life. BAYADA’s training also attempts to help its workforce develop both intellectual intelligence and emotional intelligence. Emotional intelligence, Johnson said, is a particularly important attribute to develop because most of BAYADA’s clients are at their worst when BAYADA is serving them. “Let’s be honest—they would rather not need us in their homes,” he said.

As a mission-driven, family-owned organization, BAYADA believes it has a great deal of latitude to do what it thinks is right for its clients and deliver the services dictated by market forces. The first tenet of the company mission is that clients come first, but another tenet is that its employees are its greatest asset. “You can’t have one without the other,” said Johnson. In following through on the tenet of employees being BAYADA’s greatest asset, Johnson discussed education and development, which he considers to be ongoing activities, as opposed to training, which he considers to be a one-time event. To create a framework of continuous performance improvement, BAYADA has developed advisory panels for each of its workforce categories, including nursing, physical

therapy, occupational therapy, dietary, social work, home health aide, and clinical management. “I believe there is more [collective] intelligence in our organization than there is in myself and the [small group of] people on our executive [leadership team], so the idea of getting input, getting engagement, and having these folks empowered is a really important part of our workforce development,” said Johnson. As an example, he said that no changes in documentation or clinical protocols occur without input from the workforce.

BAYADA also provides specialized education for clinical conditions such as heart failure, chronic obstructive pulmonary disease, and dementia, and also for non-clinical aspects of care, such as electronic health record documentation that is streamlined and enables clinicians to spend as much time as possible working with and listening to the clients they serve. Performance feedback is an important part of the education process, too. For example, performance scorecards for clinicians include individual hospitalization rates based on the clients they served as well as the distribution of services provided for and the primary diagnoses of the last 50 or more clients they treated. With this kind of insight, Johnson said, clinicians are able to drive their own development. They can see what services they provided on a larger sub-population level and the impact the services had on the outcomes that are important to the clients they served (e.g., hospital readmission or discharge to home).

In closing, Johnson said that he and his colleagues have invested time over the past 2 years on strategic workforce planning to identify what the various members of the health care team need to enable them to continue to succeed and what the opportunities are for them to lead and participate more fully in the organization. The goal, he said, is to create an environment where leaders can thrive and where sometimes he becomes the follower rather than the leader because somebody else has a better way to look at a particular issue. Johnson concluded by saying, “From our perspective at BAYADA, workforce development is a multifaceted animal that requires us to be thinking both about the medical and the social model[s of care].”

SUPPORTING THE ROLES OF FAMILY CAREGIVERS

Carol Levine
Director, Families and Health Care Project
United Hospital Fund

“Family caregivers are us,” said Carol Levine of the United Hospital Fund. They include family members, relatives, partners, friends, and

neighbors who provide or manage the care of someone who needs assistance because of age, frailty, illness, or trauma. Family caregivers range in age from children and teens to much older adults. Family caregivers are often thought of as only being female, but 40 percent of them are male. Approximately half of all family caregivers are employed in addition to being a caregiver. According to a 2015 survey (National Alliance for Caregiving and AARP, 2015), approximately 45 million Americans are family caregivers. If they were paid at a modest rate, it would account for $475 billion in services. Most, however, are not paid, Levine said.

Family caregivers have an ambiguous role in the workforce, said Levine. They are part of the workforce, but often they are not part of the team. “[They] do what needs to be done,” she said. “There is no scope of practice that defines what a family caregiver does.” The relationships between family caregivers and professionals providing care are often unclear and not discussed. While the client is the consumer, the health care professional often wonders what role the family caregiver is playing and who they should listen to when the client and the family member are not in agreement.

The language used when talking about family caregivers also matters, said Levine, because taking care of a “loved one” suggests that caregivers are emotion-driven rather than objective and that they want special treatment. In addition, because they are not paid, family caregivers are often called “informal” caregivers or volunteers. The latter implies that family caregivers have a choice in the matter, but they often do not. All of “this puts them in a different framework,” said Levine. “It creates a barrier.”

A study conducted by AARP and the United Hospital Fund in 2012 (Reinhard et al., 2012) found that 46 percent of family caregivers were performing complex medical nursing tasks, such as complex medication management involving multiple pills, injections, infusions, and patches, but few of these caregivers had received adequate training to perform these tasks (Reinhard et al., 2012). Family caregivers were also performing activities of daily living, instrumental activities of daily living, and care coordination. As an example of the lack of training family caregivers receive, Levine recounted a story she had heard in a discussion group of family caregivers. The story had been told by a young man who was caring for his friend who had multiple conditions. He had said,

The survey also found that employed family caregivers were providing just as much care as unemployed family caregivers, but they often felt more stress. Most family caregivers have little or no help at home. Family caregivers are always on call, said Levine, while paid caregivers have time off. As a result, family caregivers are at risk for chronic stress and depression and are generally in worse health than their non-caregiving peers (Schulz and Sherwood, 2008). Family caregivers can have diminished immune responses, leading to infections, lower response to vaccines, an increased risk of heart disease, lower levels of self-care, and increased mortality. Female caregivers, she added, fare worse than male caregivers in terms of depression, physical health, and quality of life. Mechanisms to provide long-term services and supports are not reaching the entire universe of families, said Levine. Part of this may be due to many long-term services and supports being funded by Medicaid and thus being available only to Medicaid beneficiaries even though many people who have a combination of Medicare and private insurance also need assistance.

While health care systems have created a variety of positions that fall in the categories of navigators, care managers, and care coordinators, Levine said that she hears family members complain that these employees of the health care system ask the family member for status updates on the patient but otherwise do little to help the family caregiver. “The family member is often the one who has to coordinate all of these care coordinators because [the care coordinators’] jobs are very strictly defined,” said Levine.

“Family caregivers, we like to say, do not coordinate care so much as they coordinate life,” said Levine. The United Hospital Fund, she explained, has created a website¹ that offers a series of guides for family caregivers about navigating the health care system. Some of the guides are for all family caregivers and cover topics such as becoming a family caregiver, the Health Insurance Portability and Accountability Act, medication management, advanced directives, urgent care centers, and care coordination. Care setting–specific guides discuss subjects such as hospitalists, hospital admission, surgery, hospital discharge options and checklists, short- and long-term rehabilitation, durable medical equipment, and how to work with home health aides. “This is a huge resource which we feel very proud of and continually update,” said Levine.

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¹ For more information, see http://www.nextstepincare.org (accessed September 9, 2016).

Levine concluded her presentation by posing a set of what she called difficult questions pertaining to family caregiving. These included

• What are professionals’ responsibilities to people who are not their clients or patients but who provide essential services to them?
• Are we as a society expecting too much of family caregivers in general and certain caregivers in particular?
• Are there some medical/nursing tasks that untrained family caregivers should not be expected to do?
• Are some policies and practices placing patients and family caregivers at risk because of lack of ongoing training and support?
• How can we get past the myths of the “good old days” and move together into a more realistic and equitable future?

Family caregivers, Levine said in closing, have to be part of the health care team, yet they are often pushed aside. She said that when she was caring for her husband after a severe injury, she lost many things, but the main thing she lost was her identity. “I became the wife,” she said. “People said ‘the wife will take care of it.’ I lost my name and my identity. We should not do that to people. We should be able to maintain a life as well as provide the care and love that we want to [provide].”

TRAINING FOR DIRECT SUPPORT PROFESSIONALS

Barbara Merrill
Chief Executive Officer
American Network of Community Options and Resources

The American Network of Community Options and Resources (ANCOR) is a national nonprofit trade association advocating and supporting more than 1,000 private providers of services and supports to more than 600,000 people with intellectual and developmental disabilities and autism, as well as their families, explained Barbara Merrill of ANCOR. The organization’s mission is to advance the ability of its members to support people with intellectual and developmental disabilities to fully participate in their communities. Merrill said that the United States spends $62 billion annually supporting people with intellectual and developmental disabilities, primarily with Medicaid dollars. “It is a fairly large amount of money and deservedly so,” she said. ANCOR’s providers report that they employ a workforce of 500,000 direct support professionals and other staff, though Merrill said she believes this to be an underestimate.

Merrill said that while the Bureau of Labor Statistics includes direct support professionals within the broader classification of personal care attendant, ANCOR considers direct support professionals as front-line, hands-on workers who support people with intellectual and developmental disabilities and autism to help them coordinate their lives so that they can live, work, and play. These professionals operate according to a non-medical model that emphasizes support, as distinguished from care. Direct support professionals are a distinct group who are overwhelmingly employed by third-party, Medicaid-dependent providers. There is very little private pay or commercial insurance in this area, she said, but the number of direct support professionals being employed directly by their clients is growing.

Direct support professionals support people across the lifespan, which Merrill said is a key feature of this segment of the workforce. Although many direct support professionals work with children, the group she focused on during her presentation works predominantly with adults, starting with the transition upon graduation from high school. These professionals help their clients explore job and career options; develop skills for employment; engage in hobbies, recreation, and fitness activities; consider lifestyle choices and cultural and religious interests; and decide whether to continue living with their families or move out and perhaps find roommates. Direct support professionals may also help their clients maintain or even reestablish family connections, date, marry, and raise children. Direct support professionals continue providing support over the course of an individual’s working years, which, Merrill noted, are getting longer, given that individuals with intellectual and developmental disabilities are living longer. The professionals also provide support at work and at home with non-work activities. They continue supporting their clients through retirement and, increasingly, at the end of life, which can enable an individual to remain in his or her home rather than having to transition to a nursing home. Merrill said that the services that direct support professionals provide help individuals lead meaningful lives and realize the promise of the Americans with Disabilities Act of 1990² and also enable people to be integrated into and have access to community living.

Direct support professionals work with people who have a wide variety of needs, and they may work in a wide variety of settings, including their clients’ homes, shared living settings, and the more traditional group home, as well as intermediate care facilities. They also support their clients across the wide array of day services, including integrated and facility-based care and places of employment. Some individuals may

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² Americans with Disabilities Act of 1990, Public Law 101-336, 101st Cong. (July 26, 1990).

need only a few hours of help per week with tasks such as managing personal finances, while others require round-the-clock support and complete assistance with activities of daily living or instrumental activities of daily living. Many in this latter group are medically complex or fragile, and one-third of people with intellectual or developmental disabilities are estimated to also have a behavioral or mental health diagnosis, Merrill said. There is also a level of substance abuse and involvement with the criminal justice system among some individuals with intellectual and development disabilities.

Medicaid’s home and community-based services rule, which applies to all Medicaid waiver-funded services, is a game-changer in the field of intellectual and development disabilities, said Merrill. This rule explicitly rejects group or one-size-fits-all services and an institutional culture. Instead, it requires services to be person-centered. “That is going to be the huge change for direct support professionals who have not been truly providing services in a person-centered way,” Merrill said. Training, she said, is going to have to shift from a group model—everyone in a group home eats the same meal at the same time in the same room—to a strategy that includes person-centered planning. Individuals, for example, will now have the freedom and support to furnish and decorate their sleeping or living units, control their schedules and activities and have access to food at any time, and have visitors at any time.

With regard to training, the issue of whether there will be a nationally mandated or state-mandated training curriculum remains controversial, said Merrill. Most states require a minimum amount of training, but the number of required training hours varies. Illinois, for example, requires 120 classroom hours followed by 80 hours of on-the-job training, while some states merely require that a checklist be completed. As part of its workforce initiative, the Centers for Medicare & Medicaid Services (CMS) has funded the National Direct Service Workforce Resource Center Core Competencies program, which is working to identify a common set of core competencies across community-based long-term services and supports sectors (e.g., aging, behavioral health, intellectual and developmental disabilities, and physical disabilities). The program is also working to assist states in taking a more comprehensive and standardized approach to direct service workforce training and workforce quality improvement through the creation of a nationally validated core competency set.

Merrill said that there are a number of robust national online and in-person training programs tailored specifically to the direct support professional workforce. They include

• ANCOR’s Direct Support Professionals Leadership Academy
• Association of People Supporting Employment First³
• Department of Labor’s Registered Apprenticeship Program⁴
• Elsevier’s DirectCourse⁵
• The NADD⁶
• National Alliance for Direct Support Professionals⁷
• Relias Learning⁸
• TASH⁹

New York’s Office of People with Developmental Disabilities has proposed a tiered credentialing system called Career Gear Up. This program was developed based on the results of a study in which the University of Minnesota Research and Training Center of Community Living evaluated existing training practices, research, wages, turnover, and the cost of turnover. Merrill said that the study concluded that direct support professionals gained knowledge and skills and felt more valued by their supervisors when their organizations supported training and mentoring. In addition, turnover among of workers who received such training and mentoring fell by 16 percent. More importantly, the individuals cared for by the trained and mentored workers experienced more improvement in outcomes such as employment, social relationships, inclusion, and health and safety than did their peers supported by workers who did not receive the comprehensive training.

As proposed, Career Gear Up would require 50 hours of training for the first credential and then additional hours for a second-level credential. With further training, direct support professionals could achieve a mentor credential and a front-line supervisor credential. “We think this is a particularly exciting model because it’s not one size fits all,” said Merrill. “It is a training curriculum that people can access in bite sizes as they move up.” So far, however, New York has not chosen to fund this program. In closing, Merrill said, “We have the ongoing challenge of how do we promote best practices and ensure that people get what they need when we continually are up against the deficit of funding.”

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³ For more information, see http://apse.org (accessed September 9, 2016).

⁴ For more information, see https://www.dol.gov/featured/apprenticeship (accessed September 9, 2016).

⁵ For more information, see http://directcourseonline.com (accessed September 9, 2016).

⁶ For more information, see http://thenadd.org/products/accreditation-and-certificationprograms/the-nadd-competency-based-dual-diagnosis-certification-program (accessed September 9, 2016).

⁷ For more information, see https://www.nadsp.org (accessed September 9, 2016).

⁸ For more information, see https://www.reliaslearning.com (accessed September 9, 2016).

⁹ For more information, see http://tash.org (accessed September 9, 2016).

BUILDING CAPACITY AND INFRASTRUCTURE IN THE GERIATRICS WORKFORCE

Joan Weiss
Senior Advisor, Bureau of Health Workforce
Health Resources and Services Administration

The health workforce, as Luis Padilla had described in his earlier presentation, includes patients, families, caregivers, health care professionals, direct service workers such as community health workers, and other individuals who support the health care system, said Joan Weiss of HRSA. “This workforce is the most important component of health care system infrastructure,” she said. “With the aging of the population and the increase in multiple chronic conditions among older adults, it is essential to build geriatrics workforce capacity and infrastructure.” Building this capacity and infrastructure, she added, will require the provision of inter-professional, community-based education and training as well as building linkages and partnerships among academia, community members, community-based organizations, long-term services and supports, and governments at the local, state, and federal levels as well as including other key stakeholders from the community.

In order to educate the workforce to be prepared to meet the needs of the aging population, Weiss said, the nation will need to ensure that there is an adequate supply of geriatrics specialists who can address the unique needs of older adults. Currently, she said, there is a paucity of health care providers specializing in geriatrics. As a result, she added, “It is important now more than ever to ensure that all health professionals and direct service workers receive content in geriatrics during their formal years of training, and this training must be inter-professional and community-based.”

One strategy that should be used to accomplish that goal, Weiss said, is to integrate geriatrics content into the curricula for health professionals and direct service providers, which will require a cadre of academic leaders with expertise in geriatrics who can transform and integrate geriatrics into academia, clinical practice, research, the community, and community-based organizations. She added that faculty who are not geriatrics specialists, such as community-based clinical preceptors, will need to receive training in geriatrics, as well as in the core competencies for inter-professional collaborative practice. It will also be essential to educate the next generation of researchers in conducting studies in geriatrics, Weiss said, but she did not comment on this any further because HRSA does not train the research workforce.

Enhancing the geriatrics knowledge and skills of the current prac-

ticing health care workforce is another way to increase capacity and infrastructure, said Weiss. Continuing education offerings need to be focused and delivered in more innovative and creative ways because health care professionals no longer have the time to attend face-to-face training or devote an hour out of their day to training, Weiss said. “These providers need short bursts of educational materials that can be delivered through a variety of teaching methods such as those provided by the Khan Academy¹⁰ or just-in-time training,” said Weiss. In addition, she said, all health professionals and direct service workers will need to practice to the full scope of their licenses to offset the increases in health care costs and decreases in access to services that can occur when highly educated professionals provide services that a person with less education can provide just as effectively.

Another way to increase capacity and infrastructure, said Weiss, is by maximizing patient, family, and caregiver engagement, which is a new concept for HRSA. While the agency does have the Comprehensive Geriatric Education program,¹¹ which is funded under Title VIII and incorporated into the Geriatrics Workforce Enhancement Program, it will be important to ensure that families and caregivers receive the necessary information, education, and training to care for patients, Weiss said. “Patients are being discharged from the hospital needing medically oriented treatments,” she said, “and to be successful in providing this complex care in the home, health care professionals must spend adequate time teaching patients, families, and caregivers, and they also must provide this training in a culturally competent and health-literate manner.” Similarly, health care providers need to be trained to include patients, families, and caregivers as part of the inter-professional team, Weiss said. “After all, it is the patient who is central to the team,” said Weiss. Although patients need to be engaged in the management of their multiple chronic conditions, families, caregivers, and community health workers are key members of the health care team who can assist patients in achieving their health care goals. Community health workers, Weiss said, are important in increasing capacity and infrastructure because these workers are trusted members of the community who can provide information and education as well as a wide variety of services.

Linkages and partnerships between academia and other key stakeholders can also be leveraged to build capacity and infrastructure. Such partnerships are key to transforming the clinical practice environment,

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¹⁰ For more information, see https://www.khanacademy.org (accessed September 12, 2016).

¹¹ For more information, see http://bhpr.hrsa.gov/grants/geriatricsalliedhealth/cgep.html (accessed September 12, 2016).

maximizing patient and family engagement, and integrating geriatrics into primary care, Weiss said. “Learning needs to move from the campus to the community,” she said. “Academia needs to partner with key stakeholders to create an environment in which learners and health professionals work with patients, families, and communities to address significant health problems in the individual as well as the community and achieve the Triple Aim.”¹²

Academia and community partners working together to address the social determinants of health across the lifespan will be essential to helping individuals age in place in their homes and communities, Weiss said. Such partnerships can serve to secure health and allow individuals to have the financial resources they need to manage retirement effectively when that time comes, Weiss said. Toward that end, faculty need to provide students with the opportunity to work with other sectors, including organizations that address food security, housing, transportation, labor, legal issues, social protection, policy, technology, and other areas, in order to maximize resources and coordinate efforts to assist older adults to remain in their homes and communities, Weiss said. These activities, said Weiss, can facilitate the development of age-friendly and dementia-friendly communities.

Developing strong linkages between faculty and preceptors in the community will provide students with an exposure to the broader social, political, and environmental context that influences the health and health outcomes of individuals, populations, and communities. “Community sites are crucial to student development,” said Weiss. “Through community experiential learning, students are challenged to solve problems and make new connections through exposure to other professions, sectors, and populations.”

As an example of a successful inter-professional community-based training program, Weiss discussed the Health Mentors Program at Thomas Jefferson University,¹³ which started in 2007 with funding from several sources and is now self-sufficient and supported by the university. The goal of the program, she said, is to provide health professional students in nursing, physical therapy, occupational therapy, physician assistant, couples and family therapy, and pharmacy with the opportunity to gain an understanding of each other’s roles on the health care team, as well as the patient perspective, in order to practice patient-centered

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¹² The Triple Aim is a framework for improving health care system performance through three dimensions: improving patient experience, improving health of populations, and reducing cost. For more information, see http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx (accessed September 12, 2016).

¹³ For more information, see http://www.jefferson.edu/university/interprofessional_education/programs/health_mentors_program.html (accessed September 12, 2016).

care. The health mentors are patients who have been recruited from the community and have at least one chronic condition. During the course of the 2-year curriculum, the health mentor meets three times annually for about 1 hour each time with a group of four or five students. The students are required to develop individual reflection papers, explore team-based case studies, and participate in faculty-facilitated inter-professional small group debriefing sessions. This curriculum, said Weiss in closing, has had a positive impact on student attitudes toward chronic illness, inter-professional care, and aging.

DISCUSSION

Transitioning to a More Connected Model of Care Delivery

Teresa Lee of the Alliance for Home Health Quality and Innovation spoke of the need to develop a well-connected, person-centered neighborhood to address the fragmentation that now characterizes the system for supporting community living and participation. She asked the panelists for their ideas on how to move the system away from fragmentation and toward that interconnectedness in a way that would lead to better training. Johnson replied that the answer is to change the payment methodology. The current movement toward paying for outcomes of care is an important first step, he said. “Conceptually, the accountable care organization or bundled payment is the right idea,” said Johnson, who acknowledged that implementation is not easy. Determining first what is important to the end user—the patient and the family—and what the nation is willing to pay for and then adjusting payments to those activities that will keep individuals in their homes could take the country in the right direction, he said. He added that it will be important to build on the programs that HRSA is developing for training and educating clinicians to look at health in a more holistic manner.

Levine responded that rather than talking about changing models, she would like to change the framework in which those who are involved in caring for individuals talk to one another in order to come to an understanding of what each individual—patient or caregiver—needs. “What we need to do is get to the heart of the person,” she said. While this is not easy to accomplish, it can be done, she said, by working in teams that include the individual needing care and the family members and other caregivers. “Then you create the kind of system that works to everybody’s strengths, not going to their weak points, which we often seem to do,” she said.

Weiss commented that she would like to see money set aside for HRSA to partner with CMS on a combined training–payment model in

order to strengthen the workforce and support policy change. “The reality of the situation is that payment does drive where health care goes, and we want the training to go there, too,” she said. “Then, as part of that, go beyond numbers trained to some very good outcomes, whether individual improvements in health outcomes or community-based outcomes.”

Addressing Workforce Shortages

The number one issue for the members of ANCOR is the workforce crisis, said Merrill. Workforce turnover, she said, is a bigger concern than managed care, which is not surprising, given that recent surveys have shown that the turnover rate is almost 50 percent. Merrill added that when the Commission on Long-Term Care¹⁴ examined the workforce crisis, it strongly recommended increasing training, which, the commission argued, would increase wages and reduce turnover. “The jury is still out as to whether or not that actually happens,” said Merrill. She reiterated her opinion that Medicaid’s home and community-based services¹⁵ rule is a game-changer because it starts moving the system toward paying for outcomes with its focus on the person’s experience and integration into the community.

Glen White of the University of Kansas noted that there are physicians who offer “concierge services,” which he sees as a way of increasing access to a desired physician, and he added that there are physicians who no longer accept Medicare patients because of the fee structure. Similarly, access to dental care is difficult for many people who are in dire need of dentistry. Some areas, such as Kansas City, Kansas, are hosting events offering pro bono dental services so that people can receive the work and care they need. White asked if there was some way of balancing cost, accountability, and outcomes. David Gustafson of the University of Wisconsin–Madison suggested that examining the efficiency of the way in which the workforce is used today, such as travel time between one point and another, would be a useful area of study, in much the way that companies are concerned with operational efficiency.

Kate Tulenko of IntraHealth suggested that the better use of dental therapists, who can provide much of the same care that dentists can provide, could help alleviate the shortage of dental care. She also asked if there have been attempts to change the residency requirements for becoming a geriatrician as a way of helping to reduce the shortage of geriatricians. For example, she asked if the requirement could become

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¹⁴ For more information, see http://www.ltccommission.org (accessed August 31, 2016).

¹⁵ For more information, see https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-01-10-2.html (accessed August 31, 2016).

more like that for pediatrics, where students can go directly from medical school to a pediatric residency and not have to do a full internal medicine residency first. Weiss acknowledged the shortage, noting that an estimated 36,000 geriatricians will be needed by 2030, while 2013–2014 data from the American Board of Medical Specialists show that there are only 7,400 geriatricians and 1,700 geriatric psychiatrists. Weiss also said that the American Board of Medical Specialties recently shortened the family medicine residency required before entering a geriatrics training program from 2 years to 1, though this has yet to increase the number of geriatricians.

Thomas Edes of the Department of Veterans Affairs asked if there have been any studies on how to increase retention and maintain continuity in the care being provided. Johnson replied that there is a substantial body of evidence showing that increasing retention and maintaining the “team” of providers or caregivers also increases productivity in terms of clinical outcomes. He and his colleagues are looking at ways of rewarding and recognizing BAYADA’s care teams. BAYADA piloted a model that provided a monetary reward based on multifaceted outcomes, such as reduced hospitalizations and improved patient satisfaction, as one approach for increasing efficiency and improving retention in the face of Medicare reimbursement costs.