Retooling for an Aging America Building the Health Care Workforce (2008) / Chapter Skim
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4 The Professional Health Care Workforce
4 The Professional Health Care Workforce
Pages 123-198
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From page 123... ...
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.
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Next the chapter focuses on a few individual professions essential to the care of older adults. It goes on to examine overarching themes in geriatric education and training.
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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)
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and found that the diversity of the workforce 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)
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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
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The best strategies for recruitment and retention may be those that focus on the training of existing rural providers 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)
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hosted the National Consensus Conference 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)
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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 "expert," 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 master's and post- geriatric dental one fellowship training master's 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?
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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
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ABBREVIATIONS: Advanced Practice Registered Nurse (APRN) ; Bachelor of Social Work (BSW)
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Board of Family Medicine (ABFM) , American Board of Psychiatry and Neurology (ABPN)
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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)
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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 4-2 First-year geriatric psychiatry fellowship positions, available and filled.
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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 settings of care. Thus many students and residents lack exposure to alternative sites of care of importance to the geriatric patient -- namely, home-care settings, nursing homes, and assisted-living facilities.
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Residency program directors need to ensure that their residents' schedules include adequate time rotating through these alternative settings, and the directors and hospital administrators need to be willing to collaborate 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.
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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)
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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 4-4 Numbers of physicians newly certified in geriatric psychiatry, 1991-2004.
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The professional nurse workforce consists of registered nurses (RNs) and advanced practice registered nurses (APRNs)
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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.
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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)
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. Furthermore, NPs care for a higher proportion of elderly poor adults than do physicians or physician assistants (Cipher et al., 2006)
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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.
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The American Dental Association, however, does not recognize this specialty board. Less is known about the geriatric education and training of dental hygienists, although dental hygienists are increasingly important in providing care to special populations, especially those in rural areas and long-term care settings.
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in nursing homes by consultant pharmacists (Levenson and Saffel, 2007)
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. Physician Assistants Physician assistants (PAs)
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. Social Workers The need for geriatric social workers has been recognized for decades (NIA, 1987; Saltz, 1997)
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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)
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Hartford Foundation, coordinates the Practicum Partnership Program, an innovative educational model to train masters level social workers in their field work (Box 4-2)
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These professionals are pressed to meet the needs of the growing 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, • HRSA's 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)
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. 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.
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Examples include the following: • 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,
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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.
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. • 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)
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Many GLB patients do not feel comfortable disclosing 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 O'Hanlan, 1994)
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. 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.
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. The American Geriatrics Society lists "health promotion and disease prevention strategies" among the areas of knowledge needed for the successful preparation of internal medicine physicians who care for older adults (AGS, 2004)
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GITT seeks to train health professionals to work more effectively on geriatric care teams. The announced goals included the creation of a national model to forge partnerships between geriatric care providers and institutions of education, the development of educational curricula for interdisciplinary team training, training health care professionals in team skills, and the testing of new models of training for practicing professionals (Flaherty et al., 2003)
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. HRSA has been a strong supporter of interdisciplinary training in geriatrics and has stated that interdisciplinary geriatric education should be a core requirement for every health profession (HRSA, 1995)
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The general competence of health care professionals is ensured via mechanisms of state- or jurisdiction-based licensure and national board certification, both of which may require completion of a verbal examination, a written examination, or minimum amounts of annual education and training. 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.
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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 professionals who might have previously received only on-the-job training and also offering a way to standardize training.
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. Community Colleges Innovative community college programs have great potential for playing a role in both the initial and the continuing geriatric education of certain professionals.
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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 million 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 allied health (DOL, 2006)
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In most states, anyone can use this title without any requirement of training or certification (Stone et al., 2002) , although many geriatric care managers are certified in other professions, most often in either social work or nursing.
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. Formal efforts to help nurses learn these skills are increasing, often through continuing education (Kleinman and Saccomano, 2006)
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Many of these barriers are not unique to the health care professionals 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 various financial disincentives.
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, and about one-third of all currently practicing social workers will soon be of retirement age (National Commission for Quality Long-Term Care, 2007)
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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 workforce to assist older patients (IGSW, 2007)
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Hartford Foundation 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)
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. 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)
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(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.
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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 assumption 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.
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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 assumption 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.
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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.
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Such programs date back to the 1940s. In 1987 HRSA created the State Loan Repayment Program (SLRP)
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TABLE 4-8 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 "Resident Support Programs" 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 "Resident Support Programs" financial residents and residents and practitioners in exchange incentive practitioners for service aWhile service is "required" for some types of programs, many have buyout options (with associated penalties)
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Some state-level loan-repayment programs focus specifically on geriatricians. For example, in May 2005 South Carolina introduced the Geriatric 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.
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. The NHSC recruits the following types of professionals: • Primary care physicians • Nurse practitioners
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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.
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CONCLUSION This chapter addressed the education, training, recruitment, and retention 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.
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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 institution 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 improvement, much more needs to be done to educate, train, recruit, and retain a competent and ample professional workforce to care for the older population in 2030.
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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 assumption 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.
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Journal of the American Geriatrics Society 46(5)
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2006. The supply and demand of professional social workers providing long-term care services.
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2007d. Occupational outlook handbook, 2008-09 edition: Social workers.
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2006. Licensed social workers serving older adults, 2004.
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Hartford Foundation Building Academic Geriatric Nursing Capacity Initiative. Nursing Outlook 54(4)
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2007. Infusing and sustaining aging content in social work education: Findings from gerorich projects.
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2007. Institute for geriatric social work: Education & training.
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Journal of the American Geriatrics Society 55(8)
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Journal of Gerontological Social Work 18(3-4)
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. NASW (National Association of Social Workers)
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Journal of the American Geriatrics Society 53(4)
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2000. Educating social workers for an aging society: A vision for the 21st century.
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Journal of Social Work in End-of-Life & Palliative Care 1(2)
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Journal of the American Geriatrics Society 55(6)
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