Strengthening the Eldercare Workforce
High-quality care for older adults, many of whom have multiple complex chronic conditions, requires a provider team with a diverse range of skills for addressing this population’s physical, mental, cognitive, and behavioral needs. Exposure to geriatrics and gerontological principles and practices is essential for all health care providers.
Geriatrics Workforce Enhancement Program and Geriatrics Academic Career Awards
The Title VII geriatrics workforce programs, administered by the Health Resources and Services Administration, are the only federal programs that train in geriatrics principles. The two initiatives, the Geriatrics Workforce Enhancement Program (or GWEP) and the Geriatrics Academic Career Awards (or GACA), have four main goals:
-Foster education and engagement with family caregivers by training providers who can assess and -address their care needs and preferences.
-Promote interprofessional team-based care by transforming clinical training environments to integrate geriatrics and primary care delivery systems.
-Improve the quality of care delivered to older adults by providing education to families and caregivers on critical care challenges like Alzheimer’s disease and related dementias.
-Reach underserved and rural communities by ensuring clinician-educators are prepared to train the geriatrics workforce of today and tomorrow.
The Alliance urges the administration and Congress to provide adequate funding to protect and expand this critical program.
Lifting Up Direct Care Workers
Direct care workers—including nursing assistants, home health aides, and personal care attendants—provide critical support to older adults in need of long-term services and supports, providing 80 percent of paid hands-on services delivered. To meet the demand for services and address high rates of turnover—particularly for the home care services that enable older adults to remain living at home—direct care worker jobs should offer comprehensive training, certification, and career advancement opportunities.
With the appropriate training, supervision, and support, some home care workers can play an enhanced role in improving the safety and quality of care for older adults and family caregivers. Wages would also be commensurate to the Advanced Direct Care Worker’s training and experience and higher than those of current direct care workers, creating an incentive to remain in this field. We recommend fostering Advanced Direct Care Worker (DCW) roles to help meet the current and future demand for a high-functioning eldercare workforce. EWA also believes that recruitment and retention among this essential workforce can be bolstered through policy reforms that improve wages and benefits, training, data collection, public financing, and the overall value of these workers to the health care system and the economy.
Immigrants and the Eldercare Workforce
Immigrants constitute an increasingly large percentage of the workers who care for us as we age. The following five principles that explain the connections and convey immigration-related principles supported by the EWA:
-Immigrant Health Care Workers are Vital to Caring For Us As We Age
-Direct-Care Workers, Many of Whom Are Immigrants, Are an Essential Part of the Care Team
-Immigration Restrictions Limit the Availability of Family Caregivers
-A Multicultural Workforce Relfects Changing Demographics and Affirms the Need to Deliver Culturally and Linguistically Competent Care
-Policies That Target Individuals and Groups on the Basis of Race, Color, Gender, Disability, Age, Religion, National Origin, or Other Protected Categories Impede Health Care Delivery
Eldercare Workforce and End-of-Life Care
EWA believes that ensuring that the workforce is prepared to support all of us at the end of life is a top priority. Similar to health providers specializing in geriatrics and gerontology, providers specializing in palliative care (care that optimizes quality of life by preventing and relieving suffering associated with a serious illness) remain in short supply.
Increasing the number of health care professionals specializing in geriatrics, gerontology, and palliative care will improve health care delivery as we age and at the end of life. Ensuring that the entire health care workforce understands the basic principles of these specialties will also improve care.
Interdisciplinary team care, the hallmark of geriatric medicine, is the foundation of the Department of Veterans Affairs’ (VA) approach to care. Throughout VA Medical Centers, inpatient, outpatient, and home-based programs, care is person-centered and outcome driven. Through the VA fellowship programs and Geriatric Research Education and Clinical Centers, the VA plays a critical role in training health providers in the care for older adults. In fact, nearly 50% of all geriatric medicine residents and over 50% of geriatric psychiatry residents in the U.S. receive some or all of their training in VHA facilities. EWA urges continued support for VA health workforce training programs that promote competencies in the care for older adults and specialized training in geriatrics and gerontology.
Incentivizing the Eldercare Workforce
Health care providers who care for older adults serve a complex, challenging population, and evidence shows that working with this population is highly satisfying. However, significant barriers, including financial disincentives, exist to recruiting and retaining both direct care workers and health care professionals. Financial incentives to increase the number of people who specialize in geriatrics and gerontology, such as funding to attract knowledgeable academic faculty, loan forgiveness, and scholarships should be offered.
Additionally, compensation for direct care workers should be addressed through means such as establishing minimum standards for wages and benefits paid under public programs and targeting reimbursements to ensure that public funds directly improve compensation for direct care workers.
Advancing Team Based Care
Retooling for an Aging America report urged expansion of team-based approaches to health care delivery, with care provided by a better-prepared healthcare workforce, all working to the top of their skill sets. We know that the best way to care for older adults with multiple chronic conditions is through interdisciplinary team care. There is a strong argument that geriatric team care can lead to a cost savings due to a reduction in such issues as re-hospitalization, polypharmacy, falls, and other geriatric syndromes. To optimize effectiveness and efficiency, a wide range of health care providers—direct care workers, nurses, pharmacists, physicians, physical therapists, psychologists, and social workers—along with consumers and family caregivers at the center of the team, must all work together to provide quality care.
SUPPORTING OLDER ADULTS AND THEIR FAMILY CAREGIVERS
Family caregivers are the backbone of our long-term care system for older Americans. Due to demographic changes, the demand for family caregivers of adults over the age of 65 is increasing significantly but we do not have an eldercare system properly equipped to support them. Family caregivers need more recognition, training, and support in order to provide high-quality care to their loved ones and maintain their own health and well-being. At the same time, the health care workforce needs enhanced training to identify, assess, and engage family caregivers.
Older Americans Act
Older Americans Act programs have long demonstrated a unique ability to provide quality services while enhancing and protecting federal resources. These services save taxpayer dollars by enabling seniors to remain independent and healthy in their own homes, where many prefer to be and where they are less likely to need more costly hospital and institutional care paid for through Medicare and Medicaid. EWA urges congress to reauthorize this program and provide adequate funding to ensure that a greater percentage and growing number of older adults can access home and community-based services.
RAISE Family Caregivers Act
In January of 2018, Congress passed and the President signed the RAISE Family Caregivers Act. The new law requires the Secretary of Health and Human Services to develop, maintain and update a strategy to recognize and support family caregivers. EWA applauds Congress for passing this legislation as the act will help support and inform state and local efforts to support family caregivers.
ENSURING HEALTH CARE ACCESS
Medicaid provides critical support to older adults and the eldercare workforce who cares for them. Medicaid is the principal payer for long-term services and supports (LTSS) in the United States, including nursing home and home- and community-based services, covering 62 percent of such costs. Additionally, providers of LTSS rely on Medicaid to help meet the costs of recruiting, training, and retaining, a qualified eldercare workforce and these health care jobs are major contributors to local economies. Many member of the eldercare workforce, especially the direct care workforce, also rely on Medicaid as a means to care for themselves and their families.
Reductions in Medicaid spending, such as those that would occur under block grant and per capita cap reform proposals, have the potential to be catastrophic for older adults, their families, the eldercare workforce, and communities across the country.
As a coalition committed to ensuring older adults receive person-centered, quality care, EWA supports legislation that will allow advanced practice registered nurses (APRNs)—including nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse midwives (CNMs), as well as physician assistants (PAs)—to order home health services under Medicare, in accordance with state law. We urge Congress to continue to protect Medicare and continue to invest in this important benefit.
Expanding Mental Health
Many older people live with depression and other mental or behavioral health conditions. Such conditions can complicate their medical conditions and exacerbate disability. It is imperative to support the mental and behavioral health needs of an aging America, not only by increasing the workforce specially trained in geriatric mental and behavioral health but also by properly educating all members of the interdisciplinary care team on mental and behavioral health issues affecting older adults.
EWA supports efforts to integrate mental and behavioral health services for older adults within interdisciplinary primary care teams. Supporting demonstration projects featuring innovative care models, outreach teams, and service integration in settings where older adults can most easily access mental and behavioral health services will also help to build a more efficient, effective care delivery system.
PROMOTING CARE INNOVATION
The Department of Veterans Affairs (VA), through the Veterans Health Administration (VHA), has long been a leader in geriatrics and gerontology. The commitment of the VHA to specialize in the care of older veterans has allowed for the development, testing, and training of specialized programs focused on older patients. VA research on older adults is critical to creating better models of care and improving the patient experience in all settings of care. Continued investments in geriatrics and gerontology programs within the VA will support the innovation needed to meet the growing needs of the aging veteran and U.S. population overall.
The Alliance believes that we can provide high-quality, coordinated, person- and family-centered health care and LTSS to older adults who are dually eligible for Medicare and Medicaid, while helping to control costs. EWA believes that a well-trained and supported workforce, and supported family caregivers are essential for dually eligible older adults to receive the quality care they deserve. States and managed care plans should ensure that older adults are receiving coordinated, person- and family-centered care, services, and supports from health care teams with geriatrics and gerontological expertise.
The development of new models of care is essential to meet the needs of older Americans, both today and in the future. Such models must integrate physical and mental health, long-term services and supports, social services, and home- and community-based services. Older adults and families often work closely with health care teams composed of a range of disciplines —including, but not limited to, community health workers, direct care workers, nurses, pharmacists, physicians, and social workers—who lead and participate in care coordination initiatives.
EWA strongly recommends two priorities that are necessary to promote effective, efficient care coordination. First, the workforce must be prepared with appropriate knowledge, skills, and training. Second, care design must be streamlined so that coordination of care becomes intrinsic to service delivery.