Education and Training
Education & Training: Meeting the Needs of Older Adults
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. The lack of training requirements for both health professionals and the direct care workforce results, in part, from a lack of recognition that older adults have distinct health care needs. Exposure to geriatrics and gerontological principles and practices will be essential for training all direct care workers and health care professionals, serving older adults. The Eldercare Workforce Alliance (EWA) calls for a focus on recruitment, training, retention, and compensation of health care providers serving older adults, as well as reimbursement to support participation in interdisciplinary teams.
The Title VII and VIII geriatrics workforce program, also known as the Geriatrics Workforce Enhancement Program (or GWEP), is administered by the Health Resources and Services Administration. GWEP is the only federal program that increases the number of faculty, across disciplines, who have geriatrics and gerontology expertise and who provide training (including training of interdisciplinary health care teams) in clinical geriatrics and gerontology. The Alliance urges the administration and Congress to provide adequate funding and to protect these programs.
Investing in the Direct Care Workforce
High turnover, low wages, and a shortage of qualified home care workers endanger the independence of millions of older Americans who want and rely on these services to remain living at home. Increasing funding for eldercare training and other new educational opportunities for direct care workers will not only help to meet the growing demand for home- and community-based services, but will also provide the recognition and respect the direct care workforce deserves.
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.
Current direct care worker training standards are inadequate to prepare workers to meet the increasingly complex needs of older adults. For example, the minimum federal training requirement for nursing assistants is just 75 hours of training; the Institute of Medicine recommends a minimum of at least 120 hours. For personal care attendants, training requirements vary by state, with no requirements whatsoever in 11 states. 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.
Furthermore, the Alliance believes that 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.
Ensuring the Workforce is Trained to Support the Mental Health Needs of Older Adults
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.
Primary care physicians are often called upon to treat mental health problems and without the support of interdisciplinary teams and mental health providers, these problems often go untreated and unrecognized. 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.
Workforce Recruitment and Retention
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, in aging. 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. EWA believes that extending federal minimum wage and overtime protection to this essential workforce can bolster worker recruitment and retention, thereby improving quality of care.
Supporting Consumers and Caregivers
Family caregivers —of which there are 42.1 million in the United States—provided more than 40.3 billion hours of unpaid care in 2009. In that same year, the estimated economic value of U.S. family caregivers’ unpaid contributions totaled approximately $450 billion. Moreover, almost half of family caregivers perform medical or nursing tasks for people with multiple chronic conditions (both physical and cognitive). Providing support and training opportunities to family caregivers is essential. Family caregivers must be valued members of health care teams, with health care providers identifying family caregivers, assessing their needs, and offering training and support.
Funding should be made available to ensure adequate training opportunities for family caregivers are available in the community. Both long-standing and new models already offer programs that assist caregivers in making decisions and solving problems. New models of care that provide resources and supports to maximize family caregiver physical and mental health and well-being, are also needed.
Care Models Must be Well-Coordinated, Person-Directed and Family-Centered
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. EWA strongly recommend that, as part of the design and implementation of all pilot projects and demonstrations (including those in the Patient Protection and Affordable Care Act), programs should provide well-coordinated, interdisciplinary, person-directed, and family-centered services across settings.
Encouraging Team-Based Care
The Institute of Medicine 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 rehospitalization, 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.
Caring for Dually-Eligible Older Adults
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.
Preserve Medicaid for our Nation’s Older Adults and Those Who Care for Them
Medicaid has become 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. Reductions in Medicaid spending could be catastrophic for older adults, their families, and their communities. Cuts to Medicaid could also impact employers, as increased family caregiving responsibilities increases employees’ time away from work. Moreover, Medicaid cuts could be devastating to the economic security of for health care workers who are paid hourly and could increase their reliance on federal and state programs.
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.