Consider the Needs of Older Adults
As policymakers consider the impact of the automatic across-the-board cuts, or “sequester,” as mandated by the Budget Control Act (BCA), the Eldercare Workforce Alliance (EWA) encourages consideration of how the sequester and/or alternatives under consideration would affect services for older adults and the supply of qualified professionals available to care for them. The first of the baby boomers began to turn 65 in 2011; within 20 years, one in five Americans will be over 65. Ninety percent of those Americans will have one or more chronic conditions. Because adults over 65 account for 47 percent of all hospital stays, 34 percent of all prescriptions, 34 percent of all physical therapy patients, and 90 percent of all nursing home stays, ensuring they receive high-quality, efficient care is not only a moral imperative, but a fiscal one[i].
Support a Strong Elder Care Workforce
High-quality care for older adults, many of whom have multiple complex chronic conditions, requires specialized skills for addressing their physical, mental, cognitive and behavioral needs. Unfortunately, the supply of health professionals and direct-care workers with these specialized skills is declining precisely at a time when demand, due to burgeoning numbers of older adults, is increasing at an unprecedented rate. Programs which equip health professionals and direct-care workers with these skills and which help older adults to continue living in their homes and communities, or the most appropriate setting, are among those which would be cut dramatically if the sequester, or other drastic cuts to non-defense discretionary programs, take effect. They include:
Health Resources & Services Administration:
Geriatric Academic Career Awards (GACA), Geriatric Education Centers (GEC), and the Geriatric Training Program for Physicians, Dentists, Behavioral and Mental Health Professions (GTPD), and the Comprehensive Geriatric Education Program (CGEP) provide much needed support to professionals pursuing specialized training in caring for older adults. A five percent cut to these programs equals an estimated $1.77 million cut for FY2013. Cuts of this magnitude will have a severe negative impact on eldercare workforce training, with as many as 6,070 fewer professionals with geriatric training to serve the millions of older adults who need geriatric care now and in the future.
Administration for Community Living (ACL):
Older Americans Act (OAA) programs administered through the Administration on Aging, which is under the ACL, provide important supports which allow older adults to remain in the best setting for them, which is often in their homes and communities. The link between high-quality care from the eldercare workforce with community-based supports provided through OAA programs, is key to limiting avoidable costs of care. The OAA’s National Family Caregiver Support Program (NFCSP), also plays a critical role in supporting family caregivers, who deliver the majority of the long-term services and supports in the U.S. A five percent cut to these programs equals an estimated $100 million cut for FY2013. Cuts of this magnitude could negatively impacting the more than 10 million older adults supported by OAA’s supportive services, meals, and elder abuse prevention programs and the approximately 700,000 family caregivers supported annually by the NFCSP.
Medicare ensures access to outpatient health care and preventive services, hospital care, and rehabilitation services for millions of older adults and people with disabilities. Since its inception in 1965, Medicare has achieved nearly universal health insurance coverage for this population, compared with only 56 percent with coverage before 1965[i]. The BCA requires a 2 percent cut to Medicare spending starting in 2013. According to a recent report[iii], in 2013 alone, these cuts would directly result in 211,756 fewer health care professionals employed to care for older adults.
Though Medicaid is protected from cuts under the sequester established by the BCA, Congress is currently discussing ways to avoid sequestration, including some proposals which would make cuts to programs exempted from cuts under the BCA, such as Medicaid. Medicaid plays a crucial role in funding long-term services and supports (LTSS) for older adults. Cuts to Medicaid, during this time of expanding needs for LTSS, would negatively impact the availability of home- and community-based LTSS for older adults, which are less costly than services provided in institutional settings and help people live in their homes and communities where they want to be.
A Well-Trained Workforce and Cost-Savings
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. A 2002 Health Affairs article noted, “patients who received specialized geriatric care had sizable reductions in functional decline and improvements in mental health at no additional costs. Older patients cared for by nurses prepared in geriatrics are less likely to be physically restrained, have fewer readmissions to the hospital, and are less likely to be transferred inappropriately from nursing facilities to the hospital.”[iv] Coordinated care from a well-trained team is crucial to “improving the quality, outcomes, or efficiency of care,” especially for the most vulnerable of older adults.[v] [vi] One recent study revealed that geriatricians are more efficient than other physicians at managing hospitalized older adults, measured by shorter hospital stays and lower costs per admission, with no difference in outcomes.[vii] At the very least, studies have shown that geriatric team-care can result in higher quality care that is “cost neutral from the healthcare delivery system perspective.”[viii] These cost-savings, resulting from skilled, efficient, coordinated care provided by a well-trained workforce, will become even more critical as America ages.
Cuts Would Aggravate the Existing Eldercare Workforce Crisis
The need for immediate, increased investment in preparing the U.S. health care workforce to care for older adults is already urgent. While we understand the fiscal constraints facing the nation, we feel it imperative to stress that stagnant or decreased investment due to cuts will cause the crisis to worsen, and care for our nation’s older adults will suffer.
Examples of the current crisis:
- There are only 7,029 certified geriatricians practicing in the U.S. – only roughly half the number currently needed, and falling.[ix]
- More than one million additional direct-care workers – home health aides, personal care aides, and certified nursing aides – will be needed by 2018, according to the latest employment projections.[x]
- Only 0.2% of all practicing nurses are certified as advance practice geriatric nurses and only 4% (5700) of all certified Advanced Practice Registered Nurses are certified in geriatrics.
- Approximately 55,000 social workers are currently needed in long-term care. By 2050, this number will nearly double to approximately 109,000[xi]. In 2009–2010, only an average of 5% across all social work graduates completed a specialization in aging.[xii]
- In 2010, physical therapists and physical therapist assistants had demonstrated vacancy rates of 18.6 percent and 16.6 percent, respectively, in skilled nursing facility settings across the U.S.[xiii]
- Only 4.2% of practicing psychology health service providers identify geropsychology as an area of focus and work and the current median age of these providers is 55.[xiv]
- An estimated 43.5 million unpaid caregivers provide care to someone 50 years or older annually.[xv] Family caregivers can face physical, emotional, mental, and financial challenges in their caregiving role.
Take a Balanced Approach
The Eldercare Workforce Alliance urges Congress and the President to take a balanced approach to addressing our nation’s deficit that protects our nation’s most vulnerable and invests in our country’s future by supporting proposals that would provide adequate funding to protect care for older adults and to ensure a health care workforce with the skills needed to meet their needs.
[i] IOM report Retooling for an Aging America: Building the Health Care Workforce
[ii] Gornick, M., Warren, J., Eggers, P., Lubitz, J., De Lew, N., Davis, M. and Cooper, B. (1996) Thirty Years of Medicare: Impact on the Covered Population. Health Care Financing Review, Volume 18, Number 2. http://www.ssa.gov/history/pdf/ThirtyYearsPopulation.pdf
[iii] Tripp Umbach (September 2012). “The Negative Employment Impacts of the Medicare Cuts in the Budget Control Act of 2011”
[iv] Kovner, C. T., Mezey, M., & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging society. Health Affairs, 21(5), 78-89.
[v] Boult, C., Green, A. F., Boult, L. B., Pacala, J. T., Snyder, C. and Leff, B. (2009), Successful Models of Comprehensive Care for Older Adults with Chronic Conditions: Evidence for the Institute of Medicine’s “Retooling for an Aging America” Report. Journal of the American Geriatrics Society, 57: 2328–2337. doi: 10.1111/j.1532-5415.2009.02571.x
[vi] Warshaw, G. A., Bragg, E. J., Fried, L. P. and Hall, W. J. (2008), Which Patients Benefit the Most from a Geriatrician’s Care? Consensus Among Directors of Geriatrics Academic Programs. Journal of the American Geriatrics Society, 56: 1796–1801. doi: 10.1111/j.1532-5415.2008.01940.x
[vii] Sorbero, M. E., Saul, M. I., Liu, H. and Resnick, N. M. (2012). Are Geriatricians More Efficient Than Other Physicians at Managing Inpatient Care for Elderly Patients?. Journal of the American Geriatrics Society, 60: 869–876
[viii] Counsell, S. R., Callahan, C. M., Tu, W., Stump, T. E. and Arling, G. W. (2009), Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention. Journal of the American Geriatrics Society, 57: 1420–1426. doi: 10.1111/j.1532-5415.2009.02383.x
[ix] AGS “Projected Future Need for Geriatricians” http://www.americangeriatrics.org/files/documents/Adv_Resources/GeriShortageProjected2009.pdf
[x] PHI Fact Sheet: Who are Direct-Care Workers? http://www.directcareclearinghouse.org/download/NCDCW%20Fact%20Sheet-1.pdf
[xi] U.S. Department of Health and Human Services (DHHS). (2006). The supply and demand of professional social workers providing long-term care services. Report to Congress. Retrieved from http://aspe.hhs.gov/daltcp/reports/2006/SWsupply.htm
[xii] Council on Social Work Education (CSWE). (2011). 2009 Statistics on social work education in the United States. Retrieved from http://www.cswe.org/CentersInitiatives/DataStatistics/ProgramData/47673.aspx
National Association of Social Workers (NASW).(2006a). Assuring the sufficiency of a frontline workforce: A national study of licensed social workers—Special report: Social work services for older adults. Retrieved from: http://workforce.socialworkers.org/studies/aging/aging.pdf
[xiii] American Physical Therapy Association Research Department. From: 2010 Practice Profile Survey. Alexandria, VA: American Physical Therapy Association; 2011. Unpublished data.
[xiv] APA Center for Workforce Studies (2010). 2008 APA survey of psychology health service providers. Retrieved from http://www.apa.org/workforce/publications/08-hsp/index.aspx
[xv] Caregiving in the US 2009 report http://www.caregiving.org/data/Caregiving_in_the_US_2009_full_report.pdf