The Medicare program has tested various methods for improving its fee-for-service financing system, which is broadly regarded as promoting fragmented care delivery. The imminent increase in the number of complex patients will require further innovations in financing and care delivery as the need for more effectively coordinated care becomes more pressing. The health care system as a whole must do better in ensuring that complex older patients are provided with care that is streamlined and coherent, and the committee supports various approaches to promote this, including the improvement of education and training, increases in recruitment and retention, and the development of new models of care.

The health care workforce in general receives very little geriatric training and is not prepared to deliver the best care to older patients. Geriatric care has not attracted health care professionals in sufficient numbers in the United States and clearly more professionals specializing in geriatrics will be needed to meet the needs of the coming elderly population both because of their clinical expertise as well as their role in educating and training the rest of the health care workforce in geriatric principles. Since virtually all health care workers care for older adults to some degree, the geriatric competence of all providers must also be improved more generally, through significant enhancements in educational curricula and training programs.

Meeting the demand that is expected in coming years will require expansion of the roles of many members of the health care workforce, including technicians, direct-care workers and informal caregivers, all of whom already play significant roles in the care of older adults. Patients, as well as their families and friends, also need to be considered essential parts of the health care team and learn how to be active and effective participants in the care plan. As the roles and responsibilities of individual members of the health care workforce change, the Medicare system will need to be flexible in paying for innovative models of care and perhaps emerging types of providers that have new designations and training requirements. Interdisciplinary models that support collaboration among multiple types of providers will be essential in improving care delivery for older adults.

This report calls for fundamental reform in the way that care is delivered to older adults and puts forth a plan to help ensure that the health care workforce is sufficient in both size and skill to handle the needs of a new generation of older Americans. These changes are urgently needed to prepare for a sizeable demographic shift that threatens to overwhelm present and future capacity.

John W. Rowe, M.D.


April 2008

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