RETOOLING FOR AN AGING AMERICA

BUILDING THE HEALTH CARE WORKFORCE

Committee on the Future Health Care Workforce for Older Americans

Board on Health Care Services

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
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RETOOLING FOR AN AGING AMERICA B U I L D I N G T H E H E A LT H C A R E W O R K F O R C E Committee on the Future Health Care Workforce for Older Americans Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by contracts between the National Academy of Sciences and AARP; Archstone Foundation (Contract No. 07-01-07); The Atlantic Philanthropies (Contract No. 14984); The California Endowment (Contract No. 20062172); The Commonwealth Fund (Contract No. 20070140); The Fan Fox and Leslie R. Samuels Foundation, Inc.; The John A. Hartford Foundation, Inc. (Contract No. 2006-0133); The Josiah Macy, Jr. Foundation (Contract No. B06-07); The Retirement Research Foundation (Contract No. 2006-278); and Robert Wood Johnson Foundation (Contract No. 57803). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not neces- sarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Retooling for an aging America : building the health care workforce / Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-309-11587-2 (hardcover) 1. Older people—Medical care--United States. 2. Caregivers—United States. 3. Geriatricians—Supply and demand--United States—Forecasting. I. Institute of Medicine (U.S.). Committee on the Future Health Care Workforce for Older Americans. [DNLM: 1. Health Services for the Aged—manpower—United States. 2. Aged—United States. 3. Caregivers—United States. 4. Health Manpower—trends—United States. WT 31 R438 2008] RA564.8.R48 2008 618.97′023—dc22 2008024225 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2008 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2008. Retooling for an aging America: Build- ing the health care workforce. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON THE FUTURE HEALTH CARE WORKFORCE FOR OLDER AMERICANS JOHN W. ROWE (Chair), Professor, Department of Health Policy and Management, Mailman School of Public Health, Columbia University PAULA G. ALLEN-MEARES, Dean, Norma Radin Collegiate Professor of Social Work and Professor of Education, School of Social Work, University of Michigan STUART H. ALTMAN, Dean and Sol C. Chaikin Professor of National Health Policy, The Heller School for Social Policy and Management, Brandeis University MARIE A. BERNARD, The Donald W. Reynolds Chair in Geriatric Medicine, Professor and Chairman, Reynolds Department of Geriatrics, University of Oklahoma College of Medicine DAVID BLUMENTHAL, Director, Institute for Health Policy, Massachusetts General Hospital/Partners HealthCare System; Samuel O. Thier Professor of Medicine and Professor of Health Care Policy, Harvard Medical School SUSAN A. CHAPMAN, Director of Allied Health Workforce Studies, Center for the Health Professions; Assistant Professor, School of Nursing, University of California, San Francisco TERRY T. FULMER, Erline Perkins McGriff Professor and Dean, College of Nursing, and Co-Director, The Hartford Institute for Geriatric Nursing, New York University TAMARA B. HARRIS, Chief, Geriatric Epidemiology Section Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, National Institutes of Health MIRIAM A. MOBLEY SMITH, Associate Dean and Associate Professor, Chicago State University College of Pharmacy CAROL RAPHAEL, President and Chief Executive Officer, Visiting Nurse Service of New York DAVID B. REUBEN, Archstone Foundation Chair and Professor; Director, Multicampus Program in Geriatric Medicine and Gerontology; Chief, Division of Geriatrics, David Geffen School of Medicine, University of California, Los Angeles CHARLES F. REYNOLDS III, UPMC Professor of Geriatric Psychiatry, University of Pittsburgh School of Medicine; Professor of Behavioral and Community Health Science, Graduate School of Public Health, University of Pittsburgh JOSEPH E. SCHERGER, Clinical Professor, University of California, San Diego; Medical Director, AmeriChoice 

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PAUL C. TANG, Vice President, Chief Medical Information Officer, Palo Alto Medical Foundation; Consulting Associate Professor of Medicine (Biomedical Informatics), Stanford University JOSHUA M. WIENER, Senior Fellow and Program Director of Aging, Disability, and Long-Term Care, RTI International Study Staff ROGER HERDMAN, Director, Board on Health Care Services1 MICHELE ORZA, Acting Director, Board on Health Care Services2 MEGAN McHUGH, Study Director3 TRACY HARRIS, Study Director BEN WHEATLEY, Program Officer MICHELLE BRUNO, Research Associate REDA URMANAVICIUTE, Administrative Assistant MICHAEL PARK, Senior Program Assistant 1 Starting October 2007. 2 Through October 2007. 3 Through November 2007. i

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s (NRC’s) Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: KATHLEEN C. BUCKWALTER, The John A. Hartford Center of Geriatric Nursing Excellence, The University of Iowa SARAH GREENE BURGER, The Hartford Institute for Geriatric Nursing, College of Nursing, New York University CHRISTINE K. CASSEL, American Board of Internal Medicine STEVEN L. DAWSON, PHI DON DETMER, American Medical Informatics Association WALTER H. ETTINGER, University of Massachusetts Memorial Medical Center NATHAN HERSHEY, University of Pittsburgh, Professor Emeritus ULA HWANG, Department of Emergency Medicine and Geriatrics, Mount Sinai School of Medicine JUDY R. LAVE, Pennsylvania Medicaid Policy Center, Graduate School of Public Health, University of Pittsburgh ii

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iii REVIEWERS BRIAN W. LINDBERG, Consumer Coalition for Quality Health Care MARILYN MOON, American Institutes for Research JOSEPH G. OUSLANDER, Division of Geriatric Medicine and Gerontology, Wesley Woods Center of Emory University ROBYN I. STONE, Institute for the Future of Aging Services, Association of Homes and Services for the Aging DONALD H. TAYLOR, JR., Benjamin N. Duke and Trinity Scholarship Program and Terry Sanford Institute of Public Policy, Duke University Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by NEAL VANSELOW, Tulane University, Professor Emeritus, and EDWARD B. PERRIN, School of Public Health, University of Washington, Professor Emeritus. Appointed by the NRC and the Institute of Medicine, they were responsible for mak- ing certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Foreword The retirement of the baby boom generation is rapidly approaching. Between 2005 and 2030, the number of adults aged 65 and older in the United States will almost double. This dramatic shift in the age distribu- tion of America’s population will place accelerating demands upon the U.S. health care system. For the health care workforce, the challenges presented by the aging of America are multifaceted. The sheer volume of older adult patients threat- ens to overwhelm the number of physicians and other professionals who will be available, unless more is done to ensure an adequate supply. Specific skill sets are required to treat older patients, and our country is unlikely to have enough geriatricians to meet the needs. The vast majority of older adults have chronic illnesses that take them to multiple providers each year, and the management of chronic illness depends on better coordination and team-based care. The Institute of Medicine’s (IOM’s) Committee on the Future Health Care Workforce for Older Americans, chaired by John W. Rowe, was formed to probe these challenges and to set out a course of action that will improve our nation’s readiness to care for an aging population. The com- mittee conducted a thorough analysis of the forces that shape the health care workforce, including education, training, modes of practice, and the financing of public and private programs. During the course of its work, the committee sought to answer a num- ber of questions that will be crucial in determining our readiness to meet the health care needs of a rapidly aging society, including: what is the best use of the paid health care workforce and informal caregivers in meeting ix

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x FOREWORD the needs of older adults? What new roles or new types of providers might be necessary to facilitate efficient, high-quality care? How should the health care workforce be educated and trained to deliver high-value care to older adults, and how should this training be financed? And, what will strengthen the recruitment and retention of the needed workforce? This year marks the 30th anniversary of the first IOM report on the workforce for geriatric patients, Aging and Medical Education (1978). While the aging of the U.S. population as a whole has been projected for de- cades, we are now on the cusp of this change. The actions called for in this report to bolster the health care workforce will take years to reach their full effect. We can no longer afford to delay these changes that will ultimately help ensure that all older Americans will receive adequate health care. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine April 2008

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Preface In 2007, the Institute of Medicine convened the Committee on the Future Health Care Workforce for Older Americans to recommend steps to improve health care for the growing number of adults over age 65. The committee envisions a future health care system in which the health needs of the older population are addressed comprehensively, services are pro- vided efficiently, and older patients are encouraged to be active partners in their own care. In the near future, the nation will be aging dramatically, primarily due to increases in life expectancy and the aging of the baby boom generation. Together, these factors will contribute to the largest-ever proportion of older adults, increasing from 12 percent of the U.S. population in 2005 to almost 20 percent by 2030. The 78-million member baby boom generation born between 1946 and 1964 begins turning 65 in 2011. While a large seg- ment of this group will maintain health and independent functioning well past the age of 65, reaching traditional retirement age is generally accom- panied by an increasing number of personal health challenges. More than three-fourths of adults over age 65 suffer from at least one chronic medical condition that requires ongoing care and management. Currently, 20 per- cent of Medicare beneficiaries have five or more chronic conditions. Caring for the elderly population poses a unique set of challenges. In addition to geriatric syndromes, such as falls and malnutrition, which often lead to acute health care problems, older adults also suffer from a range of cognitive impairments that can impact their ability to perform as active participants in their own care. Moreover, older adults are complex because they often suffer from a range of ailments, including chronic conditions such as hypertension and congestive heart failure, which require ongoing care and active management from multiple providers simultaneously. xi

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xii PREFACE 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 reten- tion, and the development of new models of care. The health care workforce in general receives very little geriatric train- ing 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 ex- pansion of the roles of many members of the health care workforce, includ- ing 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 pro- viders that have new designations and training requirements. Interdisciplin- ary 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 deliv- ered 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 pres- ent and future capacity. John W. Rowe, M.D. Chair April 2008

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Acknowledgments Retooling for an Aging America: Building the Health Care Workforce benefited from the contributions of many individuals. The committee takes this opportunity to recognize those who so generously gave their time and expertise to inform its deliberations. The committee benefited from presentations made by a number of experts. The following individuals shared their experiences and perspec- tives during public meetings of the committee: Marcia K. Brand, Health Resources and Services Administration (HRSA); Eric Coleman, University of Colorado Health Sciences Center; Steven Dawson, PHI; Steven DeMello, HealthTech; Federico Girosi, RAND; Stephen Goss, Social Security Ad- ministration; Jennie Chin Hansen, University of California, San Francisco; Charlene Harrington, University of California, San Francisco; Barbara Harvath, HealthTech; Jeanie Kayser-Jones, University of California, San Francisco; Bruce Leff, Johns Hopkins University Schools of Medicine and Public Health; Sharon A. Levine, Boston University School of Medi- cine; David B. Reuben, University of California, Los Angeles; Michèle J. Saunders, The University of Texas Health Science Center at San Antonio; Robyn I. Stone, Institute for the Future of Aging Services, American As- sociation of Homes and Services for the Aging; Alice Wade, Social Security Administration; Gwen Yeo, Stanford University School of Medicine; and Dan Zabinski, MedPAC. The committee commissioned several papers to provide background in- formation for its deliberations and to synthesize the evidence on particular issues. We thank the following individuals for their contributions to these papers: Chad Boult, Johns Hopkins Bloomberg School of Public Health; xiii

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xi ACKNOWLEDGMENTS Lisa B. Boult, Johns Hopkins University School of Medicine; Ariel Green, Johns Hopkins University School of Medicine; The Health Technology Center (HealthTech); Wendy King, Stanford University School of Medicine; R. Tamara Konetzka, University of Chicago; Bruce Leff, Johns Hopkins University School of Medicine; Mark Mather, Population Reference Bureau; James T. Pacala, University of Minnesota Medical School; Claire Snyder, Johns Hopkins University School of Medicine; Jennifer L. Wolff, Johns Hopkins Bloomberg School of Public Health; and Gwen Yeo, Stanford University School of Medicine. We extend special thanks to the following individuals who were es- sential sources of information, generously giving their time and knowledge to further the committee’s efforts: Dana Goldman, RAND; Seth Landefeld, University of California, San Francisco; Linda Martin, Institute of Medi- cine; and Joan Weiss, HRSA. We also thank Robert Pool, copyeditor. Finally, the committee gratefully acknowledges the assistance and sup- port of individuals instrumental in developing this project: Jeane Ann Grisso, Robert Wood Johnson Foundation; Sarah Handley, The Atlantic Philanthropies; Marilyn Hennessy, The Retirement Research Foundation; Linda Hiddemen, American Geriatrics Society; Gavin Hougham, The John A. Hartford Foundation, Inc.; Marvin A. Kauffman, The Fan Fox and Leslie R. Samuels Foundation, Inc.; Mary Jane Koren, The Commonwealth Fund; Mary Ellen Kullman, Archstone Foundation; Christopher Langston, The John A. Hartford Foundation, Inc. (formerly of The Atlantic Philanthro- pies); June E. Osborn, formerly of the Josiah Macy, Jr. Foundation; Corinne H. Rieder, The John A. Hartford Foundation, Inc.; Laura Robbins, The Atlantic Philanthropies; John Rother, AARP; George E. Thibault, Josiah Macy, Jr. Foundation; Julio Urbina, The Fan Fox and Leslie R. Samuels Foundation, Inc.; Dianne Yamashiro-Omi, The California Endowment; and Nancy Zweibel, The Retirement Research Foundation.

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Contents SUMMARY 1 1 INTRODUCTION 15 Chapter Summary, 15 Challenges to Improving Care for Older Adults, 17 Study Charge and Approach, 25 Overall Conclusions, 29 Overview of the Report, 31 2 HEALTH STATUS AND HEALTH CARE SERVICE UTILIZATION 39 Chapter Summary, 39 The Health and Long-Term Care Needs of Older Adults, 40 Current Utilization of Health Care Services, 45 Differences by Demographic Characteristics, 49 Projections, 52 Implications for Financial Resources, 65 Conclusion, 66 3 NEW MODELS OF CARE 75 Chapter Summary, 75 A Vision for Care in the Future, 76 New Models of Care Delivery, 78 Paying for New Models of Care, 96 Dissemination of New Models of Care, 101 x

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xi CONTENTS Development of Future Models and Further Research, 108 Implications for the Workforce, 111 Conclusion, 115 4 THE PROFESSIONAL HEALTH CARE WORKFORCE 123 Chapter Summary, 123 Supply and Distribution, 124 The Current State of Geriatric Education and Training, 128 Trends Affecting the Future of Education and Training, 162 Recruitment and Retention, 167 Conclusion, 181 5 THE DIRECT-CARE WORKFORCE 199 Chapter Summary, 199 Direct-Care Occupations, 201 Workforce Demographics, 203 Education and Training Requirements, 204 Recruitment and Retention Challenges, 209 Improving Recruitment and Retention, 214 Conclusion, 232 6 PATIENTS AND INFORMAL CAREGIVERS 241 Chapter Summary, 241 Patients, 242 Informal Caregivers, 247 Conclusion, 263 APPENDIXES A Committee Biographies 271 B Commissioned Papers 279 C Workshop Presentations 281 INDEX 285