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4 The Professional Health Care Workforce CHAPTER SUMMARY The need for health care professionals trained in geriatric principles is escalating, but een though opportunities for geriatric specialization ex- ist, few proiders choose this career path. The education and training of professionals in the area of geriatrics is hampered by a scarcity of faculty, inadequate and ariable academic curricula and clinical experiences, and a lack of opportunities for adanced training. Furthermore, the educa- tion and training of geriatric health care professionals is often limited in scope and needs to be expanded both to take into account the diersity of health care needs among older populations and to prepare professionals for the coming new models of care, many of which will require changed or expanded roles. The committee recommends that more be done to en- sure that all professionals hae competence in geriatric principles. Finally, the recruitment and retention of geriatric professionals are hampered by seeral factors, including the persistent stereotypes of older populations, the aging of the workforce itself, and significant financial disincenties. The committee recommends that seeral types of financial incenties be offered to promote the recruitment and retention of clinical and academic geriatric specialists. In the coming decades demand is expected to increase markedly for all types of health care professionals in all settings of care for the elderly population. This chapter examines issues related to the education, training, recruitment, and retention of health care professionals in the care of older adults. This chapter begins with a brief overview of the supply of and de- 

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 RETOOLING FOR AN AGING AMERICA mand for professionals who care for older patients. The overall pattern here is that older Americans account for a disproportionate share of professional health care services but, in spite of this demand, the number of geriatric specialists remains low. Next the chapter focuses on a few individual pro- fessions essential to the care of older adults. It goes on to examine over- arching themes in geriatric education and training. While improvements in the education and training of the health care workforce in geriatrics are evident, these efforts have failed to ensure that all providers who treat older adults have the necessary knowledge and skills to provide competent care. The chapter then considers future trends in education and training. Not only will there be a need for many more professionals working with older adults, but health care workers of the future will need to take on new and expanded roles. As discussed in Chapter 3, these changing responsibilities will affect the entire workforce, including the direct-care workforce, infor- mal caregivers, and patients themselves. (These populations are examined in more detail in Chapters 5 and 6.) Finally, the chapter concludes with strategies for recruiting and retaining professionals in geriatric specialties. These strategies largely depend on overcoming financial disincentives, such as relatively low salaries and the high cost of training. SUPPLY AND DISTRIBUTION The number of professional workers directly involved in the care of older adults is difficult to quantify, for a number of reasons: changes in em- ployment status, differing measures (e.g., licensed vs. active professionals), and the presence of ill-defined and overlapping titles for many occupations. Furthermore, many professionals treat older patients without being identi- fied as geriatric providers either by title or certification. Health care-related careers, including medical assistants, physician assistants, physical thera- pists, mental health counselors, pharmacy technicians, and dental hygien- ists, account for about half of the country’s 30 fastest-growing occupations (BLS, 2007a). Despite the rapid growth, however, the supply of health care workers does not satisfy current demands and will certainly fall short of the increased demands expected in the future. In fact, the United States will need an additional 3.5 million health care providers by 2030 just to main- tain the current ratio of health care workers to population (Table 4-1). While the general need for professionals who care for older patients is high, the particular need for geriatric specialists is even greater. For ex- ample, geriatricians1 are the physicians who are specially trained in care 1 While a physician who has extensive experience with elderly patients may specialize in ge- riatrics, the term “geriatrician” refers to a physician who has been certified in the subspecialty of geriatric medicine, or received a certificate of added qualifications in geriatric medicine.

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 THE PROFESSIONAL HEALTH CARE WORKFORCE TABLE 4-1 Number of Providers in 2005 and Projected Number Needed in 2030 to Maintain Current Provider-to-Population Ratios (in Thousands) 2005 2030 Difference Total health providers 9,994 13,522 3,528 Registered nurses 2,458 3,326 868 Nursing aides 2,009 2,719 709 Physicians 804 1,088 284 Licensed practical and vocational nurses 654 885 231 Pharmacists 236 319 83 Dentists 163 220 57 Other providers 3,670 4,965 1,295 NOTE: Numbers are for overall health care workforce and not limited to geriatric population. SOURCE: Mather, 2007. of the elderly population as a subspecialty of internal or family medicine. These specialists account for only a very small portion of the total physician workforce—just 7,128 physicians are certified geriatricians, or one geriatri- cian for every 2,546 older Americans (ADGAP, 2007b). By 2030, assuming current rates of growth and attrition, one estimate shows that this number will increase to only 7,750 (one for every 4,254 older Americans), far short of the total predicted need of 36,000 (ADGAP, 2007b; Alliance for Aging Research, 2002). In fact, some argue that there could be a net decrease in geriatricians because of the decreasing number of physicians entering train- ing programs as well as the decreasing number of geriatricians who choose to recertify (Gawande, 2007). Geriatric psychiatry faces a similar shortage. Only 1,596 physicians are currently certified in geriatric psychiatry, or one for every 11,372 older Americans, and by 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b). Other professions have similarly low numbers of geriatric specialists. For example, just 4 percent of social workers and less than 1 percent of physician assistants identify themselves as specializing in geriatrics (AAPA, 2007; Center for Health Workforce Studies, 2006). Less than 1 percent of registered nurses (Kovner et al., 2002) and pharmacists2 are certified in geriatrics. In short, dramatic increases in the number of geriatric special- ists are needed in all health professions. Even with tremendous effort, it is 2 Personal communication, T. Scott, American Society of Consultant Pharmacists, November 6, 2007.

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 RETOOLING FOR AN AGING AMERICA unlikely that we can completely fulfill the projected needs, but, still, much can be done to begin to close the gaps. Aside from concerns about the total numbers of health care workers with geriatric competencies, the composition and distribution of the health care workforce for older Americans should also be considered. This in- cludes racial and ethnic diversity as well as the geographic distribution of professionals trained to provide care to older adults. Racial and Ethnic Diversity The committee commissioned a paper on the increasing diversity of older populations (Yeo, 2007) and found that the diversity of the work- force is important for several reasons. First, minority patients often prefer to be treated by health care professionals of the same ethnic background (Acosta and Olsen, 2006; IOM, 2004; Mitchell and Lassiter, 2006; Tarn et al., 2005). Second, a provider from a patient’s own background may have better understanding of culturally appropriate demonstrations of respect for older populations and may also be more likely to speak the same lan- guage (in the case of bilingual providers). Finally, providers from minority populations often account for most of the services provided to underserved populations (HRSA, 2006a). For example, while only 3.4 percent of den- tists are black, they treat almost two-thirds (62 percent) of black patients (Mitchell and Lassiter, 2006). While older adults are more diverse than ever before, the younger gen- erations training to care for them are even more diverse (see Chapter 2). The pattern of this diversity, however, will not necessarily match up with the pattern of diversity among older Americans. Table 4-2 demonstrates, for example, that there is significant diversity among resident physicians in geriatrics, but the percentage of white residents (39 percent) is much lower than the percentage of whites in the elderly population, and the percentage of Asian residents (42 percent) is much higher that the percentage of Asians in the elderly population. Geographic Distribution The distribution of both professionals and older adults varies widely across the country. Since both of these populations may be unevenly dis- tributed across regions, states, and local communities, different areas may have different workforce needs. The committee commissioned a paper on state profiles of the U.S. health care workforce (Mather, 2007). This report showed there is an average of 443 dentists per 100,000 population aged 65 and older in the United States, but this ratio varies widely among the states. There are 759 dentists per 100,000 older adults in New Hampshire, but

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 THE PROFESSIONAL HEALTH CARE WORKFORCE TABLE 4-2 Race and Ethnic Origin of Residents in Geriatric Medicine and Psychiatry, 2006 American Native Indian/ Hawaiian/ Alaskan Pacific Other/ Hispanic Origina Black Native White Asian Islander Unknown Total Geriatrics 4 0 22 15 1 2 5 44 (Family Medicine) Geriatrics 23 0 92 103 5 20 23 243 (Internal Medicine) Geriatric 7 0 25 32 1 7 8 72 Psychiatry Total 34 0 139 150 7 29 36 359 aHispanic origin was determined separately from race, and so the categories are not mutu- ally exclusive. SOURCE: Brotherton and Etzel, 2007. only 104 dentists per 100,000 older adults in Kansas. This variance must be caused by a variety of factors, since these states do not have similar distri- butions in the numbers of other types of professionals. New Hampshire has a lower-than-average number of pharmacists per population of older adults, for example, while Kansas has a higher-than-average number of registered nurses. The need for health care workers with geriatric skills can also vary according to the distribution of older adults. For example, as discussed in Chapter 2, older adults make up 16.8 percent of Florida’s total population, while they account for only 6.8 percent of Alaska’s population (U.S. Census Bureau, 2008). Differences by community are likely to also vary widely. Therefore, the needed distribution of the health care workforce for older American can vary by both the state and the individual profession. The recruitment and retention of health care professionals in rural areas is especially challenging (IOM, 2005), and this is an important fac- tor when discussing the health care needs of the geriatric population, since older adults are disproportionately over-represented in rural areas (Hawes et al., 2005). Older adults that live in rural areas tend to be less healthy than those in urban areas and to have a higher rate of difficulty with ac- tivities of daily living (ADLs) (Brand, 2007; Magilvy and Congdon, 2000), while their access to health services is limited by the relatively small num- ber of providers (especially specialists) that choose to work in rural areas. Because of the relatively small number of specialists, physician assistants and nurse practitioners play significant roles in providing health services

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 RETOOLING FOR AN AGING AMERICA to the rural aging population (Henry and Hooker, 2007). Among the chal- lenges in recruiting any type of professional to rural areas are professional isolation, heavy call schedules, and few job opportunities for the spouses of the health care professionals. The best strategies for recruitment and retention may be those that focus on the training of existing rural provid- ers in geriatric skills via distance education in conjunction with the use of remote technologies to increase the availability of outside geriatric experts for rural elderly populations. THE CURRENT STATE OF GERIATRIC EDUCATION AND TRAINING For more than 30 years the IOM (IOM, 1978, 1993) and others (LaMascus et al., 2005; Olson et al., 2003) have called for improvements in the geriatric education and training of virtually all types of health care providers. While progress is evident, many formal training programs still do not include robust coursework in geriatrics (Berman et al., 2005; Eleazer et al., 2005; Linnebur et al., 2005; Scharlach et al., 2000). Among the barriers to increased education and training in geriatrics for all professions are the lack of faculty, lack of funding, lack of time in already-busy curricula, and the lack of recognition of the importance of geriatric training (Bragg et al., 2006; Hash et al., 2007; Hazzard, 2003; Rubin et al., 2003; Simon et al., 2003; Thomas et al., 2003; Warshaw et al., 2006). Furthermore, very little is known about the best methods to improve the knowledge and skills of professionals in caring for older adults (Gill, 2005). It is not possible to discuss every profession in detail, as virtually ev- ery professional cares for older patients to some degree. In the following section, several professions instrumental to the care of older adults are ex- amined. (See Table 4-3 for an overview.) Specifically, the status of geriatric education and training within each profession is discussed. While some professions are discussed more extensively than others, the committee does not intend for this to imply any conclusion about their importance to the care of older adults. Rather, this is a reflection of the amount of data avail- able and the extensiveness of the existing education and training programs in geriatrics. Overall, the breadth and depth of geriatric education and training remains inadequate to prepare all professionals for the health care needs of the future elderly population. Physicians Older Americans account for a disproportionate share of physician services, but a 2002 survey of primary care physicians showed that only half of these physicians believed that their colleagues could adequately treat

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 THE PROFESSIONAL HEALTH CARE WORKFORCE geriatric conditions (Moore et al., 2004). This section examines the educa- tion and training of all physicians in the care of older adults, with a focus on the path for geriatricians. Geriatric Content The geriatric curricula in medical schools has had notable improve- ments. The percent of medical schools with requirements for “geriatric exposure” has increased from 82 percent in 1985-1986 to 98 percent in 1996-1997 (Eleazer et al., 2005). Still, much of this exposure is inadequate or occurs too late in the educational process to influence which speciali- ties the students select. As noted above, several major public and private initiatives support improvement in the geriatric education of physicians. In May 2001 the Donald W. Reynolds Foundation awarded $19.8 million in grants to 10 institutions in order to develop comprehensive training pro- grams in geriatrics (Donald W. Reynolds Foundation, 2007). Because of the success of this effort, the Donald W. Reynolds Foundation repeated the grants in 2003 and 2005, distributing almost $20 million in each round, and in October 2007 the Donald W. Reynolds Foundation issued a request for proposals for a fourth series of grants. In addition to this effort, the Donald W. Reynolds Foundation has established two departments of geri- atric medicine. The Health Resources and Services Administration (HRSA) distributes grants to support Geriatric Education Centers (GECs), which educate and train individuals in the care of older patients. These centers are often col- laborative efforts among several health-profession schools or health care facilities and have a special focus on interdisciplinary training. In July 2007 the John A. Hartford Foundation and the Association of American Medical Colleges (AAMC) hosted the National Consensus Con- ference on Geriatric Education. There the participants developed a set of minimum standards for the knowledge, skills, and attitudes of graduating medical students with respect to the care of older patients (Leipzig, 2007). The standards covered a number of domains, including • cognitive and behavioral disorders; • medication management; • self-care capacity; • falls, balance, gait disorders; • atypical presentation of disease; • palliative care; • hospital care for older adults; and • health care planning and promotion.

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0 RETOOLING FOR AN AGING AMERICA TABLE 4-3 Overview of the Education and Training of Professionals in Geriatrics Nurses Oral-Health Workers Pharmacists RNs: 2.5 millionb,2 Total jobs Dentists: 161,000; 243,000 held (2006)a,1 LPNs: 749,000 (General dentists: 136,000) Dental hygienists: 167,000 Geriatric Less than 1% of RNs Unknown 1,297 certified (less than 1%)4 specialization and about 2.6% of or certification APRNs certified3,28 Academic 76% of baccalaureate 63% of dental schools 43% have two full-time leadership programs have at least have a geriatric faculty; most rely on one full-time “expert,” director or chairman9 part-time faculty10 29% have a certified faculty member8 Exposure to One-third of 100% of dental and 43% have a discrete geriatrics in baccalaureate dental hygiene schools course; all schools schools programs require have identifiable provide opportunity for exposure; 94% of content; 18.8% advanced training in fundamental courses of dental hygiene geriatrics or long-term care10 integrate geriatric schools have a discrete content8 course14 Advanced Less than 100 13 programs for 10 residency programs; geriatric master’s and post- geriatric dental one fellowship program19 training master’s programs; academic training; no programs five programs in residencies specific to geriatric dentistry18 geropsychiatric nursing3 Number of Approximately 300 Unknown 13 resident slots; one fellowship slot19 advanced geriatric APRNs produced annually3 geriatric trainees Yes21 No22 Explicit No general certification; testing on national licensure non-geriatric exam organized by approaches23 board certification exams?c

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 THE PROFESSIONAL HEALTH CARE WORKFORCE Physician Assistants Physicians Social Workers 66,000 633,000 595,000 Less than 1% specialize5 7,128 certified in geriatric About 4% of social workers specialize7 medicine; 1,596 certified in geriatric psychiatry6 27% of program Less than 1% of faculty 40% of schools have no faculty knowledgeable in aging13 directors surveyed had specialize; all programs have some form of geriatric an identifiable leader in training11 geriatrics12 Accreditation requires 98% of schools require some 80% of BSW students have no form of exposure16 coursework in aging17 geriatric exposure, including clinical experience in long-term care15 None Medicine: 29% of MSW programs offer 139 fellowship programs aging certificate, specialization, (468 1st-year positions)6 or concentration20 Psychiatry: DSW: unknown 58 fellowship programs (142 1st-year positions)6 Not Applicable Medicine: 253 in 1st year; Unknown 34 in 2nd year6 Psychiatry: 726 Yes24 Internal Medicine: 10% of No general certification; exam25 national licensure exam organized by approaches28 Family Medicine: optional module26 Psychiatry: yes27 continued

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 RETOOLING FOR AN AGING AMERICA TABLE 4-3 Continued Nurses Oral-Health Workers Pharmacists Geriatric American Nurse None Commission for certification Credentialing Center Certification in Geriatric Fellowship status body (ANCC) Pharmacy (CCGP) offered by American Society for Geriatric Dentistry (ASGD) and diplomate status offered by American Board of Special Care Dentistry (ABSCD) ABBREVIATIONS: Advanced Practice Registered Nurse (APRN); Bachelor of Social Work (BSW); Doctor of Social Work (DSW); Licensed Practical Nurse (LPN); Master of Social Work (MSW); Registered Nurse (RN). aNumber of jobs may be greater than number of practicing professionals, since some profes- sionals work in more than one position. bAs of 2004, there were 240,260 jobs held by APRNs. cRelies on description of exam content. The group then developed a total of 36 competencies based on these domains (AAMC/The John A. Hartford Foundation, 2007). The competen- cies included • identification of medications to be avoided or used with caution in older adults; • ability to define and distinguish delirium, depression, and dementia; • assessment of ADLs and IADLs; • identification of physiological changes due to aging; • identification of psychological, social, and spiritual needs of pa- tients; and • performance of examination to assess skin pressure ulcer status. While the coverage of geriatric issues at medical schools is increasing, students still express significant reservations about their abilities to treat older patients. The AAMC’s 2002 Medical School Graduate Questionnaire found 55 percent of graduates perceived inadequate coverage of geriatric issues in medical school; only 68 percent felt adequately prepared to care

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 THE PROFESSIONAL HEALTH CARE WORKFORCE Physician Assistants Physicians Social Workers None American Board of Internal National Association of Social Medicine (ABIM), American Workers (NASW) Board of Family Medicine (ABFM), American Board of Psychiatry and Neurology (ABPN), American Osteopathic Board of Family Practice (AOBFP), American Osteopathic Board of Internal Medicine (AOBIM) SOURCES: 1BLS, 2008; 2HRSA, 2006; 3Kovner et al., 2002; 4Personal communication, T. Scott, American Society of Consultant Pharmacists, November 6, 2007; 5AAPA, 2007; 6ADGAP, 2007b; 7Center for Health Workforce Studies, 2006; 8Berman et al., 2005; 9Mohammad et al., 2003; 10Odegard et al., 2007; 11Olson et al., 2003; 12LaMascus et al., 2005; Warshaw et al., 2002; 13Scharlach et al., 2000; 14Mohammad et al., 2003; Tilliss et al., 1998; 15Brugna et al., 2007; 16Eleazer et al., 2005; 17Lubben et al., 1992; 18HRSA, 2005; 19ACCP, 2007; ASHP, 2007; 20Cummings and DeCoster, 2003; 21NCSBN, 2007; 22ABGD, 2007; 23NABP, 2008; 24NCCPA, 2008; 25ABIM, 2007; 26ABFM, 2007; 27ABPN, 2007c; ASWB, 2007; 28HRSA, 2006b. for older persons in acute-care settings, and only half felt prepared to care for them in long-term care settings (Eleazer et al., 2005). In spite of this, less than 3 percent of medical students take geriatric electives (Moore et al., 2004). Adanced Training Postdoctoral training of physicians occurs during both residency and fellowship programs. As of 2003, 27 types of medical residency programs (accounting for 70 percent of trainees) included Accreditation Council for Graduate Medical Education (ACGME) requirements for some form of ge- riatrics training, but the extent of such training is highly variable (Bragg and Warshaw, 2005; Bragg et al., 2006; Simon et al., 2003). One survey showed that only about half of graduating family-practice and internal-medicine residents (48 percent and 52 percent, respectively) felt very prepared to care for elderly patients (Blumenthal et al., 2001). Although a large majority of graduating psychiatry residents felt very prepared to diagnose and treat delirium (71 percent) and major depression (96 percent), only 56 percent felt very prepared to diagnose and treat dementia.

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