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Executive Summary THIS REPORT IS THE RESULT of the first large, national study of the enterprise known as allied health. It identifies the major functions of allied health practitioners, a group that has been relatively unrecognized by health policymakers. A major consequence of this low profile has been that policymakers are often unaware of the impact of their decisions on allied health services. Allied health personnel constitute a majority of the health care work force. They work in all types of care primary, acute, tertiary, and chronic- and in all health care settings physicians' and dentists' offices, health maintenance organizations, laboratories, freestanding facilities offering special services, ambulances, home care, and hospitals. The levels of training of allied health personnel are as varied as the care they provide and the settings in which they work. These personnel include both highly educated persons and others with only on-thejob training. They work with widely varying degrees of autonomy, dependence on technology, and regulation. Yet there is a paucity of information about them. There is not even a consensus on what the term allied health means. Compared with nurses, physicians, and dentists, the allied health work force as a whole has been little studied. Prompted by a congressional mandate and funded by the Health Resources and Services Administration of the U.S. Department of Health and Human Services, this study by the Institute of Medicine was intended to answer the following questions: First, what roles do allied health workers perform and how will these roles fit into a changing health care delivery system over the next 15 years? Second, what will be the future demand for allied health personnel and how can public and private poli-

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2 ALLIED HEALTH SERVICES cymakers ensure that that demand is met? Third, should these occupations be regulated and, if so, how? Fourth, what sorts of actions should educators take to prepare allied health practitioners for the workplace of the future? The committee's recommendations are based on what existing evidence tells about vital characteristics of the allied health labor market: the composition of the labor forcenamely, the predominance of technically competent women with a service orientation; highly regulated professions and work environments; education programs that are unable to compete effectively with other academic programs for limited resources and sufficient numbers of stu- dents; and employers whose organizations are undergoing sweeping changes in their financial incentives and who must make hiring, compensation, and work force allocation decisions in the absence of good information. . Throughout the study a major challenge for the committee has been to capture the diversity of allied health occupations and at the same time devise specific yet encompassing recommendations for those who must make policy decisions that affect allied health personnel. Toward this end the committee chose to focus on 10 allied health fields. It used the following criteria in their selection: (1) each of the 10 must be large and well known; (2) collectively, they must span the spectrum of autonomy; and (3) collectively, their practitioners must work in a wide variety of health care settings. The occupations that were selected include clinical laboratory technol- ogists and technicians, dental hygienists, dietitians, emergency medical per- sonnel, medical record administrators and technicians, occupational therapists, physical therapists, radiologic technologists and technicians, respiratory therapists, and speech-language pathologists and audiologists. It is the committee's hope that this report is only the beginning of a process that will clarify the place of all allied health occupations in the health care delivery system. ALLIED HEALTH PERSONNEL: WHO ARE THEY AND WHAT DO THEY DO? There have been many attempts to define allied health and to categorize the occupations that should be covered by this umbrella definition. Lacking a satisfactory definition of allied health, however, efforts to classify occu- pations have focused on specific aspects of work and education (e.g., pa- tient-oriented groups versus laboratory-oriented groups) or on the level of education needed. The results of these attempts have not been enthusi- astically embraced by allied health practitioners. The committee chose not to join in the search for a definition. The benefits of making the term more

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EXECUTIVE SUMMARY 3 precise are less clear than the benefits of continued evolution. The changing nature of health care makes some practices and practitioners obsolete at the same time it opens up opportunities for the formation of new groups. It is more important that pragmatism continue to prevail and that old and new groups draw what benefits they can from belonging to "allied health" than that a description of common characteristics defines the group. Rather than define allied health, the committee thus chose to examine policy-related characteristics of occupations that help explain how the fields are variously affected by changes in the health care environment. These characteristics include the amount of autonomy in the workplace, the oc- cupation's dependence on technology, the substitution of one level and type of personnel for another, flexibility in the location of employment, degree of regulation, and inclusion in accreditation standards for facilities. 1 1 ESTIMATING SUPPLY AND DEMAND To respond to the congressional charge "to identify projected needs, availability, and requirements of various types of health care delivery sys- tems for each type of allied health personnel," the committee had to resolve issues of scope and approach. Given its limited funds and time the com- mittee concluded that its greatest contribution would be to try to clarify the future outlook for allied health personnel- which is crucial to strategic planning and policy rather than to systematically assess the current sit- uat~on. Data Limitations The committee's ability to fulfill its charge was severely hampered by a lack of data, the result of a relatively low interest and small investments of public resources in learning about the allied health work force. The com- mittee had to rely on data sources that included some information about allied health, however incomplete and unreliable those sources might be. It assessed the existing data and conducted hearings, site visits, and work- shops to round out its own expertise and enhance its understanding of the forces that will shape the future of allied health occupations. The committee could not make quantitative predictions of personnel shortages and sur- pluses because of the usual uncertainties of occupational projections and the absence of necessary data elements. Yet if employers, higher education planners, federal and state officials, and others had soundly based projec- tions, decision making might be improved. The federal government in its role as monitor of the nation's economic activity has a responsibility to monitor the health care work force and to inform participants in the health care labor market and public policymakers of trends and developments. The work of the Bureau of Health Professions,

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4 ALLIED HEALTH SERVICES the Bureau of Labor Statistics, and the Center for Education Statistics is to be commended and should be built upon. To improve the data on allied health fields, the committee recommends that the secretary of health and human services convene an interagency task force composed of repre- sentatives from the Bureau of Labor Statistics, the Center for Education Statistics, and other agencies that collect relevant data on the allied health work force. This task force should work toward increasing the amount and improving the quality of data needed to inform public policy decision makers, health care managers, unions, prospective students, and aca- demic institutions about the allied health occupations. To help implement this recommendation and others that require federal action, the committee recommends that the Department of Health and Human Services maintain an organizational focal point on allied health personnel to implement the grant programs recommended in this report, to coordinate the recommended work of the interagency data task force, and to facilitate communication among state legislative committees and the federal government. Factors That Affect the Demand for and Supply of Allied Health Personnel A first step in understanding or projecting the future of the allied health occupations, either as a group or for individual fields, is to understand the ways in which certain forces operate in the environment to drive demand and supply. Early action in response to these forces can forestall the need for more radical corrections at a later date. THE CURRENT EMPLOYMENT SITUATION Available data did not enable the committee to develop a reliable estimate of whether the supply of practitioners in the various allied health fields was in reasonable balance with demand. However, during the course of the study, the committee was in contact with people who observe various portions of the allied health labor market. These educators and employers expressed increasing concern about the availability of students and prac- titioners. Educators generally reported that their graduates found jobs easily; employers, on the other hand, reported increasing difficulties in filling vacancies. There are, of course, variations among fields and localities. The committee heard reports of shortage most frequently for physical therapists. For other fields there were reports of less severe shortages or of hiring difficulties that were related to local conditions, to changes in licensure, or to a particular employer's problems. The volatility of the labor market could be easily seen: at the beginning of the study, some educators

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EXECUTIVE SUMMARY 5 were concerned about an oversupply of clinical laboratory personnel; 18 months later concerns centered on employers' growing difficulties in hiring trained clinical laboratory personnel. It is clear that changes in the health care system have caused and are still causing shifts in employment patterns. Prospective payment and other efforts to control hospital utilization caused initial reductions in hospital employment for some allied health fields. For other fields the rate of increase in hospital employment slowed; still others showed a substantial increase. The growth of out-of-hospital care has accelerated, creating new sites for the employment of allied health personnel. Whether in the long run these changes translate into a substantial number of additional jobs or merely a shift in the location of employment is an important question- not only for projecting allied health personnel demand but also for the way personnel are educated to practice in new settings. Moreover, allied health practitioners working in these new settings also raise issues for reg- ulators who are concerned with the quality of care and for traditional employers who must now compete for personnel with employers who can sometimes offer more attractive salaries and working conditions. The committee used the best data available to make assessments of how the forces that drive demand and supply will affect allied health labor markets. Its intention is to alert decision makers to the kinds and magni- tudes of market adjustments that they should expect and encourage to sustain a long-term balance between allied health personnel demand and supply. Markets eventually adjust to change. Projected imbalances in demand and supply do not necessarily mean that shortages or surpluses will occur. Rather, they signal that employers and potential employees must and prob- ably will make adjustments. Only rarely do markets fail to accommodate changes in demand and supply. Yet there are inherent time lags and inefficiencies in the process that can be lessened by public and private interventions. THE FUTURE EMPLOYMENT SITUATION Barring major economic or health care financing contractions, the growth in the number of jobs for allied health workers will substantially exceed the nation's average rate of growth for all jobs. Unless some existing trends are moderated, the flow of practitioners into the work force through grad- uation from education programs will be, at best, stable. For some fields, such as physical therapy, radiologic technology, medical record services, and occupational therapy, the committee foresees a need for decision makers to improve the working of the market so that severe

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6 ALLIED HEALTH SERVICES imbalances in demand and supply may be prevented. Employers are al- ready concerned about difficulties in hiring in some of these fields, and there are signs that health care providers are beginning to search for ways to accommodate new realities. Because some of the accommodations are expensive and difficult to accomplish, the committee is concerned that inaction may cause crises that could be avoided health care services could be disrupted because providers of care are not available. For some other fields, such as clinical laboratory technology and dental hygiene, there are factors that could cause instability in both demand and supply. For these fields the market is more likely to make the needed adjustments, and serious disruptions are less likely to occur. Yet, in both of these fields, there are unresolved issues concerning the level of personnel that will be allowed to perform certain jobs. The way these issues are resolved could determine whether major demand and supply imbalances will occur. Demand and supply for speech-language pathologists, audiologists, re- spiratory therapists, and dietitians are expected to be sufficiently well bal- anced for the labor market to make smooth adjustments. The kinds of incremental adjustments that make careers attractive and the ways in which personnel are deployed appear likely to maintain a state of equilibrium over time. Nevertheless, for these and other allied health occupations, changes in a number of factors that affect the health care environment could cause disequilibrium. These factors include health care financing policies, technology change, decisions about education programs, and reg- ulatory policies. Those concerned with respiratory therapy, for example, must closely monitor an educational capacity that has proved volatile, as well as changes in home care reimbursement policy. Our conclusions about the future outlook for allied health personnel refer to the long term and are national in scope. For all fields, there are likely to be periods of greater and lesser imbalance between now and the year 2000, as well as local variations in demand and supply. The objective of policy is to make the process of adjustment less painful and costly. A decline in the quality of care, interruptions or reductions of service, and the curtailment of investment in new technologies and organizational forms (e.g., home or outpatient care) that might improve the efficiency of health care delivery are all possible by-products of personnel shortages. The de- cision to intervene in the labor market is made through the political process and reflects society's willingness or unwillingness to tolerate painful dis- locations. In many industries, such dislocations are viewed as normal and acceptable. Yet public policy actions have demonstrated that health care is viewed differently. The committee investigated how educators, employers, regulators, and government can facilitate the smooth working of the market.

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EXECUTIVE SUMMARY 7 EDUCATION The function of the education sector in determining the size and com- position of the work force is clear. Unless educators, in league with em- ployers and professional associations, are successful at fostering an interest in allied health careers among qualified prospective students, both the education programs and the allied health work force will be weakened. Demographic studies show that the proportion of the U.S. population 18 to 23 years old has been declining since the beginning of this decade and will continue to decline through the mid-199Os. This shrinkage of the college-age population will make it increasingly difficult for allied health programs to attract qualified applicants. In addition, other attractive op- portunities compete for that population's attention. This competition sug- gests that greater attention will have to be paid to maintaining allied health's share of the traditional pool of students and that less traditional sources of students (e.g., minorities, older persons, and career changers) should be tapped. Academic allied health programs must overcome the perception, and to some extent, the reality, that they are excessively costly and that their faculty do not make sufficient scholarly contributions to their institutions. Modest but strategic actions by the federal government can help education pro- grams deal with these problems and compete more effectively for acade- mia's limited resources. The committee recommends federal actions that would provide a signal to those who carry most of the responsibility for allied health education states, education administrators, and employers- that these programs must not be undervalued. The problems of allied health educators can be analyzed in terms of the recruitment of students, the financing of programs, and the supply of qualified faculty. Faced with increased competition for students, educational institutions must become creative in their approaches to recruitment. Alliances must be forged with organizations that are also interested in recruiting allied health personnel. The committee therefore recommends that educational institutions, in close collaboration with employers and professional as- sociations, organize for the recruitment of students. Students should be sought in less traditional applicant pools among minorities, older stu- dents, career changers, those already employed in health care, men (for fields in which they are underrepresented), and individuals with hand- icapping conditions. One way to create access to a larger pool of students is to allow entry into education through multiple routes. Alternative pathways to entry-level practice should be encouraged whenever feasible. State higher education coordinating authorities and

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8 ALLIED HEALTH SERVICES legislative committees should insist that educational institutions facilitate mobility between community college and baccalaureate programs. The recruitment of minority students is a particular concern for several reasons: minorities represent a relatively untapped source of manpower; their representation in the population as a whole is increasing; and minority professionals are more likely to serve underserved populations. There have been a number of attempts to recruit and retain minorities in the health professions. The lessons from successful models suggest that interventions must occur early in a student's life and continue through the academic career. The major source of support from the federal govern- ment has come from the Health Careers Opportunity Program. The committee recommends that minority recruitment efforts begin before high school. Academic institutions must offer academic support services for the retention of students and seek to promote educational mobility. To succeed over the long term, these efforts must be made integral to the mission of educational institutions. The committee endorses the objectives of the Health Careers Oppor- tunity Program and believes that funding levels must be maintained at least at current levels. Allied health programs are vulnerable to closure because they appear to lag behind other programs in contributing to the academic standing and financial health of the institution in which they are located. The committee made a number of recommendations directed toward several aspects of this problem. The overall strategy it recommends is to put allied health programs on a more equal footing with other academic programs. To enhance the stability of allied health education, national organi- zations such as the American Society of Allied Health Professions should investigate models in which academic institutions have succeeded in broadening their financial base through such mechanisms as faculty prac- tice plans, extension courses, and industry relationships. These national organizations should also hold workshops to help institutions implement the models and disseminate information. Until credible alternative approaches are developed, the federal gov- ernment and other third-party payers should maintain current reim- bursement levels and mechanisms of support for clinical education. The committee found that in some fields, shortages were inhibiting the expansion of educational capacity despite strong student and employer demand. More generally, deans believe that allied health faculty are be- coming disassociated from clinical practice to the detriment of students' preparation for the workplace. This is due in part to the academic reward system, which does not place a high value on patient care. Attention to faculty skills, however, should not come at the expense of progress in solidifying the research underpinnings that guide everyday practice.

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EXECUTIVE SUMMARY 9 The federal government and the states should fund faculty develop- ment grants in allied health fields, especially when faculty availability and lack of clinical expertise inhibit the production of entry-level work- ers. A cadre of researchers and academic leaders is needed to advance the scientific base of allied health practice. To accomplish this goal, insti- tutions with strong research commitments should consider developing programs that identify and nurture talented individuals. The committee recommends the development of a federal research fellowship program to support these activities. Private foundations should support centers for allied health studies and policy development. These university-based centers would provide a critical mass of researchers and resources to advance technology as- sessment, health services research, and human resource utilization. Institutions offering allied health academic programs should reward and encourage faculty clinical competence. Clinical practice that sustains this competence should be made a requirement and a criterion for pro- motion. HEALTH CARE INSTITUTIONS Health care employers directly generate demand for allied health work- ers and indirectly affect supply by the conditions of employment they offer. The committee reviewed the available literature to determine the sorts of activities that employers could undertake to enhance the supply of allied health workers by making a career in an allied health field more attractive to people choosing an occupation and by increasing retention rates. Few studies of allied health were found. Most of the relevant work is from nursing, where intermittent shortages have focused interest on what it takes to reduce nurse turnover. The literature makes it clear that employers are able to affect work force entrance and exit rates. Even a small increase in tenure has a significant impact on the size of the work force. The committee recommends that employers strive to increase the sup- ply of allied health practitioners by attracting people into allied health occupations and prolonging their attachment to their fields. Some ways to do this include increasing compensation and developing mechanisms for retention. Employers should also look to new labor pools that include men, minorities, career changers, and individuals with handicapping conditions. Despite the reluctance of employers to raise pay in a cost-contained environment, if shortages occur, compensation will increase as administra- tors are compelled to try to attract new entrants into allied health profes-

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10 ALLIED HEALTH SERVICES signs. This increased compensation will make allied health personnel a more costly resource. The committee found little evidence of the strategic planning and re- search that could help employers effectively use allied health practitioners and at the same time preserve the quality of care, working within regulatory constraints and avoiding professional resistance. Nowhere is there a sub- stantial body of research to improve the effectiveness of allied health prac- . . . . . Atoners activities. Available data indicate that in many allied health occupations entry-level pay is currently competitive with other comparable occupations, but allied health salaries over the life of a career are so compressed that there is no incentive to remain in the occupation. The effective use of human resources will necessitate compensation incentives to increase tenure; it will also re- quire that work be organized in a way that uses the greater experience of the more expensive members of the work force. The committee recommends that health care providers and adminis- trators seek innovative ways to channel limited allied health resources toward activities of proven benefit to consumers. Agencies such as the National Center for Health Services Research and the Health Care Fi- nancing Administration should sponsor research and technology assess- ment to ensure that allied health services are effective and that they are organized efficiently. Associations of employers, unions, accrediting agencies, and professional associations should assist in disseminating research findings and providing technical assistance in their implemen- tation. Health care managers will not succeed if they must act alone in these efforts. Educational institutions and the professional associations, which provide the basis for practitioners' goals and aspirations as well as technical knowledge and skills, must also participate. Educators, employers, and professional associations must engage in a regular exchange of ideas and . . experlmentatlon. Chief executive officers, human resource directors, and other health care administrators must develop methods for the effective utilization of the existing supply of allied health personnel. Such methods must grow cut of experimentation with new ways of organizing work efficiently and the distribution of labor among skill levels, always ensuring that the quality of care is not compromised. Employers and educators must forge a relationship to ensure that grad- uates are not frustrated by unrealistic expectations about what their work will entail and employers do not ignore the need for career paths and professional stimulation. To be successful, this effort requires that em- ployers and educators try to understand each other's concerns and con- straints and the pressures exerted by a changing environment.

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EXECUTIVE SUMMARY 11 Health care administrators and academic administrators must engage in constructive exchanges to improve the congruence of employment and education. These exchanges, which should take place at the state and local levels, will be enhanced by the participation of educators who are also leaders of the professional associations. To facilitate this interaction, the committee recommends that state legislatures establish special bodies whose primary purpose would be to address state and local issues in the education and employment of allied health personnel. LICENSURE, CERTIFICATION, AND ACCREDITATION the committee took a broad view of the charge from Congress and examined the full spectrum of allied health personnel regulation, including state licensure of individuals and health facilities, certification of individuals by private organizations, the imposition of standards by third-party payers, and voluntary accreditation of education programs. Collectively, these regulatory measures affect the size and characteristics of the allied health work force. They affect the functioning of the labor market for allied health workers by defining who may enter the various fields, by determining who has what degree of control over health care services and dollars, and by constraining the range of staffing options available to employers. They provide identity and legitimacy to newly emerging occupations and their members. Occupational licensure is of particular concern to the committee on sev- eral grounds. As the most restrictive type of regulation, it grants exclusive control over some health services to one type of worker. The committee concluded that licensure is costly and cumbersome and that its effectiveness in protecting the public has not been conclusively demonstrated. The ef- forts being made in a number of states to reform the regulatory process are encouraging, particularly the evolution of"sunrise" criteria to evaluate the need for regulating new occupations, which the committee endorses. Increasing the public's participation in the regulatory process is also a positive development. The committee recommends that states strengthen the accountability and broaden the public base of their regulatory statutes and procedures. In the near term, the committee suggests that licensing boards draw at least half of their membership from outside the licensed occupation; members should be drawn from the public as well as from a variety of areas of expertise such as health administration, economics, consumer affairs, education, and health services research. Flexibility in licensure statutes should be maintained to the greatest extent possible without undue risk of harm to the public. This may mean,

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12 ALLIED HEALTH SERVICES for instance, allowing multiple paths to licensure or overlapping scopes of practice for some licensed occupations. In light of concerns about the future availability of adequate numbers of allied health personnel and in light of the rapid changes in health care delivery, licensure appears to be inconsistent with the flexibility that will be needed in the years to come. The committee believes that states should try to find alternatives to licensure. Professional groups should work toward strong title certification, devoting their efforts to convincing the public and the industry of the credential's value much as certified public accountants have done in their sphere. The committee recommends statutory certification for fields in which the state determines there is a need for regulation because this form of regulation offers most of the benefits of licensure with fewer of its costs. Medicare and other third-party payers should accept state title certifi- cation as a prerequisite for reimbursement eligibility. Such certification can and should be based on examinations and any other eligibility criteria the states may establish. The committee was concerned that jurisdictional struggles among health occupations over scopes of practice and over referral and supervision re- quirements were conducted without a body of research literature or the informed judgments of knowledgeable, disinterested parties to guide those decisions. Without such information, there is considerable risk that deci- sions will be made on purely political and economic grounds. It was the committee's view that the federal government should take an active part in developing the necessary evidence for use by authorities responsible for these decisions. The Bureau of Health Professions (or other future focal points for allied health personnel in the Department of Health and Human Services) should sponsor a body with members drawn from allied health and other health professions and from the health and social science research com- munities to assess objectively the evidence bearing on "turf" issues. This body, in consultation with other experts and interested parties, should consider issues of risk, cost, quality, and access. It should draw on avail- able scientific evidence and identify topics on which research is needed. LON~TERM CARE The committee chose to devote special attention to long-term care for a number of reasons. The aging of the population and the need for long- term care for the elderly are major forces in future demand for allied health services. Despite broad concern about the needs of the elderly, there is no certainty that the current financing systems will enable providers to

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EXECUTIVE SUMMARY 13 satisfy those needs. Furthermore, because long-term care requires both therapeutic and social support services, it affords an opportunity to examine the issues that surround the interaction of allied health practitioners with other professionals such as nurses, as well as with workers having relatively minimal formal education an important group of workers on which the committee wished to focus attention. Allied health practitioners relate differently to their clients and to other health care providers in each of the three long-term settings that were studied nursing homes, home care, and rehabilitation facilities. In nurs- ing homes, minimally trained nurse's aides are often the primary care givers with the most frequent patient contact. Recent congressional and Health Care Financing Administration actions to increase aide training are a step in the right direction. Yet, in the future, aides will require an even higher level of training to link them more effectively to nursing and allied health personnel in the delivery of hands-on care. In recognition of the fact that the greatest amount of direct patient contact and care in long-term care settings and programs is provided by personnel at the aide level, the federal government and other responsible governmental agencies should require education and training to increase the knowledge and skills of these personnel. Demonstration projects should be funded to encourage joint efforts by educators and employers in cre- ating career paths for aides. Some types of organizations that provide long-term care, such as home health agencies and nursing homes, must coordinate a wide array of services that are needed by fragile clients with multiple disorders. If this coordi- nation is mishandled, the result may be fragmented care, sometimes du- plicative efforts, and often less than optimal use of each service. Collaborative team work by the care providers can improve the quality of care by helping team members better understand each other's roles; it also helps to ensure appropriate, coordinated care and might even reduce staff turnover by increasing each team member's involvement in the job. Therefore, the committee recommends that, because the problems as- sociated with chronic illness do not fall within the boundaries of any single discipline, administrators and care coordinators in long-term care settings develop effective means to ensure that all personnel involved in patient care work closely together to meet patient needs. More generally, allied health workers in all long-term care settings need special preparation to care for patients with chronic illness, to understand the psychological aspects of aging, and to confront disability, death, and dying. Therefore, the committee recommends that all allied health ed- ucation and training programs include substantive content and practical clinical experience in the care of the chronically ill and aged.

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14 ALLIED HEALTH SERVICES COLLABORATIVE ACTION Taken as a whole, the committee's recommendations are designed not merely to advance the role of allied health occupations but also to preserve the ability of the health care system to confront the problems of the next decade. In drafting its recommendations the committee was cognizant that no one entity in the public or private sector now has the power or re- sponsibility to determine whether allied health education and practice will adequately respond to the challenge of changing patterns of illness and care requirements. Ultimately, collaborative action will be required. None of the committee's recommendations is self-implementing. Each requires a principal party to convince others to join in their efforts or to accede to alterations in traditional ways of operating, whether in educating students, delivering services, or supporting professional interests.