[Senate Hearing 110-701]
[From the U.S. Government Publishing Office]
S. Hrg. 110-701
CARING FOR OUR SENIORS: HOW CAN WE SUPPORT THOSE ON THE FRONTLINES?
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HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
APRIL 16, 2008
__________
Serial No. 110-26
Printed for the use of the Special Committee on Aging
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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SPECIAL COMMITTEE ON AGING
HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas RICHARD SHELBY, Alabama
EVAN BAYH, Indiana SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware MEL MARTINEZ, Florida
BILL NELSON, Florida LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island ARLEN SPECTER, Pennsylvania
Debra Whitman, Majority Staff Director
Catherine Finley, Ranking Member Staff Director
(ii)
C O N T E N T S
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Page
Opening Statement of Senator Herb Kohl........................... 1
Opening Statement of Senator Bill Nelson......................... 3
Opening Statement of Senator Susan Collins....................... 3
Opening Statement of Senator Ken Salazar......................... 4
Opening Statement of Senator Bob Casey........................... 5
Prepared Statement of Senator Gordon Smith....................... 29
Panel I
John Rowe, MD, professor, Department of Health Policy and
Management, Mailman School of Public Health, Columbia
University, New York, NY....................................... 5
Robyn Stone, DPH, executive director, Institute for the Future of
Aging Services, American Association of Homes and Services for
the Aging, Washington, DC...................................... 20
Panel II
Martha Stewart, founder, Martha Stewart Living Omnimedia, New
York, NY....................................................... 39
Todd Semla, PharmD, president, American Geriatrics Society,
Evanston, IL................................................... 50
Mary McDermott, personal care worker and board of directors
member, Wisconsin Home Care Commission, Verona, WI............. 64
Sally Bowman, PhD, associate professor, Department of Human
Development and Family Services, Oregon State University,
Corvallis, OR.................................................. 69
APPENDIX
Prepared Statement of Senator Susan Collins...................... 83
Prepared Statement of Senator Robert P. Casey.................... 84
Prepared Statement of Senator Barbara Boxer...................... 85
Dr. Robyn Stone's Responses to Senator Smith Questions........... 86
Martha Stewart's Responses to Senator Smith Question............. 88
Dr. Todd Selma's Responses to Senator Smith Questions............ 89
Mary McDermott's Responses to Senator Smith Question............. 92
Sally Bowman's Responses to Senator Smith Questions.............. 94
Statement from National Center on Caregiving, Family Caregiver
Alliance....................................................... 96
Statement of The American Health Care Association and National
Center for Assisted Living..................................... 99
Statement submitted from the Association of American Medical
Colleges....................................................... 107
Statement submitted by the American Association for Geriatric
Psychiatry..................................................... 123
Statement submitted by AARP...................................... 128
Final report from the Direct Care Workforce Issues Committee..... 142
(iii)
CARING FOR OUR SENIORS: HOW CAN WE SUPPORT THOSE ON THE FRONTLINES?
---------- --
WEDNESDAY, APRIL 16, 2008
U.S. Senate,
Special Committee on Aging
Washington, DC.
The Committee met, pursuant to notice, at 3:02 p.m., in
room SD-562, Dirksen Senate Office Building, Hon. Herb Kohl
(chairman of the committee) presiding.
Present: Senators Kohl, Carper, Nelson, Salazar, Casey,
Whitehouse, Smith and Collins.
OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN
The Chairman. I want to thank you all for being here today.
We will commence--Ranking Member Senator Smith from Oregon will
be here shortly. Today, we will be discussing the need to
train, support, and expand the range of those individuals
caring for older Americans. The Aging Committee has a long and
a proud history of moving Congress forward on issues of long-
term care.
Last year, this Committee held three hearings on the
subject of long-term care in America. However, we primarily
focused on the facilities themselves and the Federal standards
that applied to them, rather than the people who fulfill the
promise and meet the obligations of care. Today, we are
shifting our focus to those caregivers.
Millions of older Americans receive care in a medical
facility from a licensed professional, such as a doctor or
nurse, or from a certified nurse aide at a long-term care
facility. You can also receive hands-on care in your own home
by hiring a home-health aide or perhaps a live-in personal care
attendant. However, the majority of older Americans in need of
care rely on a third group, namely, their own family.
There are more than 44 million people providing care for a
family member or friend nationwide. These caregivers frequently
do the same work as a professional caregiver, but they do so
voluntarily and with little or no training. To their loved ones
they are the doctor and nurse, the assistant, therapist, and
oftentimes, the soul source of emotional and financial support.
You probably know someone who cares for a family member.
Perhaps a friend, a neighbor, or a co-worker. If you don't, I
am willing to bet that in 10 years you certainly will. In fact,
in 10 years it might well be you or myself. By the year 2020,
it is estimated that the number of older adults in need of care
will increase by fully one-third.
The unfortunate fact of the matter is that, while our
country is aging rapidly, the number of health care workers
devoted to caring for older Americans is experiencing a
shortage--one that will only grow more desperate as the need
for these caregivers skyrockets. Given current workforce
trends, it is expected that, in the coming decades, we will
fall far short of the number of health care workers trained to
treat older adults than what we will need.
We indeed face many challenges. We know that few nursing
programs require coursework in geriatrics, and that in medical
schools, comprehensive geriatric training is a rarity. For the
direct care workforce, which includes home health aides and
personal care attendants, we know that Federal and State
training requirements vary enormously, despite the fact that
studies show that more training is correlated with better staff
recruitment as well as retention. We also know that family
caregivers want enhanced education and training to develop the
necessary skills to provide the best possible care for an
ailing family member.
Fortunately, knowing what we need to change is just half
the battle. After this hearing, we plan to incorporate today's
lessons into legislation to expand, train and support the
workforce that is dedicated to providing care for the older
members of our population.
The Committee is honored to welcome two distinguished
panels of witnesses to discuss how we can meet the needs of the
long-term care workforce today and work toward its expansion by
tomorrow. We will be reviewing the major recommendations
released Monday by the Institute of Medicine for improving and
expanding the skills and preparedness of the health care
workforce. Also we will hear many other perspectives and
suggestions from nationally recognized experts with backgrounds
in policy, medicine, academics, business and even the art of
living.
The United States will not be able to meet the approaching
demand for health care and long-term care without a workforce
that is prepared for the job.
Again, we would like to thank all our witnesses for their
participation today. At this time, we will introduce our first
panel.
Our first witness today will be Dr. John Rowe, a professor
in the Department of Health, Policy and Management at Columbia
University School of Public Health. Dr. Rowe is testifying
today as chairman of the Institute of Medicine's Committee on
the Future Health Care WorkForce for Older Americans.
Throughout his distinguished career, Dr. Rowe has held many
leadership positions in top health care organizations and
academic institutions, including a stint as CEO of Mt. Sinai
NYU Health System and as founding director of the Division on
Aging at the Harvard Medical School.
Our next witness will be Dr. Robyn Stone, executive
director of the Institute for the Future of Aging Services. Dr.
Stone is a noted researcher and leading international authority
on aging and long-term care policy. Formerly, she served as
executive director and chief operating officer of the
International Longevity Center in New York. Dr. Stone also held
several prominent roles in the field of aging under the Clinton
administration, including assistant secretary for aging in the
Department of Health and Human Services.
Before we commence with our first panel, I would like to
call upon my colleagues who are sitting up here on the dais for
any remarks and comments that they wish to have.
Senator Nelson.
OPENING STATEMENT OF SENATOR BILL NELSON
Senator Nelson. Thank you, Mr. Chairman.
I am concerned, as we look down the road, that we have the
proper health care for older adults--geriatrics primary health
care, and preventive medicine. That is certainly true in a
constituency such as mine--Florida, where we have a high
percentage of the population that is age 65 and older.
Mr. Chairman, one that of the little spin-offs that we are
having a problem with back on a Medicare bill in the late
1990's, a freeze was put in place on all of the residency
programs for medical schools that Medicare funds, the result of
which--with no growth since 1998--your high population increase
States, such as Florida and Nevada, have not had the
residencies to train the doctors. Those States educating the
doctors.
But then these doctors go to another residency program.
What we find is that a doctor is likely to stay and practice in
the area in which they did their residency. As a result, States
like mine and Nevada, and about half of the other States are
educating the doctors and then losing them. Now, that is a
terrible situation for a population like Florida's that is
aging. You need those residencies in geriatrics, regular care,
internal medicine and preventive care.
So it is one of the issues we are going to have to address.
Thank you, Mr. Chairman.
The Chairman. Thank you for that interesting comment, and a
very important comment.
Senator Collins.
OPENING STATEMENT OF HON. SUSAN COLLINS, A U.S. SENATOR FROM
THE STATE OF MAINE
Senator Collins. Thank you, Mr. Chairman. I want to commend
you for calling this hearing to examine our Nation's future
health workforce in the face of a rapidly aging population. I
think this hearing is particularly significant in light of a
recent report from the Institute of Medicine that sounded a
warning that we are facing a dramatic and critical shortage of
doctors, nurses and other health care professionals who are
adequately trained to manage the special health care needs of
our Nation's growing population of seniors.
We know that in this country, the most rapidly growing part
of the population are those who are age 85 and older, the
oldest old. Like Senator Nelson's state, Maine is a State that
is disproportionately elderly. I am very concerned about access
to health care as my generation and others join this population
segment.
We know that older Americans consume far more health care
resources than any other age group. We also know that there is
a real shortage of health care provides who are trained in
geriatrics. In fact, the numbers are truly astonishing. The
experts have projected that we need some 36,000 geriatric
doctors to care for our 70 million seniors by the year 2030.
But only 7,000--about 1 percent of all physicians--are
currently certified in geriatrics.
Senator Boxer and I have introduced a bill to take the
first steps in this area. It has the support of AARP and other
organizations. I look forward to working with the Chairman who
has been such a leader in focusing on this issue. I would ask
that my full statement be put in the record. Again, thank you
for focusing on this very important issue.
The Chairman. Thank you. By unanimous consent, your full
statement will be entered into the record, Senator Collins.
Senator Salazar.
OPENING STATEMENT OF SENATOR KEN SALAZAR
Senator Salazar. Thank you very much, Chairman Kohl, for
holding this hearing on the Aging Committee on this very
important issue. I come today here to the Committee with you to
address the severe shortage of long-term care professionals
available to care for older Americans.
Although the workforce shortage has been documented for
many years, new reports that have been issued by the Institute
of Medicine show that many workers who are working in long-term
care settings are inadequately trained to do the job.
Furthermore, vast improvements are needed in geriatric
education and curriculums as well as new incentives, to recruit
and retain a highly qualified workforce.
Without a doubt, these are some of the greatest challenges
facing long-term care today. The situation will only get worse.
In three short years, 75 million baby boomers will begin to
turn 65. Between 2005 and 2020, the elderly population of the
U.S. is expected to double. We must ensure that our health care
system include high-quality professionals to meet the growing
demand for long-term and chronic care.
Personally I have experienced taking care of many of our
loved ones. My mother today is 86 years old. Fortunately, she
continues to live on our ranch in southern Colorado. My
siblings and I share the responsibility of caring for her. She
is doing very well.
Most individuals and families have to make tough decisions
on how best to take care of their loved ones. At the very
least, we all want the peace of mind that the caregiver we hire
to do the job has been adequately trained and meets the highest
possible standards. I am hopeful that the witnesses today will
address that issue of the kinds of standards that we should
have for professional caregivers.
This hearing is critical for us to identify the most
effective policy solutions to meet these health care challenges
that we are now in the midst of and will only find to be more
challenging in the days, weeks, months, years ahead.
Again, I want to thank Chairman Kohl and Ranking Member
Smith for holding this hearing.
The Chairman. Thank you, Senator Salazar.
Senator Casey.
OPENING STATEMENT OF SENATOR BOB CASEY
Senator Casey. Mr. Chairman, thank you very much for
holding this hearing. I will submit a longer statement for the
record. But I did want to commend you for calling this hearing
because, in my home State of Pennsylvania, we have a
demographic challenge.
Our fastest growing population is 85 and up, as it is in
many states, I think. But we are, depending on how you count
it, second or third in the ranking of the states for the number
of people over the age of 65. It is a critically important
challenge for Pennsylvania, and I know, for the nation as a
whole.
When I was in State Government, I spent a good deal of time
on the issue of long-term care. Some of the most inspiring
people I met were people who were delivering that care--
certified nurses aides, nursing assistants, whatever categories
you use or titles you use. They were people who did back-
breaking work and delivered care in ways that--it is hard to
describe how much they have benefited our families, doing that
kind of work.
After I was in State government for a while, I had the
experience, I guess you would call it, that all of us have when
a loved one is in the hospital. My father was in a long-term
care setting before he died. I was able to see first-hand what
that care delivery and care coordination and the quality of the
care that we are talking about here today is all about. I
realized then, more so than I did as a public official, the
kind of skill that is required in delivering quality care to
older citizens in the twilight of their lives.
So this issue is important to me personally. But it is a
major issue in our State. We need to roll up our sleeves and
work on it. I am grateful you called this hearing. Thank you.
The Chairman. Thank you very much, Senator Casey.
We will now hear from our first panel. First Dr. Rowe and
then Dr. Stone.
Dr. Rowe.
STATEMENT OF JOHN ROWE, PROFESSOR, DEPARTMENT OF HEALTH POLICY
AND MANAGEMENT, MAILMAN SCHOOL OF PUBLIC HEALTH, COLUMBIA
UNIVERSITY, NEW YORK
Dr. Rowe. Senator Kohl and members of the Committee. Thank
you for the opportunity to testify before you on the critical
health care needs of older Americans. As noted by Senator Kohl,
I am Chair of the Institute of Medicine's Committee on the
future healthcare workforce for older Americans. I am here to
discuss the findings and recommendations of the report that we
have released early this week.
To start with, I think there is a great myth here in
Washington about care of the elderly. The myth is that all we
have to do to ensure older Americans' access to care is to fix
the issues related to the Medicare Trust Fund's solvency and
sustainability. I think that that is half of the problem. We
first have to make sure that the health care workforce is
adequate with respect to its numbers and its capacity to
deliver the care. Even having the money in the system isn't
going to get the care to older people if there is no one to
provide care.
So it is about time that we turned our attention to this. I
compliment you, Senator Kohl and the Committee, for having us
here today to discuss this.
Now, the future demand--and I think we can look at this as
a kind of demand side and supply side issue, Senator--the
future demand for geriatric care is driven by basically two
factors. The first is the dramatic increases in the number of
elderly that all of you are very familiar with. The second, as
noted by Senator Collins, is the fact that the elderly utilize
a disproportionate proportion of health care resources. So the
12 percent of our population that is over 65 uses 35 percent of
the hospital stays, and 34 percent of the medicines. By 2030,
when the population of elders is 20 percent of our population,
they will dominate our health care system. That is the demand
side. How about the supply side? Well, on the supply side, the
answer is quite simple. We are in denial. We are woefully
unprepared. But fortunately, we think at the Institute of
Medicine that it is not too late. The supply and the
organization of the health care workforce for older individuals
needs to be dramatically enhanced, or it will simply be
inadequate. Let me give you a couple of facts.
As Senator Collins noted, there are only about 7,000
certified geriatricians in the entire United States. More
frightening is that this is 22 percent lower in the year 2000.
So we are actually going in the wrong direction.
With respect to geriatric psychiatry, there is currently
one for every 10,000 older people in the United States. By
2030, at the current rate, there will be one for every 20,000
older people, whether he or she needs a psychiatrist or not.
Less than one percent of the nurses, pharmacists and
physician assistants we have currently specialize in geriatrics
while only 4 percent of the social workers do. This means that
most health care professionals, including doctors, nurses,
social workers and others, receive very, very little training
in caring for the common problems of older adults.
Standards for the training of nurse aides and home health
aides must be strengthened. In the State of California, there
are higher training requirements for dog groomers, crossing
guards and cosmetologists than there are for nursing aides and
home health aides. Informal caregivers, the family and friends
of older adults, are also ill-prepared for their significant
roles. Innovative new approaches to delivering care to older
adults that have been shown to be effective and efficient are
not being implemented.
We suggest three approaches. The first approach is to
enhance the geriatrics competence of all professional
caregivers. We believe there needs to be more training in the
schools of medicine, nursing and social work. We believe that
these professionals all should demonstrate competence as a
function of obtaining their licensure or certification--not
just demonstrate that they had the hours of training, but
demonstrate that they have the competence.
In addition, we believe that the number of hours that
direct workers and nurses aides be given in instruction be
increased from the current level of 75 hours, which is the
Federal standard, to 120 hours.
The second bucket, if you will, of our three
recommendations is to increase the recruitment and the
retention of geriatric specialists. We need them. We are not
saying that every old person needs a geriatrician any more than
anybody with a heart needs a cardiologist. That is not what we
are saying.
What we are saying is we need specialists who can train the
rest of the workforce on how to take care of the common
problems of the elderly, who can do research and develop new
models of care and, in fact, can take care of particularly
complex and difficult patients.
Unfortunately, there is an economic disincentive to going
into geriatrics. In 2005 a geriatrician in this country made,
on average, $163,000. An internist--with less training--made
$175,000. So if you spend the extra year or two to do a
fellowship in geriatric medicine, you are decreasing your
future earning potential with our current reimbursement
strategies for geriatric care. This suggests to me that our
society does not value this additional training.
We have a number of suggestions and recommendations in our
report that go to specific ways that we can enhance loan
forgiveness, provide scholarships and enhance payments. I would
just mention one for you. The National Health Service Corps is
well-established, and has been very effective in developing
physician manpower for underserved populations. We are calling
for a National Geriatric Health Service Corps using the same
model. We think that is something that could be put in place
pretty quickly.
The third recommendation we have has to do with new models
of care. We have a fascination with studying demonstration
projects for new approaches to care. Many of these have been
found to be effective and cost-efficient, and yet they languish
on the shelf, because once the funding for the research project
is over, there is no funding to promulgate or sustain them.
Therefore, they are just dropped, and the next demonstration
project is developed.
We need some follow up and some commitment at CMS to change
this so that new models of care which have been shown to be
effective and efficient can in fact be sustained and can
permeate to our society. Because even if we do the things we
are recommending in this report, we are still going to fall
short in the workforce. We have to be smarter, more effective
and more efficient in how we deliver the care.
We very much appreciate the opportunity to share our
recommendations and our findings with you. Thank you very much.
[The prepared statement of Dr. Rowe follows:]
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The Chairman. Thank you, Dr. Rowe.
Dr. Stone.
STATEMENT OF ROBYN STONE, DPH, EXECUTIVE DIRECTOR, INSTITUTE
FOR THE FUTURE OF AGING SERVICES, AMERICAN ASSOCIATION OF HOMES
AND SERVICES FOR THE AGING, WASHINGTON, DC
Ms. Stone. Chairman Kohl, Ranking Member Smith and members
of the Committee, I am really pleased to have the opportunity
today to testify on behalf of the Institute for the Future of
Aging Services, which is the applied research institute of the
American Association of Homes and Services for the Aging, where
I am the senior V.P. for Research.
From the beginning of our institute, and actually going
back a heck of a lot longer than that--I have been trying to
push this issue for the last 25 years--one of our signature
areas has been the development of a quality long-term care
workforce.
I really commend you, this Committee and also the IOM for
finally shining a light on what is the critical piece of our
system. Without the people who do the work, all the financing
and delivery in the world is not going to solve our problem.
Based on our own work, some of which is included in the
written testimony, and the efforts of others such as the IOM, I
would like to spend my remaining time laying out for your
consideration five broad workforce improvement goals and some
possible strategies for achieving them, some of which Dr. Rowe
has already alluded.
The first is to expand the supply of new people entering
the long-term care field. The need to do this is obvious. The
traditional labor pool paid of caregivers is shrinking.
Regardless of the vision of long-term care reform, the field
will need new sources of personnel. The U.S. Departments of
Health and Human Services and Labor should be working together
to develop the data infrastructure to track workforce shortages
and to report to Congress on the status of the long-term care
workforce over time.
Second, workforce development funding needs to be channeled
to the recruitment and training needs of long-term care
employers. Much of that money goes to other health sectors.
Funneling more of those dollars specifically in the long-term
care sector will help.
Third, information on long-term care careers should be
targeted to post-secondary education and professional schools.
Long-term care employers need to be encouraged to zero in on
labor that has been poorly tapped in long-term care, such as
Hispanics and African-Americans who are underrepresented in
nursing careers; young people coming out of high school,
individuals with disabilities; and older people who either
cannot afford to retire or who want to work part-time.
We also need to think about expanding financial incentives
such as tuition subsidies and debt relief and incentive
payments for those who choose a long-term care profession.
The second goal is to create more competitive long-term
care jobs through wage and benefit increases, including
exploring ways to achieve more wage parity between long-term
care and acute care, and to explore how to leverage current
Federal and State long-term care financing to raise wages and
improve benefits, including implementing incentives such as pay
for performance and other approaches that target payments
effectively to address workforce issues.
The third goal is to improve working conditions and the
quality of the jobs themselves. Higher wages and better
benefits are not likely to be sufficient, because high turnover
is a sign of unhappy employees. The Federal Government could
grant financial incentives and/or regulatory relief to
employers and states that achieve measurable improvements in
working conditions and are able to demonstrate reduced turnover
and improved job satisfaction while maintaining quality of
care.
We could also think about creating one or more centers on
long-term care leadership and management innovation to develop,
identify and disseminate education and training programs,
apprenticeships and best practices.
The fourth goal is to make larger and smarter investments
in workforce education and development. In my judgment, one of
the most important workforce improvement priorities--and Dr.
Rowe talked about this as well--should be to highlight the need
to rethink and totally redesign the preparation, credentialing
and on-going training of long-term care administrators, medical
directors, nurses, allied health professionals and direct care
workers.
Finally, the fifth goal is to moderate the demand for long-
term care personnel. It is unlikely that the need for new
workers can ever be completely reconciled with our growing
demand because of our aging of our population. We need to
promote significant investment in developing and testing and
disseminating promising technologies designed to improve
service delivery efficiency and to reduce the demand for hands-
on care.
In addition, we have to provide better incentives to family
caregivers who are already carrying the bulk of this work. This
should include considering things like giving social security
credits to those who leave the workforce to perform full-time
care giving and to really further develop programs, so families
know where to turn to for help and have more than the crumbs
that they are getting currently through some of our programs.
Allowing states to consolidate current grants related to
long-term care service organization and delivery and education
and training--as Dr. Rowe was saying, we need to go beyond
demos and actually get some of our promising models to scale,
so that they become the norm rather than the exception.
In closing, what is most important is that any approach be
broad-based and address the multiple issues that have and will
drive today's workforce problems and future trends. Long-term
care must be viewed as a related but independent sector from
health care. Workforce improvement initiatives must be targeted
specifically to the development of long-term care professionals
across the full spectrum of settings, and not just included as
an afterthought in efforts to bolster the hospital and
ambulatory care workforce.
AAHSA and IFAS continue to explore solutions at the policy
and practice levels and have recently created a national
``Workforce cabinet'' comprised of a range of stakeholders who
are interested in addressing this crisis. We look forward to
working with the Senate Special Committee on Aging to ensure
continued progress in this area. Thank you very much.
[The prepared statement of Ms. Stone follows:]
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The Chairman. Thank you, Dr. Stone.
This time we will turn to members of the Committee for
questions and comments. We will start with the Ranking Member,
Senator Smith.
Senator Smith. Thank you, Mr. Chairman. For the record, I
would like to put my statement in the hearing record.
The Chairman. We will do it.
[The prepared statement of Senator Smith follows:]
Prepared Statement of Senator Gordon H. Smith
I want to thank Senator Kohl for holding this important
hearing today. The work of our health care providers and
caregivers is crucial to helping of our elderly family members
age with dignity. Unfortunately, workforce shortages in this
vital health care and aging support system continue to plague
the industry. Identifying the best methods to recruit and
retain caregivers in the aging network is an issue of
particular interest for me, and I thank the panelists for
sharing their expertise on this topic with us today.
I particularly want to thank Sally Bowman from Oregon State
University for flying across the country to share her knowledge
about this field with us.
I also look forward to testimony from Dr. Rowe. As a member
of the Finance Committee, I am charged with ensuring the
efficiency of our Medicare and Medicaid systems. While I am a
strong supporter of both programs, each faces challenges as our
nation ages and health care costs continue to explode. I look
forward to hearing Dr. Rowe's recommendations for system
reform.
Last year, I had the pleasure of serving as a member of the
National Commission for Quality Long-Term Care, which was co-
chaired by former Senator Bob Kerrey and former Speaker Newt
Gingrich. The Commission studied in depth the needs and
constraints placed upon the long-term care workforce. On any
given day, the long-term care workforce serves about 10 million
Americans, the vast majority of whom are elderly. But the
workforce suffers from low retention rates and a shortage of
trained professionals.
The Commission learned that long-term care professionals
feel that they need more training, that they have high rates of
injury and that many are paid what they feel are inadequate
wages. These are just some of the many problems that we must
look at in order to ensure that when help is needed, it can be
provided.
We also know that caregivers, who may be the child or
spouse of an elderly or disabled person, suffer from the stress
of trying to lead their own life while helping their loved ones
stay in their home. Some caregivers may have disabilities
themselves and struggle under the pressure of trying to avoid
living in a facility. I am a strong proponent of supports,
including respite care, for these caregivers including the
Family Caregiver Support Program in the Older Americans Act.
I urge support for the work that I have done with Senator
Lincoln to encourage the Appropriations Committee to increase
funding to programs in the Older Americans Act. Again, this
year, we led a letter asking appropriators to provide a nine
percent increase in funding. Although more is needed, we
believe this is a good start in making our seniors a priority
and helping them to remain healthy and in their homes, where
they want to be, as they age.
As some of you may know, I am from the small community of
Pendleton, OR. I want to emphasize the particular difficulties
that are faced in maintaining a health care and support system
in rural areas. Remote locations, small numbers of patients,
and difficulties in training and maintaining staff, are just
some of the problems that lead to reduced access to help our
loved ones in rural communities.
Like most health care professions, nurses are facing
devastating shortages, especially in rural communities. Senator
Clinton and I have introduced the Nursing Education and Quality
of Health Care Act to increase the nurse workforce in rural
areas, expand nursing school faculty and develop initiatives to
integrate patient safety practices into nursing education.
Whether its nurses, physicians or allied health care
workers, as the number of older Americans grows, the shortage
of all health care professionals will be exacerbated.
In recent years, federal funding for programs to strengthen
the health care workforce has taken a direct hit. I have
written a letter to my fellow colleagues indicating my strong
support to increase this funding, which will improve the
geographical distribution, quality and diversity of the health
care professions workforce.
As we discuss the challenges facing elder care at today's
hearing, it is important to keep in mind that by 2030, the
number of older adults in the United States will nearly double
as the 78 million members of the baby boom generation begin
turning age 65 in 2011. Our health and support systems are
drastically lagging behind where we should be at this point in
time to plan for the future.
I hope that today's hearing will inspire some new and
effective ways that we can ensure providers of care are there
when our seniors are in need.
With that, I turn to Chairman Kohl.
Senator Smith. I want to give a particular thank you to
Sally Bowman from Oregon State University for flying across the
country. She will be on the next panel. I appreciate these two
excellent presentations.
I wonder, Mr. Rowe, is there a State that is doing much of
what you described? Is there a model out there that we should
look to, or other states can look to, for achieving some
progress in this area of preparing for a geriatric generation
that is coming?
Dr. Rowe. I am wishing it was Oregon. But I am not sure.
Senator Smith. I was hoping you were going to say so.
Dr. Rowe. I don't think so. But I do think that, if you
look across the states and, you know the states are
laboratories of democracy, right--there is a lot of different
stuff going on. Much of it offers good models. You will find
some models of Medicaid in some states, and some other models
in other states focusing on different elements of the health
care spectrum that are best practice. I think that one can
assemble a profile of all the best practice. Some medical
schools do a much better job of committing to geriatrics. Some
nursing schools do a much better job than others.
There are good best practices, and models out there that do
work and can be replicated, no question.
Senator Smith. Isn't it a fact that people respond to
incentives? Don't we need to look at things at the Federal
level to incent physicians and nurses to go into geriatrics?
Dr. Rowe. Absolutely, and nurses and social workers. Some
people have asked me since Monday, when we released the report,
how can geriatricians make less than internists? How can that
be? It is because all of their patients are on Medicare;
whereas the internist is practicing with a population that has
some Medicare beneficiaries, and other people paid by private
insurers that have paid generally higher than Medicare.
Internists have a different payer mix and a greater possible
income.
So obviously, the fix to that is not too difficult,
Senator; because there are--if you increase the payment from
CMS for individuals with geriatric expertise--who have a board
certification or a qualification--it is not going to cost that
much. There are only 7,100 of them in the United States. It
would at least provide an incentive, or rather, at least it
would remove a disincentive for those individuals, with
geriatric expertise.
Senator Smith. Thank you, Mr. Chairman.
Dr. Rowe. Thank you.
The Chairman. Thank you very much, Senator Smith.
Senator Carper.
Senator Carper. Thank you. My colleagues that were here
before me, Mr. Chairman. I just have one question. I am going
to ask this question tongue-in-cheek. Then I would like to
yield to them.
Dr. Stone, you said in your statement, you mentioned the
term aging baby boomers? I was wondering how old do you have to
be to be considered an aging baby boomer?
Dr. Stone. You have to be 60 this year.
Senator Carper. I will just tell you that. Thank you.
[Laughter.]
Dr. Stone. Sorry.
Dr. Rowe. I think there is some flexibility around that,
Senator.
Senator Carper. All right. Let me hasten to add, I asked
the same question of Senator Nelson before he left. He said it
is a question of mind, not of body.
Ms. Stone. Of course.
Dr. Rowe. Of course.
Dr. Stone. I have been aging for 30 years with the work I
have been doing. I love every minute of it.
The Chairman. Thank you very much.
Senator Salazar.
Senator Salazar. Dr. Rowe and Dr. Stone, thank you for the
testimony. The question I would have is on the issue of
standards.
Dr. Rowe, I think you characterized it as this is a place
in life where there really are no standards for those who work
in the profession providing direct care; that we have higher
standards for probably people who work in shops and lots of
other places than we do in this area.
What would you propose that we do in terms of standards? Is
that a function that we ought to leave to the states to devise
standards? Is it something that has to be done at the national
level? What kind of standards would you propose?
Dr. Rowe. Well, first of all, I think it is important to
recognize that the standards the number of federal training
hours of that are required, which we think should be increased
significantly, have not changed in 20 years.
The training now for these individuals--nurse's aides, home
health aides--is pretty much procedural training, how to shift
a patient from a bedside to a commode, or into a wheelchair, or
to help change dressings or the clothing of a patient, rather
than background information about the aging process and about
the characteristics of geriatric medicine and identifying risk
factors for falls or medication adverse effects. So there is a
real curriculum we think could be added.
There are Federal and State standards for some of these
providers and just State standards for others. We feel that the
Federal standards should be increased from 75 to 120 hours; and
that the State should meet at least those standards, although
if they wanted to have more, that would be fine.
But it is a dual requirement. So there is a Federal role
here, which is obviously germane to your Committee.
Senator Salazar. Dr. Stone, do you have a comment?
Dr. Stone. Yes. I would add a couple of things. First of
all, I think Dr. Rowe was talking about the kinds of training
that is provided now and that could be. I will give you an
example of a program in Wisconsin that we evaluated a number of
years ago called Wellspring, which is a quality improvement
model in nursing.
These CNAs were the leaders of clinical research teams.
They had training together with the nurses and nurse
practitioners--offsite training for several days and around
each clinical area; then they came back and were really taught,
not just through observation, but actually more like an
assessment without doing it. I think CNAs were not allowed to
actually do the assessment. But they are the nurses' eyes and
ears.
Within a year of doing this program, working around
incontinence care--and I have a doctorate in public health--and
I will tell you that these CNAs were amateur epidemiologists.
They understood everything that was involved in the care that
they were providing. They were no longer just moving somebody
to a toilet. They were helping them with hydration and
preventing decubitus ulcers.
The empowerment and the knowledge that was imparted to
these folks was totally different than the kind of training
that they get today. That is really what we are talking about
here. It is not just a numbers game. It is really a qualitative
difference in the kind of training, which then translates in
the work that they are going to be doing.
Dr. Rowe. It enhances their self-esteem and their enjoyment
and retention in the workforce.
Dr. Stone. I would say that, Senator Smith, on your end,
Oregon has the best Nurse Delegation Act in country.
Senator Smith. That is what I was expecting.
Dr. Rowe. Yes. Well, she had more time to come up with
something.
Dr. Stone. Because of the Nurse Delegation Act in Oregon,
the development of this frontline workforce has been
phenomenal. Many other states have actually looked to Oregon to
replicate that, to allow more good delegation; which is not
just letting people do anything, but delegating where they have
had significant training in dementia care and medication
management, which leaves the other levels of staff--and Jack
actually talked about this at the IOM report release a couple
of days ago--to do the work that they need to do, so that
everybody really becomes a team.
Senator Salazar. Thank you, Chairman Kohl.
The Chairman. Senator Casey.
Senator Casey. Keep it up. Thank you, Mr. Chairman.
Dr. Stone, Dr. Rowe, thank you for your testimony. But also
thank you for the scholarship that goes into the testimony
itself and the experience.
I am trying to think of it--must have been 10 years ago now
that the Philadelphia Enquirer did a whole series on, as a lot
of newspapers have over the years, on long-term care. One line
from one of those series, one of those stories, I should say,
in the series has stayed with me forever. The writer said
something along the lines of advocates for the frail elderly
say that life can have quality and meaning, even to the very
last breath. Such a simple yet profound statement about the end
of life and the value of it.
There is one thing I wanted to ask you about, because you
both addressed it in different ways and with a lot of
scholarship. It is the challenge of recruiting and retaining,
but especially recruiting people to do this work--the back-
breaking work, in many cases with low wages and inadequate
benefits--all of the things that we know that are not
attractive about this work.
My sense of it is, spending some time with direct-care
workers, especially CNAs and people at that level of the
workforce, is that they really do have a sense of mission about
it and a sense of purpose. I just wanted to get your reaction
to this--both of you have talked about the urgency of
recruitment and retention. Both of you have talked about the
wage and benefits aspects of this.
But let me ask you this. Somewhere along the way in the
last 8 or 10 years, I read a study done of what these workers
bring to the table in terms of their own attitudes about their
work. At least in one survey, I remember that wages and
benefits weren't at the top of the list. It was the stake they
had in the management of the place in a long-term care setting,
or their involvement with the care.
Dr. Stone. Right.
Senator Casey. They wanted to feel like they were part of
the decisionmaking and how care was delivered. I just wanted to
have you speak to the broader question of recruitment, but in
addition what motivates people to do this work, and how we can
incentivize motivating it?
Dr. Stone. I could talk from the direct care worker area.
We have done a lot of work in this. Clearly, that is true. The
organization of the work and the involvement in the actual
activities that go on every day is what really makes the
difference for these folks. No. 1 is caring for the people. I
mean, there is a tremendous connection. Second is having the
empowerment and the support from organizations, whether it is a
home-care agency or a nursing home or assisted living or a
hospital, to really do that work as part of the team.
The beauty of the geriatric focus is that everybody across
the entire spectrum--whether it is the physician, the nurse,
the social workers, the allied health professionals, the
frontline caregivers--all are getting this kind of
interdisciplinary training around how to really work together.
In the best of all worlds, where you have seen real models
work, everything rises.
One of the things that I really like about the IOM report
and this Committee today, that we are not just talking about
direct care workers, we are not just talking about physicians,
nurses, social workers. We are talking about it across the
spectrum. This has got to be a systemic change, because we can
help the direct care workers. I mean, they already are
committed to what they do. But unless we get the entire system
to work together around this, it is not going to work.
So we need everybody in this together at every single
level.
Dr. Rowe. I think that the difficulties that we are having
in generating and sustaining the workforce differ at each
level. There are tremendous drivers with respect to morale and
conviction and dedication for the direct care workers. But then
the characteristics of other parts of the workforce--the
shortages of other workers to help them get their work done--
and their low salary, drives them out.
At the nursing end, the problem is not enough instruction,
not enough faculty. There aren't enough geriatric nurse faculty
in American nursing schools to train individuals to be
specialists in nursing.
On the physician side, there are a lot of funded genetic
fellowship programs that go vacant every year, because
physicians aren't applying for them. About half of the slots in
the country go vacant. Part of that has to be that the average
medical student graduate has $100,000 in debt. They are looking
at the specialty, which is the lowest paid. So that has to be,
at least for some of them, an important consideration.
But I think the secret here is a commitment to help the
entire workforce, not just one piece of it; because our problem
is compounded by the deficiencies in each level. If we had
deficiencies at one level, but we were OK in the others, we
could work it out. We need a commitment to help the entire
workforce by having the sophistication to recognize that the
different elements of the workforce have different problems and
need different fixes. There is not a one-size-fits-all fix
here.
Dr. Stone. I would like to just add one little thing. This
is about economic development, because these are the sectors
that are growing in the 21st century. So it is also an
investment in our economy to think about how we shift a little
bit from where we have been putting a lot of our resources and
redistribute into where the jobs are going to be over the next
20 and 30 years. So it is a challenge. But it is also an
incredible opportunity.
Senator Casey. Thank you.
Dr. Rowe. Thank you.
The Chairman. Well, thank you both very much. You have been
informative and helpful. We appreciate it.
Yes, sir, Senator Carper.
Senator Carper. I actually did have a serious question too.
Could I?
The Chairman. Sure.
Senator Carper. Thanks. I am going to be stuck on that
first question for a while.
Somewhere in what I have read coming into the hearing
today, I noted that we are going to need an additional roughly
3 million, 3.5 million people to provide health care for us
aging baby boomers and others in our population just to
maintain the current ratio of providers to the total
population. We do a whole lot in our state, our congressional
delegation. We try to help Delaware Technical Community
College, University of Delaware, Lesley College, some of our
hospitals where they train nurses, to try to make sure that
they have the resources they need to train the workforce that
will be needed to take care of the rest of us.
On the other hand, though, we also look to a couple of our
hospitals. We have a VA hospital in northern Delaware that we
are very proud of. They use information technology. In fact, we
do this nationwide through the VA in ways that enable us to
save costs, save lives, make your folks providing the health
care more productive. I am sure you are familiar with the work
that they have done.
Another of our larger hospitals is called Christiana Care.
They have a visiting nurses association--I think they use a
telehealth system--that they find is a cost-effective, user-
friendly way to manage nursing resources and need for services.
Have you identified any technologies that are being
developed or used to reduce the demand for hands-on--care using
well-trained hands to provide the care that we are going to
need? Or some technologies that are still being developed? Can
you give us some examples that we might find encouraging?
Dr. Rowe. We have a section of our report that deals with
technologies, Senator, specifically. There are various
technologies and remote monitoring technologies, so that
problems are detected sooner, and somebody isn't lying on the
floor of their kitchen for three days without anyone knowing
it; and therefore is much more ill when they are discovered
than they would have been with earlier intervention.
Senator Carper. Give us a couple of others.
Dr. Rowe. Well, one can have technologies where you can
understand what individuals' vital signs, blood pressure and
pulse and temperature and monitoring those, so you know the
effects of various medications. There are technologies that
help move patients, that make it much easier for individuals to
move patients around and position them.
There are a whole variety of recommendations here that we
think NIH and other organizations have a real opportunity to
conduct additional research on that might be very helpful--and
that could help to make up for the shortage, Senator, in the
workforce; because we are just not going to get there. Even if
you and your colleagues did everything that we recommended and
other groups would recommend, it is really going to be hard to
get there.
So we are going to have to rely on these new technologies.
We have to invest in more bioengineering research.
Senator Carper. Dr. Stone.
Dr. Stone. I would just add a couple of things. One is in
the area of medication management, which is a big one,
particularly for people living in the community. There are
increasing technologies for actually helping patients with more
self-management. To the extent that can happen, we can have
less need for people to be in people's homes, and monitoring
them. I would also like to put in a plug for AAHSA's Center for
Aging Services Technology.
Senator Carper. What is it called?
Dr. Stone. The Center for Aging Services Technology, which
is one of the centers within the American Association of Homes
and Services for the Aging, which has brought together
researchers, providers and companies who are actually
interested in exploring technologies that are going to mitigate
the need for some of this labor, but also provide efficiency,
to complement the labor that is needed as well. So it is not an
either/or. It really is complemetarity.
Dr. Rowe. If we have the technologies, then we have to have
the standards to train the health care workers in the use of
the technology.
Dr. Stone. Right.
Dr. Rowe. This is a very, very important consideration. So
that is going to even further enhance the training
requirements. You can't just, you know, wheel the technology
into the room. We have to have somebody who understands how to
apply it and how to understand what it is telling them.
Senator Carper. We used to visit my mom when she was living
down in Florida. She had early dementia. I remember--some of my
colleagues may recall with relatives of their own, or people in
the audience--we kept her medicines in what looked like a
fishing tackle box. There are certain medicines you are
supposed to take in the morning and at noon, in the afternoon,
you know, with meals and so forth. We were always concerned
that she took the right medicine at the right time.
My sister and I used to say, ``I wonder if anybody has ever
actually looked at the medicines she is taking.'' They were
prescribed by a range of different physicians who probably
never met each other, never talked to each other. We were
wondering, ``Does anybody ever think about what all these
medicines taken together do to our mom?'' So are you suggesting
that we have some technology that actually does that kind of
thing these days? That is good. That is a good thing.
Last question, if I could, Mr. Chairman.
My youngest son is a senior in high school, graduating. His
girlfriend has an older brother who is going through med
school. He is going through his rotations right now. We were
talking to him not long ago and saying, ``Well, what kind of
doctor do you want to be?'' He told us--he obviously hadn't
really made up his mind. But I don't think he is thinking about
specializing in geriatrics.
He told us about some of the things that medical students
are most interested in becoming--dermatologists, are like,
right at the top of the list. We said, ``Why?'' He said it was
because it is the nature of the work. It is not bad. It is not
heavy lifting. They are paid pretty good. They are paid pretty
good.
Dr. Rowe. On average, $300,000.
Senator Carper. Yes.
Dr. Rowe. Versus $163,000 for geriatrics.
Senator Carper. Versus what?
Dr. Rowe. Versus $163,000 for geriatrics.
Senator Carper. That would give somebody pause, wouldn't
it? It is about what we make around here, isn't it?
Dr. Rowe. It is not that dermatology isn't important. It is
obviously important. But it is an interesting comparison.
Senator Carper. You are suggesting that one of the reasons
why the pay for those specializing in geriatrics isn't high is
because a lot of the compensation comes from Medicare. If you
look at what we pay for Medicare compared to what people can--
--
Dr. Rowe. I recognize that we have a Medicare trust fund
problem. But the fact is that if we paid geriatricians who have
qualifications and a way to recognize that, given the scale of
the financial problems you folks deal with, there are only
7,100 of them in the United States. It is just not going to
cost that much. It might remove a disincentive, so that half
those fellowships will not go empty every year.
Senator Carper. Very well. Thank you both very much.
Thanks, Mr. Chairman.
The Chairman. Senator Whitehouse, do you have any comment
or question?
Senator Whitehouse. I'm trying to get my microphone to
work. There we go. Thank you, Mr. Chairman, yes.
This has been a matter of considerable interest in Rhode
Island. As you probably know, Richard Besdine at the Brown
University Medical School is probably----
Dr. Rowe. I wrote a text book with Richard Besdine.
Senator Whitehouse. Well, he was probably the first person
to get specialized geriatric education. He had to go over to
Scotland to get it at the time. There was no such thing in the
United States. Since then, as you have pointed out, it
continues to be a very underrepresented field. The financial
incentives aren't great.
But it is a highly specialized field. People really need to
know how the body of a very elderly person is truly different
than the body of younger people and be able to appreciate that
in the way they treat them.
But the cost issue is considerable. I wonder if you could
comment on whether you find opportunities, or where you find
opportunities, in improved coordination of care that may
ideally lead to cost savings as a result of chronic care being
better managed, that could then be plowed back into.
Dr. Rowe. Yes.
Senator Whitehouse. Increased reimbursement for the
geriatric community.
Dr. Rowe. I think it is a very sophisticated question. Dr.
Besdine at Brown University and I founded the program in
geriatrics at Harvard Medical School together many years ago,
along with Dr. Wetle. I know him well.
We do speak in our report, the IOM report, about models of
care that have proven to be cost-effective and have improved
quality of care. There are a number of characteristics of these
programs. There is a long list of them here.
Senator Whitehouse. One of them is improved information
technology support.
Dr. Rowe. Some of them relate to that. Some of them are
just interdisciplinary teams, job delegation. IMPACT is a
program the Hartford Foundation funded to recognize and treat
depression in the elderly early, which was very effective and
cost-efficient. But once the study was over, there was no
funding to keep it going, because the kinds of things the
people were doing in the team were not supported by Medicare.
So the point we have made in the discussion is that there
needs to be a consideration of how to sustain new models. We
have a whole bunch of proven things that we are not
implementing into our health care system.
Senator Whitehouse. I would love to follow up with you
offline on that.
Dr. Rowe. It would be our pleasure, Senator.
Senator Whitehouse. I think there has been a lot of work
done on this. It seems to me that the next step is to find some
pilot projects where it can be given a little bit more real-
world shakeout. Then perhaps put in systemwide----
Dr. Rowe. You have some integrated health systems in Rhode
Island that could implement these in several hospitals at once.
Senator Whitehouse. Yes, great.
Dr. Stone.
Dr. Stone. I would just like to add one thing, however,
because we have about 25 years of history in this. The problem
is that we also need to have people trained to do it. The whole
new issue around the medical home, for example, that is
supposed to be the new panacea for coordination--unless you
have people who are trained to understand how to coordinate,
the model will not work. You have to get back to what people
can do in order to actually implement that.
Senator Whitehouse. Yes. You have an airplane, you have got
to have pilots who can fly it.
Dr. Rowe. Yes. It is not a naturally occurring event.
Dr. Stone. It is not just going to happen.
Dr. Rowe. We need to get these people together and they
will start behaving differently.
Ms. Stone. Yes.
Dr. Rowe. They need to be trained.
Senator Whitehouse. Understood.
I thank the Chairman.
The Chairman. Thank you very much, Senator Whitehouse.
We thank the first panel. We appreciate you being here.
Moving on to the second panel, our first witness will be
Martha Stewart, who needs little introduction. In addition to
being the founder of Martha Stewart Living Omnimedia, which
includes her expansive multi-media portfolio of award-winning
brands, Ms. Stewart has experienced life as a family caregiver
for her mother, Martha Kostyra.
In 2007, Martha was inspired to open the new Martha Stewart
Center for Living at the Mt. Sinai Medical Center in New York.
The center is an outpatient facility for geriatric medicine,
which provides clinical care and education for patients, offers
training for physicians and coordinates healthy aging research
and practices.
We will hear from Dr. Todd Semla, who is the president of
the American Geriatrics Society, where he has been a member of
the editorial board of Annals of the Long-term Care since 2002.
Dr. Semla is a clinical pharmacy specialist with the U.S.
Department of Veterans' Affairs Pharmacy Benefits Management
Service, as well as an associate professor at Northwestern
University's Feinberg School of Medicine.
Next, we will hear from Mary McDermott, a member of the
board of directors for the Wisconsin Quality Home Care
Commission. A former corporate systems efficiency expert, Ms.
McDermott left her job in 2000 to become a full-time care
provider for her parents. She understands long-term care
training and quality of care issues, as both a service provider
and a family caregiver.
Senator Smith, would you like to introduce your witness?
Senator Smith. Thank you, Mr. Chairman.
Ms. Sally Bowman is a respected professor of human
development and family sciences at Oregon State University,
where she has been a faculty member since 1994. She will share
with us her experience working with families who have long-term
care needs and the importance of gerontology specialists. Thank
you, Sally.
The Chairman. We thank you all for being here. Just one
comment. Martha Stewart does need to leave rather soon. So we
are going to ask her to give her testimony and answer
questions. Then we will move on to the other three.
Ms. Stewart.
STATEMENT OF MARTHA STEWART, FOUNDER, MARTHA STEWART LIVING
OMNIMEDIA, NEW YORK, NY
Ms. Stewart. I appreciate the invitation to testify before
you today and am honored to be here. You have chosen a subject
that is increasingly critical to our quality of life--not only
for older Americans but for family members who care for them. I
look forward to learning from the work of the Committee as it
continues to examine this issue.
The experience of the distinguished professionals on your
panel today will be important as well. I especially appreciated
the remarks of Dr. John Rowe and Dr. Stone.
I respond to your invitation today as a member of a family
whose eyes were opened by personal experience and to share what
we have been learning at the Martha Stewart Center for Living
at Mount Sinai Medical Center in New York City.
My professional life has been centered on the home, the
well-being of the family, and everything that these subjects
encompass. When I began working in this area more than 25 years
ago, the subject of homemaking as it relates to families was
largely overlooked, though the interest was clearly broad and
the desire for information strong. My colleagues and I soon
discovered we were satisfying a deeply felt unmet need.
Today I see a similarly unmet need. Our aging relatives and
the families who care for them yearn for basic information and
resources. We all know that this is a significant sector of our
society. More than 75 percent of Americans receiving long-term
care rely solely on family and friends to provide assistance.
The majority of these caregivers are women, many of whom are
also raising children. Often, these women are working outside
the home as well.
I understand the challenges family caregivers face. My
mother, Martha Kostyra, passed away last year at the age of 93.
My siblings and I were fortunate that she was in good health
almost until she died. But we still came to know first hand the
number of issues that needed to be managed.
First, it is difficult, especially in smaller cities and
rural locations, to find doctors experienced in the specific
needs that arise with age. Think of all that this includes: the
effect of medications on elderly patients; how various
medicines interact with one another; warning signs for
depression and onsets of other conditions increasingly common
in the elderly.
How do we ensure that they take their medications? How do
we help structure our parents' lives so that they can live
independently for as long as possible? How do we support the
generation of caregivers who devote so much of themselves to
their parents' aging process?
This only touches on the myriad of issues, of course. Worry
is the backdrop for everything these families do. What if the
parent falls? What if she leaves the burners on? What if he
takes his medications twice or forgets to take them at all?
Now I am learning even more about the physical, emotional
and financial toll that the experience can exact. Caring for an
aging parent or loved one can be another full-time job. In
fact, 43 percent of baby boomers have taken time off from work,
and 17 percent have reduced hours to help care for an aging
parent. They do this at a time when their expenses are rising.
One recent study found that half of those caring for a
family member or friend 50 years or older are spending, on
average, more than 10 percent of their annual income on
caregiving expenses. Many dip into savings and cut back on
their own health care spending to cover the bill. Is it any
wonder that family caregivers are at increased risk of
developing depression, anxiety, insomnia and chronic illnesses
themselves?
In our Kostyra family, we were grateful to be there for my
mother, who had given so much to us and was a well-loved
presence in our lives and in the lives of her 13 grandchildren.
Our experience in her final years, and my resulting awareness
of the issues many Americans face, is one of the reasons for
the creation of the Center for Living. The goal of the Center,
which is dedicated to my mom, is to help people to live longer,
healthier, productive lives even as they age.
We have set a goal at the Center to use research and the
practice of geriatric medicine to try to elevate the level of
eldercare and its importance in our society. Did you know that
there is currently one geriatrician to every 8,500 baby
boomers? That is clearly not adequate.
We are also working to develop new tools and resources for
caregivers. We are collaborating with a large number of
organizations and motivated, experienced individuals, many of
whom have been studying these issues for years. There are
numerous devoted and knowledgeable people in arena, and we hope
we can all learn from each other.
This is a field that eventually impacts most families in
emotional and encompassing ways. Yet sometimes it is the simple
solution that holds an answer. Not long ago at the Center, a
woman brought in her father who had suffered a stroke two years
earlier. After the stroke, he had been told that he could never
eat again and was placed on a feeding tube. He was devastated
and depressed. He had spent his life as someone with a passion
for good food, and his future looked very bleak to him.
At the Center, a doctor experienced in geriatric care asked
the man to drink a glass of water. He did, without a problem.
``If he can do this,'' the doctor said, ``he can eat.'' This
simple exchange improved the man's quality of life
immeasurably. I am sure it improved the quality of his
daughter's life, too, knowing that her father was happier and
could eat.
I want to share with you three things I have learned from
our work at the Center and that others may find useful. One, we
must make an effort to coordinate care. Most older Americans
have several doctors. It is important for these doctors to
cooperate with one another and work closely with caregivers.
Two, it is important that we as a society recognize the
stresses and challenges that caregivers face and support them
as best we can. We want to ensure that their health isn't
undermined by the demands of eldercare.
Three, we must encourage families to open up a dialog now.
Even if your older relatives are in good health, as my mom was,
it is important to plan for a day when they might not be.
I have always been a firm believer in the role of
preparation and organization in progressing toward a goal. My
concern today is whether our country and our overstretched
medical system can possibly meet the demands of those 76
million baby boomers who will start turning 65 in the next two
years. We are on the cusp of a health and caregiving crisis
that has to be addressed now. I know you recognize this, and
that is why we are here today.
I thank you for your dedication to this important matter
and for the opportunity to express my thoughts.
In fact, I am here with Dr. Brent Ridge, who was a
geriatrician at Mt. Sinai hospital. Brent is now working with
me on the Center for Living and on other initiatives involving
caregiving. We are writing a handbook for caregivers. We have
gotten as far as a very complete outline. Now we are starting
on the actual text.
It is a very difficult job. There are lots of handbooks,
lots of guidebooks. But very few of them address all the very
serious subjects that a caregiver and the aging population
really have to face.
So thank you very much again for inviting me here.
[The prepared statement of Ms. Stewart follows:]
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The Chairman. Thank you, Ms. Stewart. In what ways do you
think the Martha Stewart Center for Living at Mt. Sinai Medical
Center meets the needs of older adults, their families as well
as to professionals who serve them?
Ms. Stewart. Well, in many, many ways. We rebuilt the
geriatric center at Mt. Sinai to make it a very comfortable and
welcoming place. There are more than 3,000 patients that visit
the Center on a regular basis. Every patient at the Center is
assigned to a clinical social worker to help patients and
families with the many social and financial issues that
accompany aging.
In addition to over 20 geriatricians at the Center, there
are also cardiologists, nephrologists, endocrinologists,
nutritionists, psychiatrists, gynecologists and pain
specialists, all in one place, which really does facilitate the
coordination of the care of these patients.
Electronic medical records rather than paper charts are
used here, so that all doctors can easily access patient
information and can check up on the care of these patients.
That way, there isn't a medicine that is going to react badly
with another medicine, which oftentimes does happen with these
patients.
My mom visited, oh, I don't know how many different
doctors. She was always--and when I called her up, she was
always going to another doctor. I said, ``Mom, are you taking
all your records?'' She said, ``Oh, I know exactly what I am
doing.'' But not really. I mean, because it was very
complicated. I couldn't even understand what she was taking. I
mean, I saw the drawers of things. So this is terribly
important, this medical records sharing that is going on now.
We have wellness lectures and yoga and T'ai Chi and
meditation classes--it's also very important just to encourage
the aging to do those very vital exercises. Every medical
student who graduates from Mt. Sinai rotates through the Martha
Stewart Center for Living, so that they graduate having some
exposure to managing the care of this special patient
population. So that is another way to encourage the
universities, the medical schools, to get students into
thinking about geriatric medicine.
We just opened the Center, as I said, late last year. So it
is really too early to pronounce our model successful. But we
are confident that it will be and that our complete approach to
patient care can be integrated into other medical facilities in
this county and hopefully elsewhere.
The Chairman. Thank you.
Senator Smith.
Senator Smith. Ms. Stewart, I think we are all grateful
that you are here. Certainly I admire your Center for Living.
What you just described is ideal. Your mother was in a rural
area. I am from a rural part of Oregon. I think about all the
things that we need to do yet in Government. In fact, we are
holding this hearing to try to elicit good ideas.
It seems to me, with the demographic aging of our country,
if people are counting on Government to fix it all, make it
perfect, I think our faith in that is probably going to be
disappointed.
But you spoke about your mother. It reminded me of how we
lost our mother. My mother had 10 children. It was, at the end
of a wonderful, beautiful life, when she had a very sudden bout
of pancreatic cancer. We all took turns at her bedside taking
care of her.
It just does seem to me that one of the missing ingredients
here that is part of living is that we will all die. Her death
was, in fact, if it can be described as beautiful, it was that.
It was because she had her family around.
I wonder if you have a message for American families as to
our responsibility to our parents, not just to be there, but
perhaps to become more educated. Is there a part of your Center
that trains family members to take care of their moms as they
are dying?
Ms. Stewart. Well, that is what the book will help, the
book that we are working on, the Care Living Guide, which I
hope will encourage the children of the aging to take it very
seriously that mom or dad plans for the future. You know, my
mom just didn't--she really didn't plan.
She had six kids. We were all well-off. We could all take
care of her. She was self-sufficient. She never asked us for
anything. She had been a teacher. She had her pensions. She did
all her bookkeeping herself. She did her tax returns herself.
She was quite an astute and intelligent woman.
But she never really said, you know, maybe I shouldn't
really be in western Connecticut. It wasn't so rural, but she
still needed a car to get anywhere. She became her friends'
chauffeur. She was chauffeuring friends that were younger than
she was, because she was still able to drive at 93.
But she didn't plan to, you know, go to a warmer climate.
She didn't plan to make herself more comfortable as she aged.
She really felt that the activity around her was the most
important thing. We continued to give her that activity. I
mean, she did 40 segments on my television program. Even her
own children didn't realize that. They didn't realize what a
fantastic contributor she had been to my life and to the lives
of so many other older people in America. She gave them lots of
hope that they could age gracefully as my mother had.
But even that aside, the whole aging and the whole dying
process just made me realize that you have to plan. You have to
have help. You have to have intelligent resources, not just
financial, but from everyone to get old gracefully and live
well until you die.
Senator Smith. Perhaps to Americans living in rural places,
a word of counsel to become educated and, literate on caring
for our parents.
Ms. Stewart. Absolutely. Very important.
Senator Smith. Probably good counsel to all of us to be
nice to our kids and keep family relationships strong, because
if you live in Pendleton, OR, like I do, you may not have all
of the care that you might in Connecticut, for example.
Ms. Stewart. Well, even in Connecticut, some of her friends
don't have any care--ones without children and without--I see
it all the time. They come to me asking for help. I am there to
help them, because it is a community.
Senator Smith. Well, I thank you for what you are doing. It
is commendable example for all of us. You have added measurably
to this hearing and to bringing our focus on this emerging
problem.
The Chairman. Thank you, Senator Smith.
Senator Salazar.
Senator Salazar. Thank you very much, Chairman Kohl.
Thank you, Ms. Stewart, for testifying here today and to
all the panelists as well for being here today. Thank you also
for leading the way in helping us figure out what we ought to
be doing with our elderly population and dealing with long-term
care issues.
I have a question of you, because frankly you are a master
of marketing and communication throughout the country and
throughout the world. I think when I hear Senator Smith's
question to you about how we get our families involved and
educated about long-term health care issues, it goes way beyond
that.
I come from a family of eight children. My family has lived
on the same farm for 150 years, almost 300 miles south of
Denver, CO. We took care of my father until he passed away from
Alzheimer's at age 85. My mother, who is 86, still lives on the
ranch. We take turns taking care for her. So I understand the
importance of the nexus between the children and the parents.
But I also think that, as a society, we aren't very good in
terms of planning for those later stages of life, whether it is
financial planning, whether it is medical planning, if long-
term health care is a part of that. So based on your expertise
and communications, how is it that we can move our society to
having a more honest and educated view of what we do as we get
through the aging process?
Ms. Stewart. Well, things have changed, I think,
tremendously in the United States. We have become more youth-
centric than aging-centric. I think that that has to--we have
to have a shift because of this huge number of baby boomers
that are reaching 65 years old. That is still not old. I mean,
you are still a vital person at 65 years old.
But as you get older, you realize that you have to rely on
others many times for transportation, for meals, for just
living expenses. We have not really done a good job in teaching
our children to care for the elderly. Our advertising is still
focused on the young. We should be focusing more on the aging
population.
I think that is all going to happen. I am working on a
magazine for women over 50 now. I need this magazine. I know
all my friends need this magazine. One doesn't exist in this
country without trying to encourage and inform, and I am going
to spend the rest of my time doing this kind of educating. I
think that there are other people in my position that can also
be very, very helpful. But that doesn't mean that we can't also
focus in Government on these issues and medicine on these
issues to get people focused on the care and the well-being of
the aging population.
Senator Salazar. I appreciate it very much. Senator
Whitehouse and I once worked together as attorneys general for
a number of years and had a number of initiatives with AARP and
other organizations trying to deal with it.
Ms. Stewart. They have done a phenomenal job. But they
don't reach everybody. That is a problem.
Senator Salazar. Sometimes I wonder there are a lot of
efforts out there from lots of organizations and lots of
wonderful-meaning people. But I wonder how effective we are
being in terms of actually reaching the population at a point
where they are making decisions for the long-term. Sometimes,
my senses is that we have made some progress. But if there is
100 miles to go, we have gone maybe only the first mile----
Ms. Stewart. I think there are 100 miles. I think that we
really do have to focus. I intend to, as an individual. I hope
many other people do too.
Senator Salazar. Thank you for being here today.
Ms. Stewart. Thank you.
The Chairman. Thank you very much.
Senator Casey.
Senator Casey. Thank you, Mr. Chairman.
Ms. Stewart, thank you for your testimony and for the
insight you bring to us from a personal perspective as well,
which I think informs all of us.
I was looking at your testimony in the last section, when
you have I guess--there are three bullet points. The second
one, when you talk about, ``It is important that we as a
society recognize the stresses and challenges that caregivers
face and support them as best we can.''
I was thinking about one initiative in Pennsylvania about
20 years ago it started. I am pretty sure it is still being
funded. It was called Aid to the Caregiver. It was an
innovative way to have Government help a little bit to provide
aid or respite care of one kind or another. I think there have
been similar models in the Federal Government.
But I just wanted to have you expand upon that point in
terms of what you have seen, either in the public sector or the
private sector and non-profit sector, of models or programs
that speak to the goal of trying to give some aid or relieve
some of that stress.
Ms. Stewart. Well, there is Gail Hunt who heads up the
National Alliance for Caregiving. She has been a wonderful
resource to us at the Center for Living at Mt. Sinai also. Dr.
Robert Butler, who founded the department at Mt. Sinai. It is
the oldest geriatric department in America. I don't know if you
know that. Now, he has also founded the International Longevity
Center. He is actively involved in confronting this caregiving
crisis.
So there are people really working in this area, really
trying to help solve the problem. It is just a question of
focus. It really is--and a large focus.
Senator Casey. What is it about the way that that kind of
respite care is given? In other words, if you have a
particularly difficult situation you are caring for, and it is
usually women that are doing this--caring for an older
relative, a parent or something like that. What do you think is
the--and this is a broad generalization--but what do you think
is the most common relief they can be provided with?
Is it taking a day off? Or is it more giving them a break a
couple hours a day. Or is it a longer break?
Ms. Stewart. It is very hard to say. I personally work 7
days a week. I have many jobs that I do for my company. But I
always tried to see my mother ever single Sunday. Someone would
go to pick her up, bring her to my house. The last 6 months or
so, she wasn't really driving a distance. She could drive
around town, but couldn't really drive a distance any longer. I
live about 35 minutes from where my mother lived.
But I would have her over, try to entertain her. On her
93rd birthday, I had a dinner party for her. She controlled the
conversation. We asked her to just reminisce. I had all my
friends there--not her friends, but my friends. So they could
really get to know her. Who knew she was going to die a few
months later?
But it was fascinating, because she really wanted to be
independent. But she really wanted to have the interaction.
Making time to have the time to be interactive with an elderly
person in your family, or taking the time to just contribute to
an organization, so that you could give time to somebody else,
it is very important. It is just a way of living.
That is what we are trying to do in the Center. We are
trying to be a place where you can go, learn and be cared for,
and feel wanted. I think that is really one of the major
things.
In New York, there are many older people. I was looking up
the statistics today about the numbers of elderly. In New York,
13 percent are over 85 years old; in Pennsylvania, 15.15
percent; Maine, 14.4 percent; Florida is the highest, 16.79
percent. That is a lot of people. It is getting to be bigger
and bigger and bigger over 65 now.
So we just have this big challenge.
Senator Casey. Thank you very much.
Ms. Stewart. Wish I could answer all the questions.
The Chairman. Thank you very much.
Senator Whitehouse.
Senator Whitehouse. Thank you, Mr. Chairman.
Thank you for being here, Ms. Stewart. I was struck by the
question of the distinguished senator from Oregon, because I
did not know until this minute that we shared the common
experience of having our mothers die from pancreatic cancer.
Ms. Stewart. Painful and horrible.
Senator Whitehouse.--Senator Salazar mentioned, when we
were attorneys general, we did a certain amount of work on, in
my case, particularly end-of-life care, which is sort of a
particularly sensitive and tender aspect of all of this; but
also one that is potentially very ennobling.
The experience that I have seen and heard of from too many
people is that, at that time, there are far too many Rhode
Islanders and far too many Americans who are experiencing far
too much pain, who are experiencing far too much either
confusion about or failure of, their advance directives, and
far too many who are experiencing continuing medical
intervention that is well-intentioned, but is kind of on the
``don't just stand there, do something'' theory.
Frankly, everybody would be better off if the family had
the chance to stop, settle down and deal with the occasion and
experience of that loved one's passing away. I just think we
are terrible at that in this country, by and large.
I was delighted to hear that Senator Smith's family had the
experience of having a beautiful death. We have had a beautiful
death in my family. We have also had some pretty unpleasant
ones. The difference seems to follow along these lines. It is
something you can prepare for, if it is done right. But there
is very little support for those decisions.
In fact, institutions seem to be leaning very strongly in
favor of less pain medication, with continuing confusion over
what the advance directive means, and general disinterest in
complying with them. Then for God's sake, let's not stop doing
things until it is all over, even if that is highly painful and
costly emotionally to the family.
I am just wondering what thoughts you bring to that
particular issue.
Ms. Stewart. Well, I am a fighter. I am going to be here
forever. I am never willingly going to die. I wish I could find
the fountain of youth that we are all looking for. But you
can't really, I think in this Committee, approach it that way.
You just have to really encourage support of caregiving and
support of geriatric medicine to deal with the problems of the
elderly. I think that that is really what we have to focus on,
having places like the Mt. Sinai Center, the Martha Stewart
Center for Living that will really help those patients with
many, many, many different problems there and not burden the
family with everything. The family can't really take the brunt
of it all.
I don't think it is just the family. The family will help,
but a lot of people don't have large families and lots of kids.
What is going to happen to those people?
So it is a huge challenge. It has to be dealt with, as I
said, in a very systematic and careful way to develop programs
and encourage the universities to encourage people to study
geriatric medicine and provide subsidies for caregivers. I
don't really know anything about any of that. All I know is
that they need information, education and help.
Senator Whitehouse. Well, you are a great communicator. You
are a great person at helping Americans experience the
transitions and passages of their lives, birthdays and things
like that in a more favorable way than they might otherwise. I
would urge you to think about the end-of-life care. Thank you.
Ms. Stewart. Thank you.
The Chairman. Ms. Stewart, thank you so much for being
here. You have helped us immeasurably and we appreciate your
giving us your time today.
Ms. Stewart. Excuse me for having to leave. I have some
other obligations I have to go to. But I greatly appreciate the
invitation.
The Chairman. Thank you so much.
We now turn to the second member of the panel, Dr. Todd
Semla.
STATEMENT OF TODD SEMLA, PHARMD, PRESIDENT, AMERICAN GERIATRICS
SOCIETY, EVANSTON, IL
Dr. Semla. Good afternoon Chairman Kohl, Ranking Member
Smith and members of the Committee. Thank you for inviting the
American Geriatrics Society to address the Committee on
preparing our nation's health care workforce for the growing
number of older Americans.
The American Geriatrics Society is a non-profit
organization of 7,000 health professionals dedicated to
improving the health, independence and quality of life of older
Americans. Geriatricians are primary care physicians who
complete residencies in family practice or internal medicine,
and at least one additional year of fellowship training in
geriatric medicine.
Geriatricians specialize in the often complex health
condition and requirements of older adults. As Dr. Rowe stated,
today there are fewer than 7,200 certified geriatricians
practicing in the United States--roughly half the number
needed.
There are similar shortages in other disciplines. In all
disciplines, there are insufficient number of geriatrics
faculty to train upcoming geriatricians and conduct aging
research. Today I will offer some solutions for your
consideration. Many parallel the recommendations of the
recently released IOM report on the geriatrics workforce.
We need to establish Federal loan forgiveness programs for
geriatric health professionals. Encouraging future physicians
burdened with school loans to consider a career in geriatrics
is a challenge because of financial disincentives, as you have
heard. In most fields of medicine, additional training results
in higher income, but not so in geriatrics. A national loan
forgiveness program would offset at least a portion of the
financial burden of pursuing a career in geriatrics.
As you heard Senators Boxer and Collins have introduced a
geriatrics loan forgiveness bill. We support the principles
underlying this bill.
We need Congress to reauthorize expand and fund Title VII
health professions programs. We have specific recommendations
for the three programs that are critical to training health
care professionals in geriatrics.
First, AGS recommend expanding the Geriatric Academic
Career Awards (GACA) to support not only career development for
geriatric physicians in academic medicine, but also junior
geriatrics faculty in other health professions such as nursing,
pharmacy and social work. We recommend creating a mid-career
GACA award that would support and retain clinician educators as
they advance in their careers.
Second, we recommend expanding the Geriatric Education
Center Program to support 14 additional GECs. Currently there
are 48 in 36 states. Ideally, the mandate of the GECs would
also be expanded to include training of direct-care
paraprofessionals.
Third, we recommend that Congress consider expanding the
geriatric faculty fellowship programs by creating mid-career
fellowships that would allow faculty from all disciplines to
receive training in caring for older adults.
We need to support Title VIII nursing workforce development
programs, the largest source of Federal funding for advanced
nursing education supporting almost 50,000 nurses and trainees
in 2008. The Title nursing comprehensive geriatric education
program supports training for nurses who care for the elderly,
curricula relating to geriatrics care and training of faculty
in geriatrics.
We need to expand and enhance support for geriatric
research, education and clinical centers also known as GRECCs.
These are centers of geriatric excellence within the VA At the
outset, we believe five new GRECCs should be established and
funded, which would be in keeping with the congressional
authorization in 1985.
We need to address problems with Medicare GME policy. The
number of Medicare-funded graduate medical education slots has
not increased since the enactment of the Balance Budget Act of
1997. We need to expand the number of GME slots, particularly
in the field of geriatrics, and resist proposed funding cuts to
this program.
We need to provide adequate coverage for necessary and
cost-effective services. We must reform Medicare and the
nation's health care system to realign reimbursement and
incentives. Senators Lincoln and Collins have introduced
legislation that would fill a major gap in Medicare by covering
geriatric assessment and care coordination services for
beneficiaries of multiple chronic conditions, including
dementia. Changes like this to Medicare coverage are important
incentives for geriatricians and other primary care providers.
We need to collaborate to train and prepare the direct care
workforce and family caregivers. AGS commends the IOM report
for recommending increased standards for all direct care
workers. We are also developing materials for certified nursing
assistants with a focus on care of older adults.
In addition to our AGS Foundation for Health and Aging, we
provide support and information to informal caregivers through
programs like Eldercare at Home. We would be pleased to
collaborate with the Committee on any efforts to develop
programs for both direct care and informal caregivers.
To conclude, there are already serious shortages of
geriatrics health care providers. Given the coming silver
tsunami, these shortages will reach crisis proportions unless
we work together now to address them.
Thank you again for the opportunity to participate in
today's important and timely hearing.
[The prepared statement of Dr. Semla follows:]
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The Chairman. Thank you, Dr. Semla.
Ms. McDermott.
STATEMENT OF MARY MCDERMOTT, PERSONAL CARE WORKER AND BOARD OF
DIRECTORS MEMBER, WISCONSIN QUALITY HOME CARE COMMISSION,
VERONA, WI
Ms. McDermott. I would like to thank Chairman Kohl and
Ranking Member Smith and other distinguished members of the
Committee for this opportunity to speak to you today about home
care. I am here today with SEIU, the largest health care union
in the country with almost a million members of health care
workers.
In the last 11 years I have had the opportunity to view
home care from several perspectives. Currently I provide hands-
on assistance for my mother and coordinate work of several
other caregivers. I am also an officer on the board of
directors for the Wisconsin Home Care Commission, a nonprofit
organization established in 2006 to assist consumers looking
for providers of home care and personal care services.
Before taking on the care of my parents, I worked as an
efficiency expert analyzing, designing cost-effective quality
standards, core competency curriculums, training programs and
operational processes. My background has enabled me to bring
important professional expertise into this very personal arena.
In 1997, my mother suffered a stroke and, along with my
disabled father, moved from Michigan to my home in Wisconsin,
so that I could assist them in providing the care that they
needed. We, like many families, wanted to avoid putting my
parents in a nursing home.
Families want choices in their long-term care for their
loved ones. My experience is that caregivers who choose this
field often lack medical and geriatric skills and knowledge.
This is particularly true of people who care for family members
and are often isolated and unaware that support is even
available.
Direct care workers, like other workers, need career
support that includes continuing education, training, career
guidance. Such training can help individual caregivers in the
field create long-term caregiving relationships with their
clients and reduce the turnover that we are now seeing
nationally.
I was fortunate to work with my parents, very high-quality
RNs and LPNs to obtain the training that I needed to care for
my parents and then to train others to care for my parents. I
cannot begin to express my appreciation to Dr. Barczi and the
geriatrics team at the VA Hospital in Madison for the training
that they gave on an as-needed basis.
They were also very valuable in giving me support, when I
needed it, on making health care decisions for my father; and
gave me valuable suggestions as how to approach care planning
as changes occurred with my father's health status. Their
partnering with us significantly reduced hospitalization, cost
and improved the quality of the care that was provided in my
home.
I know from personal experience that direct care can be
physically demanding and emotionally challenging. We in the
field struggle to retain the current workforce, given the low
wages, the lack of health and other benefits available and the
lack of opportunities for any advancement. Homecare workers'
wages are among the lowest in the service sector. One in five
health care workers lives below the poverty level.
Under a recent Supreme Court ruling, most home care workers
are not entitled to even minimum wage or the overtime
protection of the Fair Labor Standards Act. Congress can
rectify this by passing S. 2061, the Fair Home Health Care Act.
I urge the members of this Committee to sign on to that
important legislation.
Until we treat home care workers with the respect they
deserve, pay them a living wage, give them health care, we fail
as a country to provide the professional workforce that is so
desperately needed with our growing population of seniors and
the people with disabilities. A knowledgeable, experienced and
responsive worker can significantly improve the quality of life
for many clients.
Some states are offering home care training for aides and
personal care workers. But in some places, it has been local
unions who have been addressing this training gap. After
developing a registry to enable consumers to choose from among
available workers, the Wisconsin Home Care Commission will
offer supportive services for both home care workers and
consumers, including training.
SEIU supports the development of a core competency
curriculum, which emphasizes consumer choice and preferences
and requires training in communication, problem solving and
relationship skills. Such training enables workers to
understand and respond to consumer preferences and to provide
them with the high quality of care that they deserve.
While training is crucial to the development of a
professional workforce, it is only one factor. We need to do a
better job with Federal and State funding for long-term care
and improving wages and benefits. If we don't, the training
alone will not be enough.
Again, I thank the Committee for giving me this opportunity
to speak today. I welcome any questions.
[The prepared statement of Ms. McDermott follows:]
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The Chairman. Thank you, Ms. McDermott.
Dr. Bowman.
STATEMENT OF SALLY BOWMAN, PHD, ASSOCIATE PROFESSOR, DEPARTMENT
OF HUMAN DEVELOPMENT AND FAMILY SCIENCES, OREGON STATE
UNIVERSITY, CORVALLIS, OR
Ms. Bowman. Good afternoon, Ranking Member Smith, Mr.
Chairman and Committee members. I appreciate this opportunity
to share my remarks today, focusing first on the links among
living arrangements, health and caregiving; and second on the
need for educational strategies to train a sustained and
capable workforce of professionals, paraprofessionals and
informal family caregivers.
In late life, the individual preference to age in place
means that housing, health care services and personal
caregiving are intertwined. Consumers and health care providers
have positively responded to the philosophy that older
individuals should be able to receive services in the least
restrictive physical environment possible.
The challenge and the opportunity is to link services to
individual needs, rather than to the type of residential
setting in which the individual happens to live. The advantage
of this approach is that declining health status does not
require multiple relocations for an individual. Moving from
place to place is difficult for aging persons and their family
members and is problematic for health care coordination.
How will the desire to age in place affect baby boomers?
They will reside in a wide variety of home, community and
institutional settings, receiving services from a combined
workforce of professionals, paraprofessionals and informal
caregivers. Projections indicate that the greatest growth in
long-term care settings will be in assisted living, residential
care and home and community-based services.
This will make Senator Smith happy. Oregon was the first
State to apply for and receive a Medicaid waiver to provide
home and community-based services in 1981. For over 25 years,
Oregon's financing, reimbursement and licensing policies have
favored the growth of adult foster care, assisted living, and
residential care facilities while reducing nursing home use.
These policies resulted in savings in public resources. At the
same time, they provided living arrangements that valued
independence and privacy.
Indeed, many frail older adults, with both physical and
cognitive disabilities, are living in all these diverse long-
term care settings and in the community rather than in nursing
homes. Because Medicaid daily reimbursement rates for adult
foster homes, assisted living and residential care facilities
in Oregon are less than half the daily rates for nursing
facilities, the decrease in Medicaid cases in nursing
facilities--from 69 percent to 37 percent over 14 years has
resulted in considerable savings of tax dollars.
So for example, in 2004, reimbursement of Medicaid long-
term care recipients who resided in adult foster care, assisted
living and residential care facilities rather than nursing
homes saved Oregon taxpayers about $700,000 per day.
The goal of combining individualized care with a normal
life is a challenge regardless of the physical setting. It
highlights the need for a well-trained network of formal and
informal caregivers. The projected shortfall in formal and
informal workers needed to care for these aging baby boomers,
including myself, requires increased efforts in education and
training at every level.
Geriatric Education Centers, GECs, are and will continue to
be a key player in this effort. These centers focus on the
training of professional workers in long-term care--including
physicians, nurses, social workers, allied health workers. GECs
have helped to provide aging-related education to these health
care workers and have also been essential to incorporating
geriatric curricula into the training of new professionals.
The Oregon GEC focuses on outreach to rural areas where, in
comparison to urban areas, a larger percentage of the
population is older, disabled and suffers from chronic
diseases. Yet most rural health care providers have not
received geriatric training.
As part of our participation in the Oregon GEC and also
part of the land-grant mission, the Oregon State University
Extension Service in the College of Health and Human Sciences
has offered a regional 2-day gerontology conference for 300 to
400 direct care practitioners annually for the past 32 years.
This conference reaches frontline workers and community service
providers who serve an aging population.
Collaborative partnerships involving higher education
institutions, community colleges, private foundations, state
and local government units on aging, nonprofits and employers
can all expand opportunities to meet the educational needs of
informal family caregivers. Educational and training strategies
may include publications for late-life decisionmaking; Web-
based checklists; interactive board games; community education
workshops, both series or as single events; and one-on-one
consultations.
The nationally disseminated caregiver training program,
Powerful Tools for Caregiving, was produced by a partnership in
Oregon between a community-based hospital and Oregon State
University faculty members. Evaluations have shown that family
caregivers become empowered to practice self-care strategies
and develop tools that enhance their caregiving efforts.
Because the vast proportion of long-term care to older
adults is provided by family members and by paraprofessionals,
attention should focus on supporting these frontline
caregivers. Because long-term care requires one-on-one
assistance, labor is the major cost and determinant of quality
of care.
Recruitment and retention of direct care workers in all
types of long-term care organizations continues to be a
significant challenge. The Better Jobs Better Care national
demonstration projects have shown that key dimensions of job
satisfaction--such as adequate training, rewards and
incentives, career ladders, reducing workloads--all affect
intentions to stay in or leave the workforce. Changes in public
policies at the state and local levels and related funding will
be required to institutionalize management practices that can
lower the turnover rates of frontline workers.
Thank you for this opportunity.
[The prepared statement of Ms. Bowman follows:]
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The Chairman. Thank you, Dr. Bowman.
Questions from the panel?
Senator Smith.
Senator Smith. You speak of the importance of Oregon's
Geriatric Education Center to rural areas. The conference, you
hold it every year? Where do you hold it? Different places?
What kind of attendance do you have?
Ms. Bowman. We hold that event in Corvallis, because that
is our tradition. We get a vast proportion of participants from
the rural areas actually not from the metro areas. There are
other conferences for family caregivers and for practitioners
held around the State. You, in fact, hold one yourself.
Senator Smith. I do, yes.
Ms. Bowman. You get a fantastic attendance, because you
have great speakers. I think you also give free lunch.
Senator Smith. Yes, we do. You all heard there is no such
thing. But there is at my aging conference, a free lunch.
Well, you know, listening to your testimony, a comment
about Ms. Stewart that, you know, in some urban areas, maybe
there are more caregivers, there are more professional people.
But I wonder if, in your judgment, end-of-life care is as good
or better in rural areas in Oregon.
Ms. Bowman. Well, I think you have to look at the whole
continuum of care and compare it, rural to urban areas. I think
if we are going to talk about end-of-life care, one of the
things that I didn't hear mentioned was the role of hospice. So
often people bring in hospice 3 hours before the patient dies.
There are resources. But, you know, one of the wonderful
things about rural areas is the social support system.
Senator Smith. That is right.
Ms. Bowman. The friends and neighbors who check on people
who are living alone. So I think we need to emphasize that
importance of the rural support. Through the GEC, we try to do
road shows and do as much as we can to provide geriatric
training to the rural health care practitioners in those areas.
Senator Smith. Well, I think I appreciate you mentioning
hospice. I think they are working alongside the angels as far
as I am concerned. I have seen the work they do as both
wonderful and merciful. I would simply add a word of
encouragement to families to bring hospice in earlier, because
they--at least in our family's case--they were helpful in
training and making sure we did the right things. They are
present in rural areas. They certainly are in rural Oregon.
But I appreciate your focus on rural Oregon. Obviously I
care about all of Oregon. So I wonder if you have any comment
about how we are doing in our urban centers of Portland and
Eugene and Corvallis perhaps as well. How are doing? Are we up
to speed? Got a lot more work to do?
Ms. Bowman. You know, I think the wonderful thing about not
having enough resources is that you partner to get things done.
What I have been so proud of and so pleased about are the
variety of partnerships to meet the needs of families in this
State. The Family Caregiver Support Program, the Alzheimer's
Association, AARP, the universities, community colleges--
everyone partners to try to meet that need.
Senator Smith. Are they communicating in that partnership?
Ms. Bowman. They do. I think we can't underestimate the
importance of community education workshops, whether it is the
extension service or whoever. You know, I, for example, did a
workshop in Enterprise, Oregon. I think they closed down the
nursing home. There were 100 people there. What they said to me
was nobody ever comes to Enterprise, Oregon.
So I think the importance of getting training for family
members as well as all the health care workers we have talked
about today who need geriatric training--I think we can do it.
But we have to really work on public-private sector
partnerships.
Senator Smith. Well, for our CSPAN audience, if you ever go
to Enterprise, Oregon, you won't want to leave. It is one of
the most beautiful parts on Planet Earth.
Again, Sally, thank you for coming this long way across the
Oregon Trail to the nation's capital, and your testimony; and
Mary, yours as well. Todd, thank you for your participation
today.
The Chairman. We thank the panel profusely for being here
and giving us your wisdom and your experience. This whole area
of caring for seniors in our society is daunting in terms of
the needs, the kind of things that we need to do to attract
people to the area, to see that they get trained and paid, so
that our seniors can get the care that they need and deserve
and must have in the years ahead.
We appreciate your being here. We appreciate your
testimony. You can be sure we will continue to be in touch with
you. Thank you so much.
Thank you all for being here.
[Whereupon, at 4:49 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Senator Susan M. Collins
MR. CHAIRMAN, thank you for calling this hearing to examine
our nation's future health workforce needs in the face of our
rapidly aging population.
This afternoon's hearing is particularly significant in
light of the report issued by the Institute of Medicine (IOM)
earlier this week. The IOM report, titled ``Retooling for an
Aging America,'' sounds a warning that we are facing a critical
shortage of doctors, nurses, and other health care
professionals who are adequately trained to manage the special
health care needs of our nation's growing population of
seniors.
America is growing older. Today, more than 37 million
Americans are age 65 and over, and these numbers will rise
dramatically when the ``baby boom'' turns into a ``senior
boom.'' Over the next twenty years, the number of Americans
over the age of 65 is expected to more than double. In Maine,
more than a quarter of our population will be over 65 in 2030.
Nowhere does the aging of America present more risk and
opportunity than in the area of health care. It is not just
that there will soon be more older Americans. It is also that
older Americans are living longer. Americans 85 and older--our
``oldest old''--are the fastest growing segment of our
population. This is the very population that is most at risk of
the multiple and interacting health problems that can lead to
disability and the need for long-term care.
Older Americans consume far more health care resources than
any other age group. Moreover, their health care needs are very
different from those of younger persons. While younger people
typically come in contact with the health care system for
treatment of a single, acute health care condition, older
people often have multiple, chronic conditions like heart
disease, diabetes, arthritis, and Alzheimer's disease--or any
combination of the above.
Geriatrics is a medical specialty or style of practice that
is specifically designed to address the complex health care
needs of older patients. The essence of geriatrics lies in
coping rather than curing. Its emphasis is on helping older
adults maintain their quality of life and ability to function
independently, even in the presence of chronic age-related
diseases and disabilities.
With its emphasis on maintaining ``functional
independence,'' geriatrics offers great promise not only for
improved health and quality of life for older persons, but it
also has the potential to reduce overall medical and long-term
care costs. According to a report by the Alliance for Aging
Research, the U.S. realizes at least $5 billion in health and
long-term care savings for every month that the physical
independence of older people is extended. According to the
Alliance, this is a conservative estimate.
Unfortunately, as the IOM report reveals, we are facing a
dramatic shortage of health care professionals who are
adequately prepared to deal with the complex health care needs
of seniors.
Despite the obvious need, relatively few physicians, nurses
and other health care professionals are pursuing careers in
geriatrics or gerontology. While experts have projected that
36,000 geriatricians will be needed to care for our 70 million
seniors in 2030, only 7,000--about one per cent of all
physicians--are currently certified geriatricians. Only about
one percent of nurses are certified gerontological nurses and
only 3 percent of advanced practice nurses specialize in care
of the aging.
Moreover, while most physicians do care for older patients,
very few receive formal geriatric training. While almost all
medical schools require some ``geriatric exposure,'' the IOM
report notes that this training is often inadequate. Less than
35 percent of our nursing baccalaureate programs require
coursework in geriatric settings.
In the face of the approaching tidal wave of aging
Americans, we simply cannot afford to ignore the IOM's warning.
That is why I was pleased to join Senator Boxer in sponsoring
the Caring for an Aging America Act, which takes some important
first steps to ensure that our health and long-term care
workforces are prepared to meet the needs of our aging
population.
Our legislation would provide $130 million in federal
funding over five years to attract and retain health care
professionals and direct-care workers with training in
geriatrics by providing them with loan forgiveness and career
advancement opportunities. It would also create a Health and
Long-Term Care Workforce Advisory Panel for an Aging America to
examine and advise the Secretary of Health and Human Services,
the Secretary of Labor and Congress on workforce issues related
to our aging population.
Again, MR. CHAIRMAN, thank you for calling this hearing,
and I look forward to working with you on this important issue.
------
Prepared Statement of Senator Robert P. Casey, Jr.
Mr. Chairman, I want to thank you for scheduling this
important hearing. It is critical that we fully investigate all
issues surrounding the direct care workforce and the
increasingly older population in America.
This is a critical time for the health care workforce in
this country. With the first of the baby boom generation on the
cusp of retirement, the demand for direct care workers will
increase exponentially in the coming years and decades. It is
estimated the number of adults aged 65 and older will almost
double from 37 million to over 70 million between 2005 and
2030. This is an 8 percent increase from 12 percent to 20
percent of the United States population.
In Pennsylvania, the projected increase is slightly larger.
People over 65 will comprise 22.6 percent of the population by
2030 going from 1.9 million to over 4 million older citizens.
As the baby boom generation ages, we will need more
caregivers and we will also need to change our approach to
care, emphasizing greater prevention and more coordinated care.
Shortages in caregivers for older citizens exist across the
spectrum of care. The direct care workforce is woefully
inadequate to meet the needs of the increasing number of older
citizens who will require care. By 2030 it is estimated we will
need an additional 3.5 million health care workers to care for
our older citizens, a 35 percent increase from today.
With respect to physicians, only one percent of all
physicians in the United States are currently certified as
geriatricians. Experts project we will need 36,000
geriatricians by 2030.
The nation is already experiencing a severe shortage of
registered nurses and less than 1 percent are certified
gerontological nurses. Without increases, the total supply of
nurses is projected to fall 29 percent below requirements by
the year 2020.
In Pennsylvania, projections indicate the state will need
an additional 24,610 direct care workers. This is an increase
of 19 percent and a rate of growth nearly three times the state
average for all occupations.
We must begin to address these shortages right now or we
will suffer the consequences of our inaction tomorrow.
Almost every person in this room has a family member or a
friend who has required long term care. From my experience with
my father, who was hospitalized for a significant period of
time toward the end of his life, I know what a positive impact
that knowledgeable and skilled health care professionals can
have.
On Monday, the Institute of Medicine released a study
entitled ``Retooling for and Aging America: Building the Health
Care Workforce''. This document provides us with a detailed
roadmap to expanding the direct care workforce, meeting the
increasing needs of older citizens, and changing our approach
to the models of care we provide our citizens in order to
emphasize greater prevention, and more effective coordination
of care.
This report highlighted three main goals we must achieve:
1) increase the training and educational opportunities for all
providers of geriatric health care; 2) improve upon the
recruitment and retention of all providers and specialists in
geriatric health care by improving wages, benefits and working
conditions; and 3) redesign models of care so that prevention
and coordination of care are prioritized and older citizens
themselves can participate as much as possible in their own
care.
These are important steps forward that we must take. Our
older citizens need and deserve quality and coordinated health
care as they age. These are our parents and our grandparents
and they've worked hard for us and for our country. Now we owe
them respect and dignity as they age. It will take time to
build up the workforce we need, this is not something we can
accomplish overnight. This is a daunting task, but a task we
simply must undertake.
I look forward to hearing the testimony of all the
witnesses today as they share their knowledge and experiences
with the committee. I look forward to working with them, the
members of this committee and others to ensure that our older
citizens will have the care they need--and deserve--in their
later years.
------
Prepared Statement of Senator Barbara Boxer
I would like to thank Senator Kohl, Ranking Member Smith,
and members of the Senate Special Committee on Aging for having
this hearing, and bringing attention to this important issue. I
also want to commend the Aging Committee for its long and
influential history of exploring and investigating issues that
concern our senior citizens and their families.
California is home to 3.9 million people age 65 and older,
more than any other state. That population is projected to
increase to 8.3 million by 2030, growing from 11 percent to 18
percent of the state' population.
Preparing our workforce for the job of caring for older
Americans is an essential part of ensuring the future health of
our nation. Right now, there is a critical shortage of health
care providers with the necessary training and skills to
provide our seniors with the best possible care. This is a
tremendously important issue for American families who are
concerned about quality of care and quality of life for their
older relatives and friends.
Quite simply, the demographic imperative is clear: with the
number of adults aged 65 and older projected to almost double
from 37 million today to nearly 72 million by 2030, we must
start now if we are going to adequately train the health care
workforce to meet the needs of an aging America. We cannot
afford to wait any longer.
According to the Institute of Medicine, only about 7,100
U.S. physicians are certified geriatricians today; 36,000 are
needed by 2030. Just 4 percent of social workers and only 3
percent of advance practice nurses specialize in geriatrics.
Recruitment and retention of direct care workers is also a
looming crisis due to low wages and few benefits, lack of
career advancement, and inadequate training.
It is clear that there is a need for federal action to
address these issues, and that is why Senator Collins and I
have introduced the Caring for an Aging America Act (S. 2708).
Senator Collins has been a strong leader on aging issues and I
look forward to working with her and this Committee to move
this legislation forward.
The Caring for an Aging America Act would help attract and
retain trained health care professionals and direct care
workers dedicated to providing quality care to the growing
population of older Americans by providing them with meaningful
loan forgiveness and career advancement opportunities.
Research suggests that geriatricians have the highest job
satisfaction ratings among all physician specialties, and they
find working with older adults to be richly rewarding. Yet
despite high job satisfaction rates, it remains difficult to
recruit adequate numbers of health and social service
practitioners to the fields of geriatrics and gerontology,
which remain among the least well-compensated specialties. This
is why Senator Collins and I introduced our bill. The Caring
for an Aging America Act would help to address these financial
disincentives.
Specifically, for health professionals who complete
specialty training in geriatrics or gerontology--including
physicians, physician assistants, advance practice nurses,
social workers and psychologists--the legislation would link
educational loan repayment to a service commitment to the aging
population, modeled after the successful National Health
Services Corps. The bill would also expand loan repayment for
registered nurses who complete specialty training in geriatric
care and who choose to work in long-term care settings, and
expand career advancement opportunities for direct care workers
by offering specialty training in long-term care services.
Lastly, the legislation would establish a health and long-term
care workforce advisory panel for an aging America.
Ensuring we have a well-trained health care workforce with
the skills to care for our aging population is a critical
investment in America's future. This legislation offers a
modest but important step toward creating the future health
care workforce that our nation so urgently needs.
Our bill has strong support from the health care and senior
communities. The report released this week by the Institute of
Medicine, Retooling for an Aging America: Building the Health
Care Workforce, endorses the financial incentives in our bill--
including loan forgiveness linked to service--as a key way to
recruit geriatric providers in the health professions.
The Caring for an Aging America Act has been endorsed by
nearly 30 national organizations, including AARP, American
Academy of Physician Assistants, American College of Nurse
Practitioners, American Geriatrics Society, American
Psychological Association, Coalition of Geriatric Nursing
Organizations, and the National Association of Social Workers.
I look forward to working with my colleagues to ensure that
we meet our obligations to the seniors of our nation to improve
their care. We owe it to our parents, grandparents, and
ourselves.
------
Dr. Robyn Stone's Responses to Senator Smith's Questions
Question 1--Support and Training for Caregivers
In the testimony that each of you provided, you state that
you believe training opportunities should be made available for
informal caregivers. I agree and I feel that we should work to
better support our nation's caregivers, as they are the
backbone of the system to ensure the safety and welfare of our
seniors. They also help seniors age in their homes, where all
of us would prefer to be as we get older. I am working with
Senator Lincoln to increase funding to the National Family
Caregiver Support Program run by the Administration on Aging. I
think the help provided by this program, primarily coordinated
by the Area Agencies on Aging located throughout each state, is
so important. But more supports must be made available as the
number and needs of caregivers increases.
Question 1. How do you think we can engage the aging
network, including Area Agencies on Aging, State Agencies on
Aging, and other entities to facilitate additional training and
help for informal caregivers?
Answer. The SUAs, the AAAs and other aging network
organizations have multiple opportunities to improve upon and
expand training for informal caregivers. First, they need to
recognize that family and other informal caregivers face the
same challenges as paid direct care workers including how to
provide care to their loved one (both the clinical and
technical aspects of the care delivery), how to communicate
with the formal sector (including communication related to
cultural competence), how to make decisions in crisis
situations and how to take care of themselves. Since community
colleges, vocational tech schools, and other educational
institutions are developing more comprehensive training
programs for direct care workers (certified nursing assistants,
home health aides, and personal care workers), aging network
providers should consider partnering with these entities to
offer the same curriculum and teaching methods to informal
caregivers. Many nursing homes also provide both orientation
and in-service training to direct care workers and could
provide a venue for offering training programs to informal
caregivers in the community. These organizations should also
partner with local workforce investment boards in their
communities (funded through Department of Labor) who are
charged with career development for entry level workers in the
long-term care sector. Finally, I believe the Family Support
Program, administered through the Older Americans Act, has been
a great symbolic gesture to the millions of informal caregivers
across the country. But the resources are limited and the
ability of the AAAs and other organizations to provide
assistance to families varies tremendously. The Congress should
look at options for expanding the resources to this program
through the OAA and also ensuring that the organizations are
meeting some standard in terms of the services offered to
caregivers.
Question 2--Support for Community Health Centers
Community Health Centers (CHCs) are the foundation of the
nation's health care safety net. I believe these centers have
an important role in keeping the doors open to patients who
otherwise might be unable to afford health coverage. In Oregon,
health centers provide over 130 points of access, where upwards
of 180,000 Oregonians receive care each year.
However, the success of these centers, and indeed, our
entire health care system, is directly dependent on a well-
trained health professions workforce. A March 2006 study in the
Journal of the American Medical Association found that CHCs--
especially those in rural areas--are understaffed, including
shortages of family physicians, dentists, pharmacists and
registered nurses.
Question 2. Although there are existing health professions
programs to encourage health care providers to serve in these
settings--they still are not receiving the support they need.
Do you believe they are effective? What more could be done to
encourage medical professionals to practice medicine in rural/
underserved areas?
Answer. The Community Health Centers have targeted
primarily families and children; relatively few of these
organizations have identified the geriatric population as a key
user group. This is ironic given the fact that most rural
communities are aging much more rapidly than their urban
counterparts. The first step in ameliorating this situation is
to build the capacity of the CHCs to care for the elderly
population, including hiring staff that are trained in
geriatrics and gerontology and that know how to meet the needs
of rural elders. Special financial incentives need to be
created to attract physicians, nurse practitioners and
physician assistants, nurses, social workers, therapists and
others who are interested in caring for the geriatric
population, including debt relief surrounding educational
expenses and stipends that allow people to live in these
communities. The CHCs also need to expand their use of
technology to help reach the elderly in remote, frontier areas.
Finally, they need to understand the aging network resources
that are in most rural communities (including the AAAs, senior
centers, special transportation programs, rural nursing homes
and senior housing providers) and partner with these
organizations.
Question 3--Medicare and Medicaid Legislative Relief
Each of the panelists' testimony mentioned the important
role that Medicare and Medicaid play in the topic of ensuring a
robust health care workforce. As a member of the Finance
Committee, I am deeply committed to ensuring that the system
works for our beneficiaries and responds to our nation's
demographic change. I feel that apart from big funding
increases to ensure appropriate training and recruitment of
professionals, we also need to make sure administration of the
Medicare and Medicaid programs is running smoothly and we're
reducing burdens on training opportunities. A bill that I have
introduced with Senator Lincoln, the Long-Term Care Quality and
Modernization Act, would among other things, allow nursing
facilities to resume their nurse aide training program when
deficiencies that resulted in the prohibition of the training
have been corrected and compliance has been demonstrated,
instead of the current two-year wait period.
Question 3. Knowing the great need to educate our nurses
with more experiences in geriatrics, what support can be given
to schools of nursing and long-term care facilities to develop
strong clinical partnerships?
Answer. Many nursing homes have developed excellent ``home
grown'' training programs for their direct care workers that
not only help them to do the their current work but provide
career ladders or lattices for these individuals. Given the
lack of quality training programs in many communities, I
commend you for your efforts to allow nursing homes to resume
training programs as soon as possible. In addition, there are
relatively few opportunities for nursing students to have
rewarding clinical placements in nursing homes and other long-
term care settings. When they do, however, many become
committed to this sector and seek out job opportunities there.
The Congress needs to consider mechanisms for supporting
nursing school placements in nursing homes, assisted living and
home care that provide meaningful and challenging experiences
for students who then will help to expand the labor pool in
these settings. This might entail developing Centers of
Excellence where Nursing School/Nursing Home partnerships that
meet certain criteria would be eligible for multiple years of
funding to support the training program and placements costs. I
would suggest that similar programs be developed for medical
and social work schools to prepare medical directors and
clinical social workers for this growing field.
Question 4--National Service Corps vs. Title VII (Health
Professions) Programs
We understand older Americans tend to utilize health
services more than younger individuals, and by 2030, 20 percent
of the U.S. population (71 million Americans) will be age 65 or
older. Conversely, many health professionals are retiring as
this population will require greater demand of our public
health workforce. As you know, the President proposed to zero
out many health professions programs in the Fiscal Year 2009
budget. Through the years, the Administration has conveyed that
funding direct primary care through the National Health Service
Corps is a better investment than funding HRSA's Title VII
programs, which they believe lack focused objectives.
Question 4. What are your thoughts on this issue--is the
National Health Services Corps a better program to improve the
placement of providers in underserved areas and support
training in primary care?
Follow Up: a. What are your suggestions for improving the
efficacy of or expanding Title VII programs as we face the
aging of our population and of the healthcare workforce?
Answer. I do not believe that these options are mutually
exclusive. I strongly recommend developing a specific track in
the National Health Services Corp for people who are interested
in working in geriatric settings--including nursing homes,
assisted living and home care. For this to work, however, funds
would need to be dedicated specifically to these settings to
attract the ``best and the brightest''. At the same time, it is
important to strengthen the Title VII programs that invest in
educational opportunities for the professions as well as
helping to develop a larger cadre of health professionals in
the field. In particular, some resources need to be redeployed
to target the development of the geriatric workforce, including
physicians, nurses and ancillary health professionals who would
be interested in geriatric/long-term care settings if financial
incentives were available. I would, furthermore, recommend
strengthening the Geriatric Education Centers across the
country that have helped to train many health professionals in
the field.
Question 5--Recruiting a More Diverse Workforce
In your testimony, you mention the need for long-term care
employers to focus on new sources of labor that previously have
been poorly utilized in the health care workforce, such as
minorities and retirees.
Question 5. How do you think long-term care employers can
best be encouraged to do this and are there models for ways
that employers can effectively reach out to better recruit from
these under-utilized groups?
Answer. With respect to older adults and retirees as
prospective caregivers in the long-term care sector, one of our
BJBC studies found that elderly individuals and employers are
interested in expanding these opportunities. This may be a
viable option for many older adults who cannot afford to retire
as well as those who are interested in pursuing a caring
career. Title V of the Older Americans Act currently focuses on
job development for older adults. I recommend that a special
program be developed to create partnerships between the Title V
providers and long-term care employers (nursing homes, assisted
living and home care) to explore the potential of using this
program to expand the labor pool. The National Health Services
Corps could also experiment with a Retiree Corps that could be
recruited to work in these settings. Both of these options, of
course, would require sufficient training resources to prepare
and support this workforce. In addition, a study would be
required to explore challenges to the recruitment of older
workers including issues related to access to Medicare and
Social Security benefits and physical barriers (e.g., the need
to lift residents/clients) that would deter the hiring of
elderly workers.
With respect to a more diverse workforce, the direct care
workforce in long-term care settings is already incredibly
ethnically, racially and culturally diverse. The real issue
here is to develop culturally competent workplaces that respect
all caregivers and that provide training in the overt and more
subtle cultural differences that can cause communication
problems and poorer quality care delivery. Employers also need
to explore mechanisms for hiring a more diverse supervisory and
clinical staff including nurses, social workers, therapists,
medical directors, primary care physicians and administrators.
This could start with the development of partnerships between
these employers and historically black colleges and
universities and their counterparts in the Hispanic community.
Resources could also be provided to employers with a diverse
direct care workforce to help them develop career ladders for
CNAs, home care aides and personal care workers who are
interested in becoming nurses, social workers and
administrators in this sector. Finally, some providers have
developed strategies for recruiting foreign professionals
(particularly nurses) into this sector (although most of this
recruitment has been for hospitals). A targeted strategy needs
to be developed that recognizes a code of ethics as it relates
to both the countries or origin and the needs of the workers
who come to work in the U.S. through these routes.
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Martha Stewart's Response to Senator Smith's Question
Question 1--Geriatric Education & Training at Mount Sinai
I understand the Martha Stewart Center for Living supports
the education of both practicing and future physicians, as well
as patients, caregivers and the community. Further, physicians
at the Center also support education through community talks,
screenings and health fairs.
Question 1. Would you describe how this model of care was
created and how it has benefited the patients who receive care
at the Center for Living?
Answer. The Martha Stewart Center for Living, now with
4,000 patients, is one of the largest outpatient practices in
the country catering specifically to the health care needs of
older adults. The models of care have been developed over time
at the Department of Geriatrics and Adult Development at Mount
Sinai School of Medicine, which was founded by Dr. Robert
Butler and is the oldest such department in the country.
Doctors, nurses, and social workers at the Center continue to
innovate their approach. Patients see the Center as their
medical home, and its interactive programming allows them to
become active participants in managing their well-being.
Todd Semla's Responses to Senator's Smith Questions
Question 1--Lack of Nurse Educators
Currently, less than one percent of the nation's 2.4
million practicing nurses are certified as gerontological
nurses or geriatric advanced practice nurses. This statistic
underscores the importance of educating students in
gerontology. In 2007, the American Association of Colleges of
Nursing reported that 40,285 qualified applicants were turned
away from baccalaureate and graduate nursing programs. The top
reason cited by schools of nursing was a lack of expert
faculty. The bill I introduced with Senator Clinton, The
Nursing Education and Quality of Health Care Act of 2007, would
help to address the faculty shortage by creating a Nurse
Faculty Development program focused on offering scholarships
and fellowships for nurses who wish to become faculty.
Question 1. Knowing the demand for educators is high, what
other support can be given to nurses who wish to become
geriatric nurse faculty?
Answer. AGS recognizes that the shortage of faculty in
schools of nursing with baccalaureate and graduate programs is
a continuing and expanding problem. AGS requests that Congress
supports providing $200 million in fiscal year 2009
appropriations funding for Title VIII Nursing Workforce
Development Programs, the largest source of funding for
advanced nursing education. As stated in our testimony, before
the Senate Special Committee on Aging, Title VIII nursing
comprehensive geriatrics education program supports training
for nurses who care for elderly, curricula on geriatric care,
and training of faculty in geriatrics. In addition, the
programs are the largest source of federal funding for advanced
education nursing; workforce diversity; nursing faculty loan
programs; nurse education, practice and retention;
comprehensive geriatric education; loan repayment; and
scholarship.
AGS also requests that Congress support all Title VII
Health Professions Programs at FY 2005 levels of $300 million.
Specifically, we ask that Congress fund Geriatrics Health
Professions Programs under Title VII at least at the FY 2007
levels of $31.5 million. Title VII Geriatrics Health
Professions Programs supports three initiatives: Geriatric
Education Centers (GECs) Program, geriatric faculty
fellowships, and Geriatric Academic Career Awards (GACAs) all
which are critical to improving recruitment and retention of
Geriatrics Health Professionals. The AGS supports efforts to
develop and enhance the GACA program to support junior
geriatrics faculty and expand its availability to other health
care professionals, including nurses. We also support
establishing a mid-career GACA award that would support and
retain clinician educators as they advance in their careers. In
addition, we recommend creating a GACA-like award for advance
practice nurses.
In addition to the suggestions outlined in our testimony,
we ask Congress to consider the recommendations contained in
the June 2005 American Association of Colleges of Nursing
(AACN) white paper entitled, Faculty Shortages in Baccalaureate
and Graduate Nursing Programs. The paper addresses the scope of
the problem and strategies for expanding the supply of nursing
faculty (See http://www.aacn.nche.edu/publications/whitepapers/
facultyshortages.htm for more information).
Among the strategies to alleviate the shortage and expand
the supply of nursing faculty are:
Identify any existing regulatory requirements that limit
nurses with non-nursing graduate degrees from teaching in
nursing programs, so that efforts to remove these barriers can
be planned.
Utilize the expertise of junior faculty by partnering
them with senior, fully qualified faculty who can provide
course oversight and faculty support without requiring the more
labor-intensive team teaching.
Remove impediments to graduate study for working nurses,
such as offering more convenient times for courses, encouraging
partnering institutions to offer students more flexible work
schedules to accommodate class schedules, and offering courses
specifically for partnering health care facilities, possibly at
their site(s).
Examine college/university retirement policies and work
to eliminate unnecessary restrictions to continued faculty
service, particularly mandatory retirement ages and financial
penalties for retired faculty who return to work part-time.
In collaboration with the Hartford Institute for Geriatric
Nursing, the AACN also administers a Geriatric Nursing
Education Project (GNEP), which is funded by the John A.
Hartford Foundation. The GNEP incorporates several
complementary programs to ultimately improve nursing care for
older adults through curriculum enhancement, faculty
development and scholarship opportunities. (See http://
www.aacn.nche.edu/education/Hartford/index.htm for more
information).
The programs include:
Awards for Excellence in Gerontological Nursing Education
A Faculty Development Institute Offered through the
Geriatric Nursing Education Consortium
New Series of Web-Based Interactive Case Studies
Available
The AACN also administers The John A. Hartford Foundation
funded Enhancing Geriatric Nursing Education for Baccalaureate
and Advances Practice Nursing Programs, an initiative that
supports gerontology curriculum development and new clinical
experiences in 30 selected baccalaureate and graduate nursing
programs. (See http://www.aacn.nche.edu/education/Hartford/
ShowcasingInnovations.htm for more information).
According to projections from the Bureau of Labor
Statistics (BLS), there will be more than one million vacant
positions for registered nurses (RN) by 2010 due to growth in
demand for nursing care and net replacements due to retirement.
It is critical that we ask Congress to implement the
recommendations from AACN and continue to encourage our nursing
workforce to participate in the program opportunities outlined
above to ensure we have an adequate and well-trained nursing
workforce to care for the aging population.
Question 2--Public Health Emergencies
In the event of a public health emergency, public health
providers at the local level will be among the first
responders.
Question 2. Does HRSA train individuals so they are able to
respond to the needs of vulnerable populations, such as
seniors?
Answer. AGS Recommendations: Currently, HRSA does not train
individuals so they are able to respond to the needs of
vulnerable populations such as seniors, in the event of a
public health emergency.However, it would seem like a natural
extension of their training as it is estimated that some 3.4
million, or 34 percent, of all calls for emergency medical
services involve older patients. Our rapidly aging population
will only increase the pressure on our emergency medical
system. This population has specific and often complex medical
needs. To ensure that older adults receive quality care prior
to arriving at the hospital, first responders must acquire the
additional knowledge, skills, and attitudes that encompass the
basic concepts of geriatric medicine.
In 2003, AGS and the National Council of State Emergency
Medical Services Training Coordinators (NCSEMSTC), along with
Jones and Bartlett Publishers (J&B) partnered to develop a
program that will train prehospital professionals (first
responders, EMTs, and paramedics) to deliver state-of-the-art
care to older adults. The continuing education curriculum
called GEMS (Geriatric Education for Emergency Medical
Services) emphasizes the unique conditions and needs of older
patients. (See http://www.gemssite.com/ for more information).
As America's 77 million baby-boomers age, the number of
emergency calls involving older patients will likely rise
significantly. People are living longer and therefore are often
sicker and present more complicated conditions. Emergency
responders are going to have to be well-trained at recognizing
serious medical problems in the elderly.
The AGS believes that first responders must be aware of the
complexities of treating older people or they may not take
correct action. Communications are particularly important and
EMS providers will need to recognize symptoms of drug
interaction, dementia, elder abuse, and heart disease, all
common problems among older people.
Unfortunately, there is no identified source of funding
that would support states offering such training to EMS
providers. Congress could look at creating an Emergency Medical
Services Geriatrics program that is modeled on the Federal
Emergency Medical Services for Children (EMSC) Program. This
program was developed in 1984 and since that time, Federal
grant money has helped all 50 States, plus the District of
Columbia, the Commonwealth of the Northern Mariana Islands,
American Samoa, US Virgin Islands, Guam, and Puerto Rico. (See
http://bolivia.hrsa.gov/emsc/ for more information).
The EMSC program has improved the availability of child-
appropriate equipment in ambulances and emergency departments.
Federal grants to States and territories have supported
hundreds of programs to prevent injuries, and has provided
thousands of hours of training to EMTs, paramedics and other
emergency medical care providers. The success of the program
has led to legislation mandating EMSC programs in several
states, and to educational materials covering every aspect of
pediatric emergency care.
The EMSC Program is saving children's lives. A similar
program focused on geriatric patients is needed as well as
these populations both present unique health care needs that
require additional training. Such a program would support the
state training coordinators in ensuring that EMS providers
receive training in the unique health care needs of older
adults.
Question 3--Importance of Social Workers
In your written testimony you mentioned the importance of
loan forgiveness and specifically mention social workers. As
you may know, yesterday was World Social Work Day, and I was
honored to introduce a bill with Senator Mikulski to work to
increase the number of social workers and ensure federal
assistance exists to help them remain in their field, including
loan forgiveness. As you also mention in your testimony, care
coordination is important for so many of our vulnerable elderly
with chronic health conditions, and while we may not think of
them in this capacity, social workers do a great deal to ensure
care is coordinated for so many of our vulnerable citizens.
Question 3. What do you think are the best ways to support
social workers who focus on our elderly vulnerable populations
and how can we perhaps better train them in care coordination
models that you've discussed today?
Answer. AGS Recommendations: The AGS believes that social
workers trained in the field of geriatrics are imperative and
therefore, strongly supports incentives for social work
students who train to care for our aging population.
Incentives, such as federal loan forgiveness legislation, are
among the remedies needed to make careers caring for older
adults more appealing and to address recruitment and retention
problems.
The National Institute of Aging estimates the nation will
require 70,000 trained, ``aging savvy''professional social
workers by 2020. Currently, only 5% of social workers are
trained in aging issues.
As stated in our testimony, the AGS strongly supports the
`Caring for an Aging America Act' introduced by Senator Barbara
Boxer (D-CA), which would, among other things, establish the
Geriatric and Gerontology Loan Repayment Program for social
workers, along with physicians, physician assistants, advance
practice nurses and psychologists who complete specialty
training in geriatrics or gerontology and who agree to provide
full-time clinical practice and service to older adults for a
minimum of two years. While loan forgiveness is a very good
start, it is also important to find a method to support
specific training programs--as all schools do not equally
prepare students for practicing with older adults and for care
coordination.
The Hartford Partnership Program for Aging Education
(HPPAE) was created to meet the workforce demand for geriatric
social workers by training and educating more than 1,000 social
workers in older adult care and to establish a specialized
aging curriculum in Masters of Social Work programs across the
country. The HPPAE is an eight-year initiative coordinated by
the Social Work Leadership Institute (SWLI) at the New York
Academy of Medicine and is funded by the John A. Hartford
Foundation. In 1999, 80 percent of the HPPAE graduates who
participated in the program's pilot study went on to pursue
careers in the field of aging. Currently, 72 schools in 32
states have adopted the Hartford Partnership Program for Aging
Program. Graduates of these programs are highly sought after by
employers in the field. (See http://
www.socialworkleadership.org/nsw/ppp/about.php for more
information)
In addition, current practitioners and those who enter the
aging field do not always stay in the field because of
challenging working conditions. Continuing education focused on
care coordination and payment for care management are important
methods to increase retention.
The AGS also supports creating a GACA-like award for social
workers. The Geriatric Academic Career Awards (GACA) funded
under Title VII Health Professions Programs of the Public
Health Service Act supports the career development of newly
trained geriatric physicians in academic medicine.
The field of geriatrics promotes preventive care, with an
emphasis on care management and care coordination that aims to
help older patients maintain functional independence in
performing daily activities and improve their overall quality
of life. Social workers are an important part of the geriatric
team. Now is the time to address social work recruitment into
the field of aging and build on programs that train social
workers to provide care coordination and case management.
Mary McDermott's Responses to Senator Smith's Questions
Question 1--Nursing Shortage in Rural Areas
In Oregon, our nursing shortage is most acute in rural
areas, as I can imagine is the case in Wisconsin. Our schools
are turning away potential nursing students that could be
serving in these areas. Since the 2002 academic year, the
number of qualified applicants turned away by Oregon nursing
schools has increased by more than 300 percent, with more than
1,500 qualified applicants being turned away in 2007.
Question 1. I am curious if Wisconsin is experiencing
similar challenges, and as a personal care worker, could you
share with us what effects older Americans are experiencing
from the health care workforce shortage, including nurses and
other health care professionals, in rural areas?
Answer. The problems with nursing schools which you site
for Oregon are identical in Wisconsin. This happened to my
daughter who was a four point student and wanted to be a nurse.
When she reached the point in her education to enter the
nursing program she was told there was a two year wait before
she could continue her education. Long story short, she changed
directions. My sister-in-law, a surgical RN in California
complains that the nurses coming out of nursing school now are
inadequately trained as they attempt to rush as many through as
possible. This is a complaint I have heard from RNs in WI, MI,
NJ, NC, and FL. The problem appears to be on two levels,
limited training availability and inadequate training. The
impact to the elderly is they have less availability to nursing
professionals and people who are available lack some basic
training and most generic training.
The farther you get from communities with populations of
ten thousand the worse the problem becomes and the elderly are
forced to rely on friends, family, and neighbors. While I
personally feel the old fashioned community support model is
beneficial to all parties involved, it should not be the sole
avenue of home care support. It does not provide the consistent
preventive professional service that older people need. It can
also diminish their feelings of independence, dignity, and can
cause feelings of being a burden which leads to depression with
its corresponding health care issues. They are also open to
criminal predators who target the elderly.
I have worked in a consulting capacity with a few home
health care agencies over the last ten years to improve their
hiring and training practices as well as the quality of their
care. Actually I think they got tired of my stealing their
employees. An agency will receive $25.00-40.00 dollars per hour
and pay their workers between $5.00-9.00 per hour. The agencies
are in a population base of 400,000 and my community has a
population of 9,000, but I advertised in the larger population.
When the agencies placed ads in good economic times, they
average between three to five responses from uneducated people
or students. They are lucky if they get one qualified person
and will need to run ads repeatedly to get that one person.
During bad economic times they may get eight to twelve
responses with the same results of a possible one qualified
person.
There is a perception, which for the most part is true,
that privately advertised home care pays more. Consequently the
ads get more attention as well as a greater number of highly
trained overly qualified people. Generally these are people who
are looking to supplement their income, flexible hours that
will work with their family's needs. Also included are those
who work better outside of an institutional environment and
professional home care workers. I set up a system of three team
members with myself as back-up between 1997 and 1999. The team
included one RN ($27.00 per hour), one LPN ($17.00 per hour),
and one CNA ($9.00 per hour). In 1998 I was told both my
parents were in critical condition and would most likely not
live six months. I utilized each team members's talent/training
level to the tasks best suited with the mandate to spoil my
parents rotten. It must have worked well since my father lived
until October 2005 and my mother is still alive.
Once we passed this critical and financially burdensome
stage, we switched the team profile to two CNAs daily and one
RN for weekly visits. By this time I had become able to train
aides in my parent's care, including the generic skills that
most were lacking. In 1998 the ads we ran generated eight
responses of which three were qualified. In 2000 we had ten
responses of which two were qualified. In 2003 we had 150
responses. Twelve people over qualified foreign licensed RNs
and LPNs (one of which was a doctor) highly trained medical
personnel which had to be retrained and re-licensed in this
country, from Ireland, Russia, and Palestine, and Romania.
Their employment needs were too temporary to suit our situation
and their monetary expectations were no longer feasible for us.
Three respondents were students in medical fields and two were
professional home care workers. The majority of respondents
were not fit for a phone conversation. Several did not speak
English. Even when English was their native language they took
the term unintelligible to whole new level. Imagine the dire
health consequences of miscommunications with people who maybe
hard of hearing or suffering from dementia when being cared for
by such workers. We hired one student willing to make a one
year commitment who is now a medical assist specializing with
the disabled and elderly and one professional home care who
still works here 4 hours a week.
While the numbers may look like an upturn is occurring with
people in the home health field it is not. Economic conditions
and population growth through immigration have an increasingly
greater impact on the number of those who are responding to ads
for home care work. Workers who are in the field because of
economic reasons are not always the best because they leave as
soon as their financial issue is resolved or are not consistent
on the job. It is impossible not to notice that for private
care ads, as well as agency ads, qualified applicants have flat
lined or even declined, though the number of responses has
increased.
Many people who have found themselves in the position of
suddenly making care decision for their parents have sought
direction from me over the years. It is always the case that
solving their problems is much more difficult when their
parents live in small towns. I can't tell you how many times I
hear ``Thank God for that lady next door''. Programs targeting
rural areas are most certainly warranted and will only increase
in necessity with the experiential growth that our population
of seniors is experiencing.
Question 2--Caregiver supports
In your testimony, you mention that you are a caregiver for
your mother and that you also were for your father. You also
mention that you did extensive work to ensure an appropriate
and trained team was hired to help you care for them. I know
that the purpose of funding through the Older Americans Act is
to help provide supportive services and referrals for the
elderly and their family members to help seniors stay in their
home, and out of facilities, as they age.
Question 2. Did you receive any information, referrals or
caregiver help through your local Area Agency on Aging and how
do you think we can better ensure that caregivers, like you,
receive the support you need?
Answer. From 1997 to 1999, I was exposed to many doctors,
hospital social workers, nursing care facilities. With all the
health care professionals I dealt with not one provided the
information or resources that would have saved me over
$300,000.00. I did aggressively go after information in the
first year. The only option anyone wanted to speak to me about
was putting my parents in a nursing home. It was a learning
experience without direction. Thankfully that fit my career
specialty, so developing processes and analyzing needs allowed
me to put together the perfect team profile and care plan for
my parents. In 2000, I left my career to pick up some of the
time with my parents and reduce cost of care. While I made many
inquiries, most agencies were only interested in their special
area that related to some funding table, while others only
wanted to talk about nursing homes. Finally in 2003, while at
the mall getting a battery for my father's watch, a woman
working at the kiosk and I started talking about health care
costs. I said I didn't know how much longer I could afford my
health insurance because I was taking care of my parents and it
cost me $480.00 per month which, along with everything else,
was breaking me financially. She said her sister took care of
their parents and got health insurance and was paid to do so.
She gave me the number to call for the state agency and from
that point on we received help and information. Yes, I had
called the county and state agency previously, but was only
given misdirection and useless information.
Subsequently, I discovered that too many agencies had small
qualifying focuses and an inability to understand where to
direct people who may not fit their particular profile.
Everyone is protecting their small piece of the pie and failing
to provide cost effective solutions. Each agency has a set of
rules which may conflict with others, causing more confusion as
well as increased cost to those providing care and those
getting care. This situation enables those prone to fraud, a
lucrative playing field, which in turn reduces the availability
of services. The conflicting regulations are a nightmare for
both care recipients and administrators of the various
programs. One example occurred in my home when a doctor ordered
a blood draw after a hospitalization. The private agency's RN
we hired could not do the blood draw because of Medicare
restrictions from another agency whose RNs could not perform
the task due to liability and some other restriction. It had to
be done and the two agencies actually got into a fight over the
rules and regulations they each work under with my mother
caught in the middle. Not one tolerant of silliness when a
person's health is at risk. I just hired a private nurse to
come in and get the blood the doctor needed. Other options,
proposed by the two agencies would have had adverse
consequences for my parents, which both agencies agreed they
did not want to see.
Addressing this issue is currently underway in Wisconsin,
and is also one of the proposed goals for the Wisconsin Quality
Home Care Commission. To this end, there have been many
positive efforts in Wisconsin. Persuading any agency to work
efficiently and cooperatively with other agencies
(governmental, qusi governmental, or private) is a very
difficult task to accomplish. If someone told you that merging
the states of Oregon and Washington would save 10 million
dollars a year and would improve the services to both states,
but you would have to fine another job and could no longer
control the money to the state, how fast would you jump on that
band wagon? And how do you convince the law makers of Oregon
that they should now use the laws of Washington?
I discovered several ways the county and state could cut
cost and improve services. However, with the current protect
your turf attitude, the majority of initiatives will continue
to be layered costly fix after costly fix instead of real
solutions. This will continue until the financial back is
broken and the baby gets thrown out with the bath water in cut
backs. I am very proud of the initiatives that have taken place
in Wisconsin since I found myself in this life altering
circumstance in 1997. People in this state now have better
access to information. But there is so much more work to be
done. The first paragraph of Charles Dickens' A Tale of Two
Cities runs though my mind regularly when I reflect upon this
unexpected phase in my life. While one of the most rewarding of
my accomplishments, it has also been one of the most difficult.
It is the conditions in which I found the elderly and the care
givers which drive my conscience to help make things a little
better. This world that I have adventured into is so far from
who I am that I do stand in awe of those who have chosen this
as a career path. I also pray they will at some point in time
receive the recognition and assistance they so justly need and
deserve.
When my job is finished here, I have the option to avoid
the homecare field if I so choose, but I can't avoid getting
old any more than you can. What caliber of person do you want
in your home making decisions that could mean the difference
between life and death?
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Sally Bowman's Responses to Senator Smith's Questions
Question 1--Geriatric Education Centers and the Aging
Network
In your written testimony you mention the great
publications and information that OSU has worked on related to
ensuring elderly consumers and their caregivers are aware of
the options available to them.
Question 1. How do you ensure that seniors and their
caregivers have access to this information, and do you work
with the aging network, such as the State Unit on Aging and
Area Agencies on Aging to ensure that the products are offered
where seniors and their caregivers will have access to the
information?
Answer. OSU Extension Service publications on aging are
available for free on the OSU web site. They can also be
ordered for a small charge. They are included in the next
eXtension national Family Caregiving website located at
www.extension.org. Because we are part of the national network
of University Extension Services, other Universities also
utilize our educational materials with their audiences.
In addition, our partners in the state, including the State
Unit on Aging, AARP, Area Agencies on Aging, and our Oregon
Geriatric Education Center partners, OHSU and PSU, distribute
our publications at health fairs and trainings. We share our
educational materials in these venues, and disseminate up-to-
date lists of educational resources at events and conferences.
We also actively co-teach with partners from other agencies,
thus expanding our outreach. For example, we collaborated with
AARP on a statewide Prepare to Care project, in which one of
our activities was viewing the recent PBS special, Caring for
your Parents, at selected locations around the state, followed
by a panel of local and state experts.
Our OSU Extension faculty members with county assignments
partner with the State Unit on Aging, regional Area Agencies on
Aging, nonprofit agencies, and businesses to provide trainings
in chronic disease self-management, tai chi, strong women, and
family caregiving to older adults and their family members.
Other workshops and events include medication management,
optimal aging, aging in place, financial planning in later
life, etc. These offerings are available in both urban and
rural areas, although not in every county due to funding
limitations for staffing.
Question 2--Federal Geriatric Programs
For Fiscal Year 2008 (FY08), Congress provided $31 million
for geriatric programs. In FY07, Oregon received $390,000.
Unfortunately, the President's FY09 budget zeroed out
geriatrics programs, including the Geriatric Education Centers
Program, Geriatric Training for Physicians, Dentists, and
Behavioral and Mental Health Professionals and Geriatric
Academic Career Awards Program.
Question 2. In your testimony, you speak to the importance
of Oregon's Geriatric Education Center to rural areas--how
would you evaluate its success?
The Oregon Geriatric Education Center has fostered a
collaborative relationship between OHSU, PSU, and OSU in the
area of geriatrics and gerontology. One of the results of that
collaboration is that we work together on developing train ing
opportunities around the state. We provide a resource center of
educational materials that are lent to professionals and to
long-term care facilities. We develop curricula, if there is a
gap in educational resources. The OHSU geriatrics physician who
serves on the GEC is very active in providing geriatric
training to other physicians around the state. In addition, we
partner with geriatricians through their professional
association. We report our activities and our outreach in the
federal reports, and we are also working together this year to
improve our evaluation of outcomes. In short, the Oregon GEC
helps focus the energy of the three Oregon universities on
working together on health programs and aging. It provides
leverage that helps us respond to private foundation grant-
related opportunities.
Follow Up: What other incentives could help induce
physicians to pursue careers in geriatrics?
Answer. Financial incentives, such as scholarships and loan
repayment programs, have been shown to be effective in
recruiting health care providers, such as physicians and
nurses, to practice in specific fields, such as geriatrics.
Research also provides evidence that if you want to recruit
health care providers to practice in rural areas, the greatest
likelihood of success is if you recruit amongst students who
grew up in rural areas. If you want to recruit health care
providers to serve older adults from minority groups, the
greatest likelihood of success is if you recruit amongst
students from minority groups. If you want to recruit health
care providers to work with older adults, the greatest
likelihood of at some point in their life. These findings
should inform the design of recruitment programs because they
will contribute to their overall success.
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