[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?

=======================================================================

                                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/
                               index.html


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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

                              ----------                              
                                                                   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.
                                ------                                


         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?
                                ------                                


         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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