[Senate Hearing 111-820]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-820
 
                      TAKING CARE OF MOM AND DAD:
      WHY WE NEED A QUALITY WORKFORCE TO SERVE OUR OLDER AMERICANS

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

                             FIELD HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                               __________

                            WILKES-BARRE, PA

                               __________

                             AUGUST 2, 2010

                               __________

                           Serial No. 111-22

         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                    BOB CORKER, Tennessee
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
BILL NELSON, Florida                 GEORGE LeMIEUX, FLORIDA
ROBERT P. CASEY, Jr., Pennsylvania   ORRIN HATCH, Utah
CLAIRE McCASKILL, Missouri           SAM BROWNBACK, Kansas
SHELDON WHITEHOUSE, Rhode Island     LINDSEY GRAHAM, South Carolina
MARK UDALL, Colorado                 SAXBY CHAMBLISS, Georgia
KIRSTEN GILLIBRAND, New York
MICHAEL BENNET, Colorado
ARLEN SPECTER, Pennsylvania
AL FRANKEN, Minnesota
                 Debra Whitman, Majority Staff Director
             Michael Bassett, Ranking Member Staff Director

                                  (ii)

  
?

                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Bernard Graham, Ph.D., Dean, Nesbitt College 
  of Pharmacy and Nursing, Wilkes University.....................     1
Opening Statement of Senator Robert Casey........................     2

                                Panel I

Statement of Janet Heinrich, DrPH, Associate Administrator, 
  Bureau of Health Professionals, Health Resources and Services 
  Administration, Rockville, MD..................................     6

                                Panel II

Statement of Robert D'Alessandri, M.D., Executive Officer and 
  Chief Academic Officer, The Commonwealth Medical College, 
  Scranton, PA...................................................    22
Statement of Vera Salter, Ph.D., Professional Development 
  Director, the Direct Care Alliance, New York, NY...............    35

                               Panel III

Statement of Melissa Lear, President, Beck N'Call and President, 
  Allen Lear Home Care Associates, East Stroudsburg, PA..........    45
Statement of Connie Kreider, Direct Care Worker, Columbia, PA....    55

                                APPENDIX

Dr. Heinrich's Responses to Senator Casey's Questions............    65

                                 (iii)

  


                      TAKING CARE OF MOM AND DAD:
      WHY WE NEED A QUALITY WORKFORCE TO SERVE OUR OLDER AMERICANS

                              ----------                              --



                         MONDAY, AUGUST 2, 2010

                                       U.S. Senate,
                                Special Committee on Aging,
                                                  Wilkes-Barre, PA.
    The Committee met, pursuant to notice, at 10 a.m., at 
Wilkes University (Hon. Robert P. Casey Jr.) presiding.
    Present: Senator Casey [presiding].

 STATEMENT OF BERNARD GRAHAM, PH.D., DEAN, NESBITT COLLEGE OF 
            PHARMACY AND NURSING, WILKES UNIVERSITY

    Dr. Graham. Good morning. My name is Bernie Graham, and I 
am the Dean of the Nesbitt College of Pharmacy and Nursing here 
at Wilkes University.
    The college is the home to the School of Pharmacy, which 
has graduated approximately 700 Doctors of Pharmacy since the 
first graduating class in the year 2000. These graduates have 
mainly settled in northeastern Pennsylvania and are having a 
positive impact on the healthcare of our population, especially 
in the area of immunization and medication therapy management, 
areas in which pharmacists have gained the knowledge and 
experience and now have the privileges in the Commonwealth.
    We are also the home of the School of Nursing. Nursing 
education, in one form or another, has been a hallmark of 
Wilkes University since 1952. Since inception, Wilkes 
University has awarded over 1,500 degrees in nursing. Wilkes 
currently awards a B.S. in nursing, has an accelerated entry-
level Master's degree for career-change adult learners with a 
Bachelor's degree in other fields, has a traditional Nursing 
Master's of Science programs and, most recently, the Doctor of 
Nursing Practice.
    At the master's level and now the doctoral level, Wilkes 
has concentration areas to prepare clinical nurses, nurse 
specialists in geriatrics, which is the care of the aged 
population, and psychiatric mental health. We also prepare 
graduates for the areas of nursing management and nursing 
education.
    We in education also see this train of aging citizens fast 
approaching. The need for a larger workforce of well-trained 
healthcare individuals is obvious, but also perplexing. We have 
responded to the well-publicized need, but something, probably 
the economy or lack of money, has led to an interesting 
problem. Some--not many, but an increasing number--of our 
graduates are having a hard time finding employment. This is 
both in nursing and pharmacy.
    We see the workload of the existing workforce increasing 
almost beyond capacity, but yet employment market is very slow. 
This has also led to a very interesting problem with the 
training of the bachelor-level nurses in Wilkes-Barre. This 
problem is with all B.S. programs here in the region.
    The local hospitals are so overworked that they cannot 
precept any senior-level nursing students. These students, in 
their last year, need individual mentoring and leadership 
experiences, which can only be accomplished at bedside. This is 
a problem that we, as educators, are trying to address.
    As you can see that this hearing today will be informative 
and extremely timely, and we thank the Senator for his concern. 
Senator Bob Casey, who will soon be the senior Senator from 
Pennsylvania, will chair this U.S. Senate Special Committee on 
Aging field hearing, entitled ``Taking Care of Mom and Dad: Why 
We Need A Quality Workforce to Serve Our Older Americans.'' The 
hearing will focus on legislative action in the Senate and 
taking measures to ensure that Pennsylvanians have access to a 
quality workforce to care for an aging population, with a focus 
on medical education in the frontline healthcare workforce.
    Senator Casey.

           OPENING STATEMENT OF SENATOR ROBERT CASEY

    Senator Casey. [Off-mike.] I call this hearing of the 
Senate Special Committee on Aging to order.
    I do want to, first of all, thank Wilkes University and 
President Gilmour and Dr. Bernie Graham for having us here, for 
welcoming us and giving us this opportunity----
    OK. We want to thank Dean Graham and President Gilmore and 
others for welcoming us here to Wilkes University today to 
focus on a series of challenges that the people of northeastern 
Pennsylvania, the people of our Commonwealth, and, indeed, our 
country face as it relates to caring for older citizens 
throughout our Commonwealth and our country.
    There are many, many challenges, but there are also, as we 
will find out today, a lot of solutions to those difficult 
challenges. We have in Pennsylvania one of the fastest-growing 
populations in the country over the age of not only 65, but 
also the age of 85. We know that, for example, when you compare 
that to the United States of America, we know that the baby 
boom generation will start turning 65 next year.
    By the year 2030, all 78 million--that is hard to believe--
but 78 million will have reached that age, the age of 65 by the 
year 2030. Between 2005 and 2030, the number of adults age 65 
and older will almost double--almost double, just imagine 
that--from 37 million to over 70 million, accounting for an 
increase of 12 percent of the population to 20 percent.
    So what that means is that the country will look like 
Lackawanna County or Luzerne County because, as you know, now 
about 12.5 percent roughly of our U.S. population is over 65. 
Pennsylvania is above 15 percent, just about 15.5 percent. But 
here in Luzerne County and next door in Lackawanna County, 
consistently over the last 20 or 30 years, but it is certainly 
in the last 10 to 20 years, both counties have been right about 
19 or 20 percent over 65.
    So that increase nationally will mean that the country will 
have a percent over 65 that we have had here for many, many 
years.
    What we have to do, though, is not just recite those 
numbers and list the many challenges we have. We have to 
recommit ourselves to make sure that those who are, as Hubert 
Humphrey said a long time ago, in the twilight of life, that 
those who are in that age bracket get all the help that they 
need.
    Who are we talking about here? We are talking about people 
who fought our wars, worked in our factories, taught our 
children, and gave us life and love. All of those 
Pennsylvanians and all of those Americans, we have an 
obligation to make sure that they are taken care of in the best 
way possible.
    We have the blessing in this country of the best education 
systems in the world, the best schools in the world. When it is 
working as it should and when we are focused on the best parts 
of it, our healthcare is the best in the world. We have to 
bring all of that learning, all of that knowledge, all of that 
expertise and ability to strategies to care for, to take care 
of those in the twilight of their lives.
    In Pennsylvania, we have a particularly significant 
challenge over the age of 65. We are fourth in that category 
for the country. This puts us in a unique position to be able 
to be, in a sense, a laboratory for all kinds of great 
strategies, all kinds of new ideas, all kinds of new pathways 
of learning to make sure that we are taking care of people who 
have contributed so much to Pennsylvania and to our country.
    I remember reading a story, a series of stories in the 
Philadelphia Inquirer about a decade ago, about I want to say 
it was 1998, or 1999. I will get the date, but it was in that 
time period. The writer of the story was Michael Vitez, and he 
was talking about long-term care in Pennsylvania and across the 
country. I will never forget something he wrote in that story, 
that series.
    I think I am quoting him accurately. He said, ``Advocates 
for the frail elderly say that life can have quality and 
meaning even until the very last breath.'' Life can have 
quality and meaning even to the very last breath. Sometimes we 
forget that. Sometimes we think of long-term care, nursing home 
care, care for older citizens as somehow--oh, I don't know, I 
guess somehow just kind of managing old age and figuring out a 
way to make it as comfortable as possible.
    Well, we don't really believe that if we think about it for 
a little while. We don't believe that. We believe that life 
does have quality and meaning, even to the very last breath. 
That means that people can have full lives, lives of great 
contribution and lives of great promise even when someone is 
very old. That there is not just a dignity and a worth, but 
also a lot of opportunity and a lot of promise in the life of 
someone much older. They can contribute so much if we have the 
strategies in place to take care of them.
    So, first of all, it is a necessity that we get this right. 
The people of our country who are in that age bracket know that 
we have not just an obligation to them, but this is critically 
important that we get this right for our workforce and for our 
quality of life.
    In Pennsylvania, we know that the trend, just like it is 
across the country, those who are over the age of 85 are going 
to increase even faster than the population over 65. 
Pennsylvania is expected to grow by 50.6 percent between the 
years--we are 10 years into this now--2000 and 2030. So in that 
30-year time period, the population over 85 is supposed to grow 
by more than 50 percent.
    We also believe that when we are focused on these sets of 
challenges, this is an opportunity for our State of 
Pennsylvania. We were talking just earlier this morning about 
our healthcare infrastructure. We have a lot of it in 
Pennsylvania. A big workforce, you can make an argument, pretty 
good argument, that healthcare is our biggest employer if you 
set aside the jobs that are in agriculture or the economic 
impact of agriculture or tourism, Government employment.
    But you can make a very good argument that healthcare is 
either the biggest employer or a very close second. The bill 
that we passed in Congress and the President signed into law 
this year, the healthcare reform bill, presents an opportunity 
to create new models of care for people across this country.
    We know that in Scranton, for example, we have a medical 
school. A lot of people didn't think that would happen. But 
because of the leadership of a number of people, including Dean 
D'Alessandri, who is here with us today, will provide 
testimony, this school allows us to test some of those new 
models of care in primary care, comparative effectiveness 
research, all kinds of new discoveries and new ways of 
approaching the care for older Americans, to benefit them.
    We know that collaboration will be critically important 
with other healthcare providers and other experts in the field 
to make northeastern Pennsylvania a leader, literally a leader 
in this field in the world. Not just in the State or the 
country, but indeed across the world.
    So this isn't just some problem we have got to manage. This 
is an opportunity. It is an opportunity for Pennsylvania, and 
it is an opportunity especially for northeastern Pennsylvania. 
For that reason, we should embrace it, not just hope we can 
deal with it. We should embrace it as an opportunity.
    Third, I think we are also at the same time, as much as we 
think of this as both a necessity in terms of demographics and 
opportunity because of our values, it is also something that 
calls us to be summoned by our conscience and our commitment to 
get it right. We will not be the kind of community that we have 
been in northeastern Pennsylvania and across the State unless 
we get this right.
    The good news is we know exactly how to get it right, and 
we can do this. Our parents and our grandparents who raised us 
and cared for us and built this region, built this 
Commonwealth, and really built the country, when you think of 
the generations two or three that just preceded ours, how they 
got us through World War II. We weren't prepared for World War 
II. But they fought that battle, and they built our economy. 
They built the middle class.
    They made us the envy of the world--our economy, our way of 
life, our ability to defend freedom. All of that came from one 
or two generations of Americans. So we have a great opportunity 
not only to improve and grow strategies to care for older 
citizens, but also to build a very strong economy.
    We are told that the American Association of Medical 
Colleges predicts that the United States is expected to face a 
shortage by the year 2025 of between 124,000 and 159,000 
physicians across the country. The American Association of 
Colleges of Nursing reports that the number of registered 
nurses needed will grow, will grow by 260,000 nurses by that 
same year, 2025.
    So we are going to need more doctors. We are going to need 
more nurses, and we are also going to need more direct care 
workers in roughly that same time period. Direct care workers 
are often not given the respect they deserve for the work that 
they do. It is the direct care workforce that provides most of 
the care to our loved ones. They help every day of the week a 
quarter of a million Pennsylvanians and their families, every 
single day.
    It is one of the fastest-growing populations. According to 
the Bureau of Labor Statistics, employment of home health aides 
and personal and home healthcare aides is expected to grow 
between 46 and 50 percent between the years of 2008 and 2018. 
Just imagine, in one decade in one part of our healthcare 
workforce, direct care workers is going to grow by roughly 50 
percent in Pennsylvania.
    So it is our responsibility to make sure these jobs are 
both personally rewarding, but also that they provide an 
opportunity for advancement and economic stability. So, for 
that reason, tomorrow I will introduce in the U.S. Senate the 
Direct Care Workforce Empowerment Act. This legislation will do 
three things.
    First of all, ensure that home care workers receive the 
Federal minimum wage and overtime protections of the Fair Labor 
Standards Act. That is a good idea. I can't believe we haven't 
done it already. It doesn't make any sense that we haven't done 
it. No. 2, improve Federal and State data collection and 
oversight with respect to the direct care workforce. Three, 
establish a grant program to help States improve direct care 
worker recruitment, retention, and training--three or four 
words that we hear over and over again when it comes this part 
of our healthcare workforce.
    So we are here to talk about how we care for Pennsylvanians 
and Americans in the twilight of their lives, just as we hear a 
lot of talk about folks that we worry about in the dawn of 
their lives, our children. Both ends of our age spectrum, young 
children and older citizens, both need our help, both need our 
attention, and both need much more of our focus.
    So we will have three panels today. Our first panel will be 
one person, but someone who I think will be able to give us a 
great overview of some of the opportunities we have, especially 
in relationship to the new healthcare bill. Dr. Janet Heinrich, 
the Associate Administrator of the Bureau of Health 
Professionals of the Health Resources Services Administration.
    Dr. Heinrich is a former executive director of the American 
Academy of Nursing. She is here today to discuss many of the 
important changes that the Affordable Care Act, the health 
reform bill I referred to earlier, has made to improve and 
support the healthcare workforce.
    As I will tell her and I will remind our other witnesses, 
if we can keep your testimony to about 5 minutes, you should 
know, each of the witnesses should know that your entire 
testimony will be made part of the record. So if there is a 
part of it that you want to make sure is part of the record, 
don't worry, it will be part of the record.
    If you can keep it to around 5 minutes, Doctor, we would 
appreciate it. So, Doctor, why don't you start us off? Thank 
you very much for being here.
    [The prepared statement of Senator Senator Casey follows:]

  STATEMENT OF JANET HEINRICH, DRPH, ASSOCIATE ADMINISTRATOR, 
 BUREAU OF HEALTH PROFESSIONALS, HEALTH RESOURCES AND SERVICES 
                 ADMINISTRATION, ROCKVILLE, MD

    Dr. Heinrich. Senator Casey, Mr. Chairman, thank you for 
the opportunity to testify today on behalf of the Secretary of 
Health and Human Services and the Administrator of Health 
Resources and Services Administration, which I will refer to as 
HRSA.
    The Affordable Care Act provides us many opportunities, 
especially as we think about expanding the essential healthcare 
workforce and the importance of the direct care worker, as you 
so eloquently described.
    HRSA is the primary Federal agency for improving access to 
healthcare services for people who are uninsured, isolated, 
medically vulnerable, including the elderly. Our programs help 
Americans receive quality care without regard to ability to 
pay. HRSA programs also help train the future nurses, doctors, 
and other clinicians so essential to providing our healthcare 
services.
    My testimony today will focus on new activities related to 
the Prevention and Public Health Fund, our programs to improve 
access, the new programs we have for the frontline direct care 
workers, and specific programs for training people to care for 
older people. I want to give examples of organizations in this 
area especially that are taking advantage of these new 
opportunities that are made possible through the Affordable 
Care Act.
    Let us start with the Prevention and Public Health Fund. We 
know that communities across the country have suffered from a 
shortage of primary care workers. Without action, experts 
continue to say that we will have a shortfall in our needs to 
care for the aging population, with a decline in the number of 
students selecting primary care.
    To address this, Secretary Sebelius announced a series of 
new investments worth $250 million, made possible by the 
Affordable Care Act, to increase the number of providers in 
primary care. Specifically, we will be funding additional 
primary care residency slots to train new primary care 
physicians. We will be supporting physician assistants training 
for primary care, as well as nurse practitioner training 
programs--nurses who will be going into primary care, and one 
of those specialties, of course, is geriatrics.
    There will be $5 million to fund States to plan and 
implement innovative strategies to expand their primary care 
workforce. This is a terribly important program, again made 
available under the Affordable Care Act, to encourage our 
States to address barriers to expanding the healthcare 
workforce, especially for primary care. So that, in fact, 
States can address issues of scope of practice which limit what 
providers other than physicians can provide, especially to 
older populations. Certainly, we know that Pennsylvania is a 
leader in this area of addressing scope of practice issues.
    Let us focus now on the programs we have to increase access 
to care. HRSA's mission to improve health and achieve health 
equity through access to health services includes the 
administration of the Community Health Center Program, and the 
National Health Service Corps.
    With the community health centers, their mission is to 
provide primary care to vulnerable populations, including older 
citizens, no matter their ability to pay. Across the country, 
we have a network of over 1,100 healthcare centers. In fact, 
there are more than 20 HRSA-funded community health center 
service sites within 50 miles of where we are today.
    Community health centers are a vital source of healthcare 
for aging populations. In 2009, health centers served over 1 
million patients age 65 years and older.
    The Affordable Care Act provides $11 billion in funding 
over the next 5 years to increase support for community health 
centers. About $9.5 billion of that will increase services at 
existing sites, provide funds for new community health center 
sites, and fund plans to create more community health centers 
in underserved areas.
    With the National Health Service Corps, HRSA seeks to 
strengthen primary care by placing healthcare providers in 
communities where they are needed most. For example, the 
National Health Service Corps, through scholarship and loan 
repayment programs, help address specific shortage areas for 
medicine, dentistry, and mental health providers.
    In fact, there are currently 12 National Health Service 
Corps providers serving across northeastern Pennsylvania. 
Moreover, in recognition of the aging of the U.S. population, 
geriatricians were included recently as a physician category in 
the National Health Service Corps to help provide more of these 
essential services in underserved areas.
    The Affordable Care Act increases and extends funding for 
this corps. Through the loan repayment program, we now offer 
$145,000 over 5 years to repay student loans that treat 
uninsured and underinsured citizens. This is a substantial 
increase from what was available to students before.
    With the scholarship program, there is payment for tuition, 
fees, a living stipend to students enrolled in accredited 
programs for dentistry, nurse practitioners, nurse midwives, 
and physician assistants, as well as physicians.
    Let us now talk about the frontline worker and the needs 
that you just spoke about. Across the United States, there is 
growing concern about current and projected shortages of 
frontline workers, direct care workers such as nursing and home 
health assistants who provide the services for the elderly, 
chronically ill, and disabled. The number of older and disabled 
patients with very complex healthcare needs is outpacing the 
supply of workers trained to meet these needs.
    As a result, the need to train personal and home health 
aides is ever increasing. The Affordable Care Act addresses 
some of these challenges in training for frontline workers. Let 
me describe three new programs that we are administering.
    We have now, as a result of the Affordable Care Act, the 
Personal and Home Healthcare Aide State Training Program. This 
program is designed to address the challenges that you have 
just described. The Personal and Home Care Aide State Training 
Program aims to ensure the supply of competent personal and 
home health aides with acquired skills that would be 
transportable to any job market in the Nation, thus 
strengthening the direct care workforce.
    This program will support the development, evaluation, and 
demonstration of competency-based uniform curriculums to train 
qualified personal and home health aides. That program is now 
in the review process, and we will be making awards by the end 
of September.
    Another new program is the Nursing Assistant and Home 
Health Aide Program. This program establishes a new initiative 
to train nursing home aides and home health aides. It will 
support the development, demonstration, and evaluation of, 
again, competency-based uniform curriculum to train qualified 
assistants, strengthen the direct care workforce, making sure 
that they have the necessary skills that can be transportable 
and building blocks for moving up to other higher paying 
professions in healthcare.
    Awards and grants will be made to colleges and community-
based training programs for development, testing, and training 
of these programs and emphasize telehealth and new 
communication methodologies for training.
    Another program is the Patient Navigator Outreach and 
Chronic Disease Prevention Program. This program is 
reauthorized under the Affordable Care Act and expanded. This 
program supports individuals serving within communities to 
assist patients in overcoming barriers to receiving healthcare 
services.
    Patient navigators help patients coordinate healthcare 
services, determine whether clinical trials are right for them, 
conduct outreach to populations to make sure that they have 
access to the care they need.
    We have several geriatric programs, and I will be brief 
here in consideration of time available. In addition to 
supporting the frontline workers, the Affordable Care Act 
reauthorizes HRSA programs specifically focused on training the 
healthcare workers we need with the special skills in 
geriatrics.
    Moreover, it is important that we appreciate the fact that 
these training programs, as a result of the Affordable Care 
Act, are more focused than ever before on interdisciplinary 
training. We need to be able to work in teams. No one 
profession can do it alone. We are not only relying on 
physicians or nurses, but an array of health professionals that 
we will be needing.
    So one of our programs, the Comprehensive Geriatric 
Education Program, really targets nurses and nurses who will 
receive degrees in geriatric nursing, long-term care, 
geropsychiatric nursing, and other nursing areas that 
specialize in elderly populations. In 2009 in Pennsylvania, 
HRSA awarded these grants to the Community College of Allegheny 
County and the University of Pennsylvania.
    We also have a Geriatric Education Center Program. These 
programs provide interdisciplinary training for health 
professionals in assessment, chronic disease syndromes, care 
planning, emergency preparedness for elderly, and cultural 
competencies unique to caring for older Americans.
    The Affordable Care Act authorizes supplemental grants to 
these programs in geriatrics, chronic care management, long-
term care for faculty in a broad array of health professions 
schools, as well as training for frontline, direct care workers 
and family caregivers. The Affordable Care Act authorizes these 
short-term intensive courses to assist in these areas.
    Currently, in 2010, we have awarded grants to the 
University of Pennsylvania, University of Pittsburgh, and 
Thomas Jefferson University. Interestingly enough, Thomas 
Jefferson University provides these geriatric education 
programs through a consortium that includes Marywood University 
and The Commonwealth Medical College in Scranton, and The 
Commonwealth Medical College then expands these through three 
regional campuses in Scranton, here in Wilkes-Barre, and 
Williamsport. So a broad reach that I think is very innovative.
    We also have the geriatric training program for physicians, 
dentists, and behavioral and mental health professionals. This 
program supports geriatric training to train these 
professionals who will go into the geriatric specialties in 
their professions. We also have a Geriatric Career Award that 
provides career development for faculty who will be training in 
these programs.
    Another program that you have in this area is the Area 
Health Education Center Program. We fund the Area Health 
Education Center programs to really encourage the establishment 
and maintenance of community-based primary care training in 
off-campus rural and underserved areas. One goal is to educate 
and train students to become culturally competent primary care 
providers.
    The Pennsylvania Area Health Education Center has seven 
AHEC centers, including northeastern Pennsylvania center, which 
is located on the campus of Keystone College and serves a nine-
county regional area that includes Wilkes-Barre and Scranton. 
The northeast Pennsylvania center also offers programs to spark 
interest in science and preparing for health careers among 
students in the high school and lower grades and encourages 
students to enter the health professions careers.
    In this area, there are consortium that include East 
Stroudsburg University, Wilkes University, and the University 
of Scranton to provide these experiences for students still in 
their high school years. I can't stress enough that we really 
do need to encourage the pipeline to go into the health 
professions careers.
    Whether we like it or not, in medicine and nursing for 
sure, we have a huge cadre that are just at the cusp of 
retirement. So, as fast as we are bringing in the health 
professions on the front end, we are losing them to retirement 
on the other end.
    So, in conclusion, we are extremely proud of our programs, 
look forward to continuing to work with you, Mr. Chairman, to 
ensure the provision of quality care to all Americans and by 
ensuring the availability of highly competent, adequately 
prepared healthcare workers, especially workers who can care 
for our older citizens.
    Thank you very much. I am happy to answer any questions.
    [The prepared statement of Dr. Heinrich follows:]

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    Senator Casey. Doctor, thank you very much.
    I wanted to ask you a few questions that relate to 
northeastern Pennsylvania in particular. We have, fortunately, 
passed the Affordable Care Act. It took a lot of work to get 
that bill passed. I spent a substantial amount of time working 
on a lot of different parts of the bill.
    We are happy it passed. In fact, we are very happy it 
passed. But we know that if this were a five-chapter book, as 
hard as passage and enactment was, there are probably four 
chapters after that that are all going to be difficult. A lot 
of those chapters, a lot of the challenges are on 
implementation.
    We have an opportunity I think in northeastern Pennsylvania 
and throughout the Commonwealth to take advantage of parts of 
the bill that, frankly, not enough people have heard a great 
deal about, which is true of a lot of parts of the bill. I 
think there is a chance, as we begin to implement different 
parts of the Affordable Care Act, that people will have a 
better sense of what those provisions are all about.
    As it relates to the whole series of programs that you 
outlined, we have a lot of program names, a lot of acronyms, 
and fortunately, a lot of funding to be able to help move those 
programs forward, either new programs, new strategies, or 
existing programs that will be expanded or reauthorized.
    I guess one question a lot of people might have is if 
someone bumped into you walking out of here today and said I 
heard you passed this big healthcare bill, and I know here in 
northeastern Pennsylvania, we have got a number of healthcare 
challenges. One of them is this challenge of taking care of and 
providing quality care for older citizens. How would you rank 
or prioritize the programs within the legislation that would be 
most helpful in the near term?
    In addition to the programs, what Health and Human Services 
resources do you think could be made available for the people 
of northeastern Pennsylvania?
    Dr. Heinrich. It almost sounds like you are asking me to 
choose among my children. [Laughter.]
    The fact is that there are themes, I think, in the 
Affordable Care Act that are very important to this area, as 
well as the rest of the country. But it seems as though you may 
have a head start on some of these areas.
    So I think there is definitely the theme of expanding the 
primary care workforce. With the primary care workforce, we 
have to emphasize the fact that it is physicians, yes, but it 
is also nurses. It is also pharmacists. It is also physician 
assistants. They all play a critical role in providing primary 
care access, especially for older and a growing older 
population.
    Senator Casey. Can I just stop you there?
    Dr. Heinrich. Yes.
    Senator Casey. Just so we kind of go program by program. 
You stated in your testimony with the Prevention and Public 
Health Fund, and you spoke there about primary care workforce. 
The bullet points you have, it is $168 million for residency 
slots, $32 million for physician assistants training, money for 
nurse practitioners, innovative strategies, nurse-managed 
health clinics.
    What is the best way for individuals--well, let me say what 
is the best way for institutions in northeastern Pennsylvania 
to take advantage of the Prevention and Public Health Fund? Let 
me just start with that.
    Dr. Heinrich. OK. The Prevention and Public Health Fund 
was, in fact, a one-time--the $250 million was a one-time 
initiative that may be, in fact, repeated in the future, but we 
are not sure. It depends on the availability of funding. But I 
think that the message for the institutions in this area is 
that you have a new and developing medical school. You have 
nursing programs. I haven't heard about physician assistant 
programs.
    But there are, in fact, opportunities for different levels 
of training for healthcare providers. It sounds like the School 
of Nursing here at Wilkes is already taking advantage of a lot 
of the increasing, expanding programs in nursing. I would hope 
that they would continue to do so in the future. I learned, as 
I came in this morning, that, in fact, the new expanding 
medical school is also taking advantage of some of the ongoing 
programs.
    So the message is that primary care is interdisciplinary 
and that there are monies that are available for expanding the 
numbers, and we would hope to continue that in the future.
    Senator Casey. So for all those areas that I just talked 
about, this fund is a 5-year program, right?
    Dr. Heinrich. Right.
    Senator Casey. It will support 16,000 new primary care 
providers. So there are obviously opportunities.
    What is the best way to access these programs? In other 
words, how do you apply? What is the process?
    Dr. Heinrich. There is a Web site called www.grants.gov, 
and on that Web site, you will see all of the initiatives, all 
the competition for all of our grants. You can also go to HRSA, 
hrsa.gov, and look for grant opportunities, and they will be 
listed there as well.
    Senator Casey. Obviously, you mentioned before the impact 
that the community health centers will have. I don't think many 
people understand that we have had a very successful community 
health center program, strategy--I don't know how you want to 
define that. But it has been in place for years. In your 
testimony, you pointed to some of that history and the network 
of sites all around the country.
    But this community health center part of the healthcare 
bill is $11 billion more that will be provided over 5 years to 
support that. It is almost impossible to calculate, in my 
judgment, the positive healthcare benefits that will provide to 
the country. That community health center part of the 
healthcare bill could be its own bill, and it would be 
considered a substantial piece of healthcare legislation.
    So it is a part of the bill that I don't think people know 
much about yet, but it will be of tremendous help. As you said, 
you said there are more than 20 HRSA-funded community health 
center service delivery sites within 50 miles of Wilkes-Barre, 
as we sit here today. That is substantial.
    I wanted to also go to the part of your testimony on page 4 
and 5. You talked there about increasing the number of 
frontline direct care workers as a major priority.
    Dr. Heinrich. Right.
    Senator Casey. You talked about in particular I highlighted 
``older and disabled patients with very complex healthcare 
needs.'' Sometimes I think we forget that it is not just 
demographics, but the complexity of the healthcare needs is 
significant.
    Obviously, the rates of vacancy and staff turnover. We talk 
about that over and over again. I have always found that in a 
long-term care facility, when you walk in the door--and I know 
I am simplifying this a bit, but it tells you a lot. You walk 
in the door, one of the first questions you should ask is what 
is your turnover rate?
    Interestingly, in my experience, and I am not a 
professional, but in my experience you can have a very 
successful long-term care facility even though the turnover 
rates are pretty high--40, 50 percent. A lot of them have 90 
percent, right?
    Dr. Heinrich. I was going to say that would be good.
    Senator Casey. Much higher. I mean 40, 50 percent would 
be--it is hard to believe that that would be actually a good 
number compared to a lot of other sites.
    But in this category, I wanted to clarify something on page 
4. You have two sections here, two programs. Personal and Home 
Healthcare Aide State Training Program. That is No. 1 on that 
page. It is a $5 million program. No. 2, you have the Nursing 
Assistant and Home Health Aide Program. That is $2.5 million.
    What I wanted to know was, and get a better description of, 
the difference between home care aide, that part of the first 
program, and home health aide? I think people can get confused 
by the overlap in the terminology. What is the difference 
between those two?
    Dr. Heinrich. In fact, you have a number of terms that are 
used for people who are direct frontline workers, and it is one 
of the issues that we hope to address in our programs, as a 
matter of fact. So you have your personal assistant. You have 
home health aides. You have nursing assistants who work in 
nursing homes. Then you also have assistants who work in 
hospitals.
    Each of those areas have been looked at separately, and it 
seems to me very few people, very few organizations have looked 
across all of these siloed areas and said what are the basic 
competencies? Can you build those competencies as you move 
from, say, personal assistant, personal care assistant on 
through to maybe the more complex activities you would be 
expected to perform in a nursing home or even a hospital?
    What we would hope is that through our model curriculums, 
we could actually look at competency-based skills where an 
individual could build their skill base and progress forward, 
even to thinking about entry into new types of jobs, new jobs 
in the healthcare provider disciplines.
    Senator Casey. Both these programs are 2 years, 2010 to 
2012?
    Dr. Heinrich. Yes. Well, one is 3, I think.
    Senator Casey. OK. I also--I wanted to ask you as well. We 
have obviously the great opportunity, which is to say that it 
might be one of the few, if the only place in the country to be 
able to say this is accurate, and that is because we have a new 
medical school that is just getting off the ground.
    The medical school has their second class coming in. Is 
that right, Doctor? I don't mean to jump ahead to panel No. 2. 
I want to make sure we are right.
    As that school develops--and it is a tremendous 
opportunity, and that is an understatement--it just happens to 
be developing and growing as we are beginning to implement the 
healthcare bill. So it is a tremendous opportunity for lots of 
reasons.
    But what role can medical schools play in developing this 
workforce that we have spoken about this morning already? 
Especially when we have both a significant challenge, but also 
a tremendous opportunity here at the medical school but even 
nationwide the new strategies, the new programs that the 
healthcare bill provides?
    Dr. Heinrich. Right. Well, again, with the new focus on 
primary care and the new focus on interdisciplinary education, 
it seems to me that there are many opportunities, as a new 
school is developing curriculum and thinking about how they are 
going to meet the needs of the population in different ways, 
and it sounds like you are very fortunate that the leadership 
of the medical school is really moving in that direction.
    So for many of our medical schools, it is very difficult to 
fight tradition. So, here you are with the opportunity to think 
about how you train together medicine, pharmacy, nursing, and 
the area of mental health. I was just so excited to hear about 
the program in pharmacy and nursing that you have here where 
you already have training programs, basic science programs 
where people are leveraging your existing resources so that you 
are much more efficient in the training programs.
    Sad to say, though, that you still have issues with the 
preceptorship and the placement because you have to have the 
clinical training, and it sounds like that is still a challenge 
for many of these programs. So we have to find ways of 
addressing the barriers that we have there with our expanding 
student populations but still needing the excellent preceptors 
and the clinical sites for the training.
    Even when we expand physician clinical traning beyond the 
hospital walls, which is wonderful to hear is happening in this 
community, into home care, into skilled nursing care, you still 
need to have hospital clinical sites to have an excellent 
program. It sounds like that is the direction that people are 
going.
    Senator Casey. Well, we are fortunate to have these 
opportunities.
    Doctor, I know we are over time by a little bit, and I have 
a lot more questions. But what we will do is I and, I think, 
others will submit questions for the record. If you could 
answer those in writing, we are grateful. I wish we had more 
time to spend, but we have got two more panels.
    Dr. Heinrich. Thank you very much. Appreciate it.
    Senator Casey. Doctor, thank you for your testimony. We are 
grateful for your service. Especially at this time in our 
Nation's history, we are confronting a lot of difficult 
healthcare challenges. So thanks for your service.
    Dr. Heinrich. But it is fun doing all that implementation. 
Thank you very much.
    Senator Casey. Thank you.
    We will move to our second panel. What I will do by way of 
introduction, as our witnesses are moving to the witness table, 
I would, first of all, like to welcome, as I mentioned him 
before, Dr. Bob D'Alessandri, the Executive Officer and Chief 
Academic Officer of The Commonwealth Medical College, who is 
responsible for setting priorities, institutional direction, 
and management, and functioning of The Commonwealth Medical 
College, as well as the curriculum development and execution, 
the student experience, faculty recruitment, and the execution 
of the research agenda at the medical college.
    Dr. D'Alessandri is an educator with over 18 years of 
experience in senior leadership positions at West Virginia 
University, including almost 15 years as dean of the West 
Virginia University School of Medicine.
    Our other witness today on our second panel, Dr. Vera 
Salter, Professional Development Director of the Direct Care 
Alliance. Dr. Salter was the founding director of the National 
Clearinghouse on the Direct Care Workforce at PHI, where she 
worked from 2001 to 2007. Before that, she co-owned a national 
planning and marketing firm with clients across the continuum 
of health and long-term care services.
    She has served as vice president of a multi-institutional 
healthcare system and has held a number of health planning and 
research positions. Dr. Salter, thank you.
    Dr. D'Alessandri, thank you. I think we will start with Dr. 
D'Alessandri.

 STATEMENT OF ROBERT D'ALESSANDRI, M.D., EXECUTIVE OFFICER AND 
   CHIEF ACADEMIC OFFICER, THE COMMONWEALTH MEDICAL COLLEGE, 
                          SCRANTON, PA

    Dr. D'Alessandri. Thank you very much.
    Good morning, Senator Casey, Dr. Heinrich, staff, and 
honored guests. I am delighted to be here this morning to speak 
to you about our aging population and the need for more medical 
personnel to care for them.
    While we have all seen the statistics--the percentage of 
the population aging, the increased demand because of chronic 
diseases, the aging of the provider population--those 
challenges are different in rural and small-town America. We, 
as a Nation, need to come up with solutions that are not one-
size-fits-all because our needs and challenges are unique.
    I would like to take just a minute and introduce myself and 
my school to you because why we were created is specifically 
relevant to these interests. Wilkes-Barre, Scranton, 
Pennsylvania, northeast Pennsylvania has many small 
communities. Like many small communities in the United States, 
we suffer from a number of concerns.
    We have an aging population with many chronic diseases. In 
fact, Pennsylvania has the third-oldest population in America. 
Our physician population is also aging. In fact, almost half of 
the current physicians in this region will retire in the next 
decade. It is estimated that by 2025 this region will lack 
almost 1,500 needed physicians to care for our population.
    We have a very fragile healthcare system. Hospitals 
incapable of investing capital in infrastructure improvement.
    We have had a poor track record of recruiting physicians, 
both primary care and specialists, to the region. Almost half 
of Pennsylvania physicians practice either around Philadelphia 
or Pittsburgh despite the fact that only one-quarter of the 
population resides there. Not surprisingly, that is where 
Pennsylvania's medical schools have traditionally been located. 
Northeastern Pennsylvania suffers from a shortage of almost 
every type of physician and has fewer physicians per capita 
than national averages.
    We have over $1 billion in care. Yes, that is $1 billion 
leaving the region because people cannot get appointments with 
physicians or cannot get access to physicians for the type of 
care they need. This involves increased expense, hardship, and 
inconvenience for families and patients.
    We also have a region that has experienced tough economic 
times. The heyday of coal has been and gone. The economy here 
is not made up of major corporations. It is small companies, 
businesses trying to hang on. We don't have a lot of wealthy 
people to support healthcare, the arts, and community civic 
programs.
    As I said at the beginning, we have a scenario that is 
typical of most of America's small cities and towns--nothing 
remarkable, significant, or special, just people who work hard, 
who are trying to carve out good lives for their families and 
get their loved ones good, high-quality healthcare. What is 
unique about this community is how it decided to address the 
problem of physician aging, lack of access to care, and their 
relative lack of success in recruiting replacements for these 
aging physicians.
    This community came to the conclusion it needed to grow its 
own physicians and thus start its own medical school. The 
community had several goals for the school that included 
improving healthcare in northeast Pennsylvania by increasing 
the number of area specialists and primary care physicians; 
improving the quality of care in the region; improving access 
to care, especially in underserved and rural areas; generating 
economic impact by creating high-paying, sustainable jobs and 
attracting fresh dollars into the economy; increasing the 
education of the area residents; and providing the region with 
``intellectual capital.''
    I was hired in 2007 from West Virginia University to take 
these ideas and help create the school. In 3 years, we have 
obtained degree-granting authority from the State, received 
provisional accreditation from the LCME, the Liaison Committee 
on Medical Education, and the Middle States Higher Education 
Commission. We offer two degrees, a Master's in Biomedical 
Sciences and a Doctor of Medicine Degree.
    We have hired 160 full-time faculty and staff. We have over 
700 community-based physicians participating on a volunteer 
basis to train our M.D. students and have graduated our first 
class of Master's students. Next week, our second class of M.D. 
students--65 of them like the first class--begins.
    Our 40 Master's students began in July. Our second-year 
medical students begin in late August. It has been a very busy 
3 years.
    Now we are not a model that is easily replicable in 
America. Starting a freestanding medical school is not a model 
that is really economically feasible. We exist because Blue 
Cross of Northeastern Pennsylvania invested $25 million in 
funding our startup and another $45 million in our new 
building. Our State invested $35 million in our building, 
funded our feasibility study, and gives us an important, but 
modest grant every year.
    Thanks to Senators Casey and Specter and our congressional 
representatives, the Federal Government has supported TCMC, 
helping us with grants to fund our Clinical Skills and 
Simulation Center and other small projects. Ongoing funding is 
a challenge not only for us, but for the other dozen or so new 
startup schools across the country. But solving the problems of 
communities such as ours, the small towns and cities in 
America, and having enough doctors and other health providers 
to take care of our aging population is a complex issue.
    The solution starts, like many problems, with changing our 
educational process because we don't just need more doctors, we 
need doctors with different skills. We need to address the 
problem of fragmentation in the healthcare system by training 
physicians, nurses, pharmacists, physical therapists, and 
others to work as a team.
    As Dr. Heinrich mentioned, this is the interdisciplinary 
model. We need each of these individuals to understand not only 
their role, but others as well. We need to train physicians not 
just to lead, but how to work effectively as a team member.
    At TCMC, we have created the first Consortium of Health 
Professions Education Program with all the regional schools 
that have health education programs to develop opportunities 
for our students to learn to work as a member of an 
interdisciplinary team.
    We need physicians who can communicate effectively. 
Effective communication is essential for safe and effective 
care. This is one of the major complaints we hear from seniors. 
``My doctor doesn't listen to me.'' We need to develop these 
skills as rigorously as we teach molecular biology.
    We need physicians who know how to find information on 
state-of-the-art care and then incorporate it into their 
practice. One of our faculty told our students recently that he 
is not doing one procedure the same way he learned in medical 
school or his residency. What we teach today has a very short 
shelf life. We need to develop their interest in being lifelong 
learners and their skills at finding the information on care 
that they need, when they need it.
    We need physicians who understand the process of care 
improvement, how systems of care work and how to improve 
quality and safety as members of the healthcare team. Concepts 
like 6 Sigma and other quality improvement strategies and 
processes need to be learned by students, and they need to see 
they play a role in care and process improvement so care is 
both effective and cost efficient. Students need to understand 
critical thinking and systems thinking.
    We need physicians who understand when care should be 
standardized and when patients need proven therapies modified 
for their particular issues. Standardization of care flies in 
the face of how many schools select and train physicians. They 
are selected because they are independent thinkers, not because 
they can follow a formula. But data shows that, in many cases, 
standardization improves care and improves costs. We need 
physicians to know when each is important.
    Physicians need to be trained in cultures that are 
collaborative, transparent, outcomes focused, accountable, team 
based, patient focused, and service oriented. They need to see 
this culture modeled not only at their medical school, but in 
their community sites where they train.
    To do that will take a culture change in many of our 
healthcare organizations. They need to see models of care that 
work, first and foremost, for the patient, but also for the 
care team. They need to see innovative, cost-effective models, 
and we need a system that supports the development of these 
models, another place the Federal Government could provide 
support perhaps.
    Physicians must understand the critical issues facing our 
seniors--polypharmacy, end-of-life issues, depression, 
dementia, and the need to feel that you can still contribute in 
some way. Each of our students is assigned to a multi-
generational family. The student follows this family for 4 
years, makes house visits, hears from family members about how 
they have to make choices between medicine and food.
    I have to tell you that I have learned a great deal from my 
mother, who is 92. She keeps teaching me all the time. In 
recent years, she continues to get her Medicaid bills when she 
sees a physician, and frequently, she hands me the bill and 
tells me, ``Pay this.'' I look at it and say, ``Mom, this is 
not a bill. I don't have to pay this.''
    She said, ``No, no, pay it.'' I say, ``No. I'm not paying. 
It's not a bill.'' A month later, she receives another bill, 
and she says, ``Pay it.'' I say, ``It says, Mom, this is not a 
bill.''
    The next month, of course, she gets a letter from the 
collection agency saying that she is late. So I pay the bill. 
Then 6 months later, she gets a check from the provider saying 
you have overpaid. She says to me, ``Don't you know what you 
are doing?'' I said, ``No, I really don't.''
    This is a complicated system, and seniors face this all the 
time. We would like our students to hear that from the families 
that they follow. We would like them to actually see what 
healthcare is all about in the home, not just in the clinic.
    So the very first part of this program is that the student 
visits the family in the home, and one of the first things we 
ask them to do is look in the medicine cabinet because that is 
where you will find an entire history of healthcare. It is a 
very important part of the educational experience, and to my 
knowledge, this may be unique in the education of medical 
students.
    We also want our students to follow healthcare providers, 
not just physicians, but many of the direct providers that we 
are talking about. Experiences in nursing homes and in other 
facilities where care is provided, that is part of our new 
curriculum.
    Our country needs a cadre of physicians specialized in the 
problems of our seniors. To that end, we are also planning a 
special training program in geriatrics. These specialists 
become resources for primary care physicians as well as 
seniors. Part of that program is not merely learning about the 
diseases and the illnesses that relate to seniors, but it is 
also learning about the social problems and also the health 
policy issues.
    We want these geriatricians of the future to relate not 
only to the diseases and illnesses that affect our seniors, but 
also the economic and social problems as well. We want them to 
become leaders in policy changes as well. This is an important 
new aspect of geriatric training.
    We need to view medical education as a continuum of 
competency. We need an educational program that is cost 
effective and allows students to move through it not in 
lockstep, but as they develop competencies that build through 
the educational process. We are in some danger of pricing the 
cost of medical education out of the marketplace.
    Finally, we need to connect the education of physicians to 
their community and to service. We need to select bright 
students who want to serve, who want to make healthcare better, 
stronger, more effective--who want to care not only for the 
individual but improve the care in their community. We need to 
prepare physicians in their educational program to do that.
    I would recommend to the Committee three excellent 
resources--the new Carnegie Foundation Report, entitled 
``Educating Physicians: A Call for Reform of Medical School and 
Residency,'' the Josiah Macy Foundation's reports on medical 
education and the new medical schools, and a wonderful book by 
Boston physician Atul Gawande, entitled ``The Checklist 
Manifesto,'' that addresses how healthcare can be safer and the 
importance of team communication. All these resources discuss 
what physicians need to know to care more effectively for 
patients.
    At TCMC, we are addressing many of these issues and 
recommendations. Our curriculum was easy to adjust to current 
needs since we could start from a clean slate and attracted 
faculty who want to teach state-of-the-art curriculum.
    Our model also has a community benefit. Since most of our 
faculty are community practitioners, they learn state-of-the-
art care and thinking in their faculty development courses. 
Changing the way they deliver care will change over time the 
quality of care in our communities. Our educational model is 
deeply rooted in our goals and our reason for being. Our 
students are assigned a multi-generational family that they 
follow for 4 years. I mentioned that.
    They are exposed to an integrated curriculum from the very 
beginning where science and patient care are constantly tied 
together to create relevance. They are deeply embedded in our 
region's communities. In the first 2 years, they have a 
clinical mentor, they do community research projects, and they 
learn about quality and safety processes all in a community-
based setting.
    In their third and fourth years, they actually live in 
those communities and learn directly from over 700 volunteer 
clinical faculty who have been specially trained to teach 
students community-based medicine. Our students learn how to 
work in teams in our Clinical Skills and Simulation Center and 
develop their professionalism and community service skills as 
part of the educational process.
    It is good public policy for the Federal Government to 
support new schools--to support new models of education, 
innovative models that seek to educate the students 
differently. The answer to our problems is not just to have 
more resources to train more doctors. We need to provide new 
models of medical education that lead and support new, 
effective models of care.
    We need to support educational innovation and the programs 
that are trying to do that and educational programs that are 
trying to change community-based care. We need to give our 
students the tools that they are going to use to take care of 
us and our children and grandchildren.
    Then we need to invest in our hospitals and clinics who are 
barely hanging on. We need to make it possible for them to 
innovate and support quality improvement. If we are going to 
keep these newly trained physicians in this community, the 
places they practice must support the way they have been taught 
to practice.
    Our hospitals and clinics need infrastructure, information 
technology, training in systems thinking, quality improvement, 
improved communication. They must be examples of innovation, 
not just places that are themselves on life support.
    Then our small cities and towns will be able to care for 
our aging population. Our students who train in these 
communities will want to stay and raise their families in these 
communities. The answer is not just more money. It is money we 
spend differently to creatively meet the needs of an aging 
America in an effective and sensitive manner.
    The medical schools in this country committed to innovation 
and reengineering the educational and care delivery models 
deserve your consideration and support. The new medical schools 
can be a community-based catalyst for change, creating a 
national model that will enhance the efficiency and 
effectiveness of healthcare that is available to all Americans 
of every age.
    Our aging population must have access to the latest, most 
effective treatments, to providers who are sensitive and 
knowledgeable about their special needs, and we will be able to 
provide the kind of healthcare that works for everyone.
    Thank you very much.
    [The prepared statement of Dr. D'Alessandri follows:]

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    Senator Casey. Thank you, Dean. Thank you, Dean, for that 
testimony.
    Dr. Salter, thank you.

   STATEMENT OF VERA SALTER, PH.D., PROFESSIONAL DEVELOPMENT 
        DIRECTOR, THE DIRECT CARE ALLIANCE, NEW YORK, NY

    Dr. Salter. Thank you, Senator Casey.
    I want to start by thanking you for your announcement that 
you are going to introduce the Direct Care Worker Empowerment 
Act tomorrow. That is very exciting news for us, and I think 
the very title is critical because what is so important is to 
recognize that there will soon be 4 million direct care workers 
working daily, one on one, with elders and people with 
disabilities.
    It is only if direct care workers have the resources and 
are empowered to take the actions that are needed to improve 
the quality of life for those they are working with, that is 
the way we are going to get quality care. I work with Direct 
Care Alliance, and I am proud to work for an organization that 
is the advocacy voice for direct care workers throughout the 
country.
    I won't go through the statistics again of the greatly 
increasing aging population, but I think one theme I have heard 
from many of the panelists is that as the population ages, the 
cohorts of people that are available to do the work to care for 
them is shrinking.
    Senator Casey. You might want to move that mike a little 
closer.
    Dr. Salter. Saying that there is a gap between the care 
needs and the number of people who will be available to do that 
work, whether they are family caregivers or paid caregivers 
because you were talking of the physicians aging out of the 
profession and this is aging out of the profession. So the 
crisis becomes amplified by that care gap.
    I want to add that in 2008, there were 3.2 million nursing 
assistants, home health aides, and personal assistants in the 
United States. That number is projected to increase to 4.3 
million by as early as 2018. I would like to also comment on 
the question you asked about the difference between home care 
aides and personal assistants and home health aides.
    In some ways, if you think of an elder or a person with 
disabilities that needs care in their home for a long period of 
time, the complexity of the work that a personal assistant has 
to provide may be greater than a home health aide, who is 
defined as someone who is working for a home care agency under 
the Medicare program.
    So, in some ways, the definitions of workers are created by 
the funding stream and not by the competencies that are 
required to do the work. That is why I think it is so important 
that the training and the compensation be based on 
competencies, as many of you have already said.
    So who are direct care workers? There are 165,000 direct 
care workers employed in Pennsylvania, and these are among the 
largest and fastest-growing occupations in the Commonwealth, 
projected to increase by 50 percent in the next 10 years. Most 
direct care workers receive low wages--on average, $10 an 
hour--little or no benefits, and insufficient training and 
professional development.
    As a result, as we have said already, this profession is 
plagued by high turnover rates that compromise the quality of 
care of the people they serve. If we are to retain direct care 
workers in this profession and make it an occupation that 
people want to enter, we will need to provide basic labor 
protections as are provided in the bill that you are 
introducing, livable wages and benefits, training and 
opportunities for advancement.
    I was asked to address the issues of what is needed in 
terms of training, certification, and advancement to make 
direct care a desirable profession. First, I want to stress 
that all direct care workers should be required to receive 
adequate training.
    Currently, Federal regulations require only 75 hours of 
training for nursing assistants and home health aides, and 
there are no Federal requirements for personal care assistants 
who provide services under the Medicaid program or to private 
individuals. We recommend, in line with a recent Institute of 
Medicine report, that all direct care workers receive at least 
120 hours of training, either before they start work or while 
they are working on the job.
    We also think it is very important that direct care workers 
have competency-based credentialing and recognition of their 
professional competency. The Direct Care Alliance has just 
established a National Professional Credential for personal 
assistance workers, the group that is not currently federally 
regulated. We also recommend that specialty credentials in such 
areas as dementia, peer mentoring, wound care, diabetes 
management, and many other areas be available to direct care 
workers.
    I would love to see more recognition of the role of direct 
care workers in the care team because while they are the people 
who are spending all day with an elder in their home, they are 
often not included as part of the medical team.
    One of the things that struck me as we look at the 
competencies of this workforce, this is difficult work. The 
same issues of communication, knowledge of a variety of medical 
background are critical for people to do their work well. Yet, 
as you know, under the Fair Labor Standards Act, they have 
been--home care workers have been categorized as ``companions'' 
and not as professionals that are a necessary part of the team.
    One of the most critical things is respect and 
opportunities for advancement. There have been numerous 
evaluative studies of what it takes to retain direct care 
workers, and it is really in some ways blazingly obvious. But I 
just want to tell you about some of those studies.
    There was a program funded through the Robert Wood Johnson 
Foundation called the Better Jobs, Better Care program, and 
there was a special edition of the Geriatric Journal that gave 
the results of some of those studies, and the message gets 
repeated. For example, a study in Massachusetts found that 
nursing assistants were more committed to their jobs when they 
perceive their jobs as having more autonomy, use of knowledge, 
and teamwork.
    In another study at Cornell, a retention specialist program 
demonstrated that assigning a manager with expertise in all of 
the techniques of retaining people improved retention when 
compared to facilities without such a program. The WIN A STEP 
UP program in North Carolina provides continuing education and 
compensation for education modules, also had great success.
    There are numerous career ladder programs throughout the 
country, and at Genesis Healthcare, headquartered in Kennett 
Square, PA, they have had a geriatric nursing assistant 
specialist program for 21 years that trains and compensates 
nursing assistants for their advanced knowledge.
    There have been many studies of what direct care workers 
are looking for, and in one study conducted by Dr. Peter 
Kemper, a professor at Penn State, he summarized what is 
important to direct care workers. What they want is more pay, 
better work relationships, being appreciated, listened to, and 
treated with respect, which is basically what we all want in 
our work.
    Unfortunately, recognition of these issues and efforts to 
create the right work environment is limited and sporadic. What 
is needed is a broad public policy that changes the way direct 
care work is managed and compensated so this becomes a 
respected profession that people want to enter.
    [The prepared statement of Dr. Salter follows:]

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    Senator Casey. Well, Doctor, thank you very much.
    I want to thank both of our witnesses for your testimony. I 
just had a couple of questions, and in light of our time, 
probably just maybe about 5 minutes of questions.
    First of all, Dr. D'Alessandri, I wanted to ask a basic 
question about--kind of a ``where we are'' question. I know the 
medical school is up and running. You have got your second 
class coming in. But can you give us a little update on the 
construction, kind of where that is.
    Dr. D'Alessandri. Construction is proceeding very nicely. 
We will be occupying the building by April 11, 2011, in plenty 
of time to accept our third class. At that time, the class will 
increase in size to 100 and eventually 120 students per year. 
So we are right on target for that and feel very, very good 
about that.
    Senator Casey. This incoming class is?
    Dr. D'Alessandri. Sixty-five.
    Senator Casey. Last year's was 65?
    Dr. D'Alessandri. That is correct. We are currently at 
Lackawanna College, utilizing their temporary space there, and 
that is really the limit that we could manage at the present 
time.
    Senator Casey. You mentioned the students working with a 
multi-generational family. We don't hear enough about those 
kinds of approaches, and I wanted to have you expand on that 
and why you think that is so critically important to expose a 
young medical student to that kind of experience?
    Dr. D'Alessandri. Right. It really is a very important 
concept. Our students are relatively young. Not relatively, 
they are young. Most of them, if not all of them, have very 
little experience with the healthcare system. Their parents are 
young.
    By the time they become familiar with the healthcare system 
from a patient perspective, they are physicians and treated 
differently. Physicians don't really understand healthcare from 
the patient perspective, and we see the patient in the clinic, 
in the office, and patients just won't tell you things.
    So the young mom who takes her two children, waits in the 
waiting room for 2 hours, then sees the doctor in a skimpy 
gown, waits there for 20 minutes, and her doctor walks in and 
looks at her and wonders why her kids are running around and 
she can't take care of them. That young lady will never say a 
word to the doctor about all of that.
    But she will go home, complain about that. Our students, we 
hope, will hear that and will learn about the problems about 
the healthcare system from the patient's perspective. It isn't 
learning about medical knowledge. It is really learning about 
the social-economic impact that this has on a family and on 
their health, and that is really why we think this is so 
critical.
    It will also bond those students to those families, and we 
hope those families will also play a role in recruiting those 
students and keeping them in our community.
    Senator Casey. I also want to note for the record that in 
Dr. D'Alessandri's testimony, starting on page 3 and going 
through most of page 5, when he walked through those various 
points about working effectively as a team member, helping 
physicians to communicate better, finding information on state-
of-the-art care, how a system of care works, standardization of 
care, collaborative and transparent outcomes-focused, 
accountable team-based focused strategies, critical issues 
facing seniors--when he went through that whole list, he starts 
with the word on page 3, ``solutions,'' which we want to hear 
about.
    We know that sometimes, especially in Washington, we can be 
very good at diagnosing problems and challenges and not often 
enough outlining solutions and then pushing forth ways to 
implement those solutions. So we are grateful for that kind of 
roadmap or list of solutions that we can all work on together.
    Dr. Salter, I wanted to ask you about--and a lot of your 
testimony is very consistent with my own unprofessional 
observations, but I think significant experience as a public 
official. I am not sure there is any public official in the 
State over the last decade or so who has spent as much time on 
some of these issues as they relate to direct care workers and 
older citizens as I have. I still don't consider myself an 
expert, but I learned a lot along the way.
    Your testimony was very consistent with experiences I have 
had, as both a public official and as a member of the family. 
As Dr. D'Alessandri and others have noted, we learn a lot more 
about healthcare and the work and the policy as members of the 
family than we do sometimes in our professional lives.
    But one observation, one insight that you and others have 
had is that the direct care worker wants to be seen as a 
professional, wants to be valued more, and sometimes one of the 
ways to get there is to develop what people in the industry 
have said not a career ladder necessarily--it could be that, I 
guess--but a career kind of lattice. In other words, they can 
move almost laterally or--can you explain that, what your sense 
of that is?
    Dr. Salter. Well, we have found that when somebody enters 
an occupation, at the beginning they are learning the basics of 
doing it. But when you have spent 10, 20 years in the 
occupation, you have learned a lot of skill. There can be lots 
of ways to recognize people's advanced knowledge so that people 
can have specialty training in geriatrics, in dementia, in 
diabetes management, and be compensated for it so that people 
are moving up a ladder, as it were, within the direct care 
profession.
    There are also some people that do want to take that 
learning and move on to LPN or RN programs, but we have found 
that that is a minority. Many people who do this work do it 
because they love the work but find it impossible to stay in 
the occupation because it is so poorly compensated and 
regarded. So I think there are a lot of different pathways for 
different people, which is why the word ``lattice'' has been 
introduced.
    There has also been a lot of success with peer mentoring 
programs because one of the biggest turnover times is in the 
first 6 months of the work. People enter the work in the 
nursing home, for example, and leave within 6 months. Whereas 
if there is a senior aide who has already done this work who is 
assigned to support them, they are much more likely to stay. 
Again, that peer mentoring role can be trained and supported 
with compensation.
    So I think there are opportunities for people to move ahead 
in the profession and also to work in more supervisory ways 
because there is a shortage of RNs and a shortage of people to 
take on some of the management functions because a lot of self-
scheduling where people are allowed to schedule their own work 
that can be organized. So, there are many ways that people can 
be empowered more and compensated for their knowledge and their 
advanced work.
    Senator Casey. Well, I can't tell you how many times over 
the last it is now 15 years since I have been a public official 
that people have told me that are experts in long-term care 
that run nursing homes about a whole myriad of problems. It 
would be complicated enough if this were just a worker, direct 
worker, direct care worker problem, but this is a big employer 
problem.
    Dr. Salter. Right.
    Senator Casey. We haven't gotten our public policy right to 
the extent that you have a nursing home might train over the 
course of a year or more, or maybe more than a year, they might 
train 10 people and retain 1.
    Dr. Salter. Yes.
    Senator Casey. So they spend all that time, all those 
dollars training someone who leaves within months. So it is 
obviously bad for the worker, bad for the employer in a 
significant way, and bad for the person in that bed who is 
dealing with Mary or John for a couple of months, maybe longer, 
and then they have a turnover and then another turnover, 
another turnover.
    So the family is confused. The person who is the recipient 
of that care is not getting the quality of care they should 
get. The employer is out money, and the worker is bouncing 
around to different jobs. So we need to get it right, and there 
is a lot more to do to get it right.
    I did want to ask Dr. D'Alessandri one more question. Just 
about the--you did mention the training program in geriatrics. 
Can you talk about that for a moment just a little more?
    Dr. D'Alessandri. Sure. Also, I wanted to mention just a 
couple of things that relate to that, if I might?
    Senator Casey. Yes.
    Dr. D'Alessandri. One is that we think pipeline programs 
are really critical, and I know that Dr. Heinrich mentioned 
that. We are actually involved in and have applied for an HCOP 
program and have been working with Wilkes and LCCC, Luzerne 
County Community College, in developing those pipeline 
programs.
    So we think that has a real important aspect in terms of 
training workforce in healthcare for this region and really 
focusing on rural, first-generation, underserved minorities. So 
that is a really strong program for us.
    The second is that in residency programs--and I really 
applaud the effort that HRSA is making in increasing residency 
slots primary care. But very often, primary care residency 
slots go unfilled. Where the dollars would be better spent or 
at least equally well spent, let me put it that way, would be 
really encouraging medical schools to increase primary care 
training among their students and giving incentives for medical 
schools to really educate primary care physicians.
    The geriatric program is a very important one. Ninety-five 
percent of the care, primary care for seniors is really going 
to be with primary care providers, not with geriatricians. We 
see geriatricians as being a resource for the primary care 
provider, as well as the patient and for other agencies that 
work with seniors. We see the geriatrician as the advocate in 
terms of public policy for the senior from the healthcare 
perspective.
    So, with that in mind, the training program involves not 
only the usual aspects of medical education, disease, and that 
sort of thing for the geriatrician, but it also involves an 
intense knowledge of the social agencies and other agencies 
that relate to seniors----
    Senator Casey. To be an advocate.
    Dr. D'Alessandri. To be an advocate. An understanding from 
the senior's perspective of how they may utilize and work with 
those. I was intrigued by the navigator concept that Dr. 
Heinrich talked about. In some ways, the geriatrician is also a 
navigator, helping the senior through the system, and maybe 
even helping the primary care provider through the system.
    So we think that the traditional model teaching knowledge-
based content, skills, all of that is very important, but also 
the other aspect of this, health policy and also understanding 
dynamics within the community, are really important.
    For example, transportation is a huge problem in our area 
for not only seniors, but for everyone. Getting to an 
appointment, relying on family, those kind of things. Helping 
work through those problems with seniors, we see the 
geriatrician as being a very important part of that.
    Senator Casey. Well, Doctor, thank you so much. Dr. 
D'Alessandri, Dr. Salter, I know we have more questions, but 
not enough time. But we will send questions for the record that 
will be additional to amplify your testimony. We are grateful 
for your time here today. Thank you very much.
    Dr. D'Alessandri. Thank you, Senator. Thank you.
    Senator Casey. We will move to our third panel. As our 
panelists are getting to their seats and we are transitioning 
to our third and final panel, we will be pleased to welcome 
Melissa Lear and Connie Kreider.
    Melissa is President of Beck N'Call Home Health and 
President of Allen Lear Home Health. In these positions, she 
has focused on providing in-home assistance to older citizens 
in the indigent, serving people whose activities of daily 
living are not covered under Medicare, Medicaid, or other 
insurance programs.
    Ms. Kreider is a Certified Nurse's Assistant and since 1998 
has worked at Luthercare, an assisted living facility in our 
Commonwealth. She is also the co-chair of the Pennsylvania 
Direct Care Workers Association.
    So, Ms. Lear, we will start with you.

     STATEMENT OF MELISSA LEAR, PRESIDENT, BECK N'CALL AND 
 PRESIDENT, ALLEN LEAR HOME CARE ASSOCIATES, EAST STROUDSBURG, 
                               PA

    Mr. Lear. OK. Good morning and--I guess almost afternoon 
now. I can't thank you enough for letting me come here and do 
this.
    Senator Casey. Let me interrupt for one second. I know your 
printed testimony is longer than 5 minutes.
    Mr. Lear. I am going to make this amazing for you.
    Senator Casey. Summarize as best you can.
    Mr. Lear. The fact of the matter is that I am one of the 
faces of home care. I am not only the CEO, I am a registered 
nurse. As the CEO of two companies, I still see patients on a 
regular basis.
    I could talk about home care from now until years after I 
am dead and gone. I think that the reason that it is important 
for me to be here today is to let you know that recruitment has 
always been a problem in home health for both aide--direct care 
workers, home health aides and nurses. But my agencies have 
been successful over the years by making the rewards and 
benefits of working in home care a primary focus.
    I don't believe that the financial rewards of doing this 
kind of work are ever going to match the personal satisfaction 
that the people who do it get. So a few of the real important 
factors of working in home care is our one-to-one patient 
relationships. I graduated with a bunch of nurses who work in 
hospitals. They see 10, 12, 14 patients a shift. I see one at a 
time. They have my undivided attention for the amount of time 
that I am there, and I am there however long I need to stay to 
get done what I am there to do.
    If you would imagine for a moment sitting in the kitchen 
with Miss Vivian in her late 90's, and she cries and speaks 
softly to you about how cruel it is for her to continue living. 
She has lost most of her sight. She has outlived all of her 
friends, and her family lives too far away to help. She knows 
and you know that without home care she would be placed in a 
nursing facility, being forced to leave her home.
    Imagine working with Miss Margaret, performing wound care 
on a dressing and listening as she tells the story of how her 
husband built the home she still lives in with her son. She 
reminds you that your agency took care of her husband also, and 
it has been a few years since he passed away.
    She lets you know that what she wants most for her 100th 
birthday, which is right around the corner, is a record number 
of birthday cards. So you head back to the office. You spread 
the word. All the employees that can get a card in the mail to 
her do so. Miss Margaret got an unbelievable number of cards, a 
spot on the local news, huge bouquets of flowers, and one more 
birthday before she passed away at 101 years of age.
    In total, your agency provided almost 9 years of care to 
Mr. and Mrs., but they rarely required more than 3 or 4 hours 
per day because their son, in his 80's, bridged the gap between 
our services.
    The only difference between you and I is that I don't have 
to imagine these stories. These are not the stories of my 
employees or employees of other agencies. For me, they are real 
events, and they belong to me.
    Benefits to working in home care include flexible schedules 
that work for patients as well as staff. It is a process of 
care that I have kind of coined the phrase ``wholistic,'' 
meaning W-H-O-L-E, because we solve care management problems 
that stem across the entire family dynamics. We find many 
problems in home care that we can fix that we have talked about 
earlier today that physicians don't know about, hospital 
discharge planners don't know about, clinics don't know about 
because families are either too embarrassed to share it or 
don't believe that anyone has the solution.
    I can offer to you that the first single-biggest impact you 
can make in the future recruitment of individuals is to 
encourage and support a growing influx of available nurses, 
home health aides, and caregivers, and that would be to show 
firsthand potential pool of individuals the impact that they 
can make on another person's life.
    What makes a young man or woman at the age of 18 enlist in 
the military is not a paycheck. It is a deep-seated love for 
their country and the freedom that being part of this country 
brings them. It is the need to be part of something bigger than 
is just themselves. It is a lifestyle that is presented to them 
when they are very young.
    This is what we need to do for the home care agency. I was 
not a nurse since a long, long time ago when I was 18. I quit 
college three times before I finally finished. I didn't finish 
in nursing. I have a Bachelor's degree in computer information 
systems. I have a Master's in business. I didn't graduate from 
nursing school until I was in my late 30's, when I went back 
and decided this is what I wanted to do.
    I spent 2\1/2\ years working full time while I attended 
classes and did clinical rotations. During my 2 years of 
clinical care work, I spent weeks in nursing homes learning to 
apply what I had learned. I moved to a hospital clinical 
rotation. I spent three semesters, did clinical rotations in 
four or five different hospital settings. I spent one day in 
home care and hospice. That was not enough to change my life.
    I already knew home care. I already loved home care. That 
is what keeps me in home care today. Most people that I meet 
still have no idea what a home care nurse is, what a home care 
aide is. They don't understand what we do or the impact that we 
make. My very small agencies employ 75 people, and we see 
approximately 200 patients a day. We make a huge difference in 
the community that we serve.
    Picking through to see what I really want to add. I think 
that home care also has a very serious place in chronic care 
management, and I would hope that as different issues of the 
healthcare reform come through that home care is not left off 
the table. We are a very important resource to kind of spread 
that physician avenue for patients out geographically.
    I know that there are a lot of initiatives under the 
healthcare reform legislation that focus on chronic care 
management, and I would like to let everybody know that home 
care would certainly love to partner in many of these endeavors 
in reaching out to people from telehealth right on up through 
any other demonstration projects that are going on. We 
certainly would be appreciative to be present at the table when 
those are put forth.
    The only other thing I can share is that we serve a large 
number of populations who are squeezed between Medicaid and 
Medicare. When you cross over, just over the Medicaid border of 
financial eligibility is a population of individuals who are 
making hardcore choices between taking their meds every other 
day, between doing their lab work as regularly as they should 
because they can't afford to have someone come into their home 
and do it. Medicare doesn't cover it in many, many cases for 
them, and they don't have the ability to get out to a physician 
or a lab to do this kind of testing.
    The example would be like a Coumadin patient, someone who 
takes blood thinners, requires frequent blood monitoring. Right 
now, you can have a Medicaid patient who gets that service 
covered for them. They could be monitored every 2 weeks like a 
physician would order.
    Somebody who just misses those financial eligibility 
guidelines is negotiating with their physicians, trying to 
stretch that time period out because they don't have the 
resources available or the means to get that kind of medical 
care as regularly as they should.
    The one final note I will toss in is if there is an 
opportunity at some point in the near future to allow 
Pennsylvania physician assistants and nurse practitioners to 
order and write home care services, that would be a huge help 
for us. We work with a lot of nurse practitioners who right now 
are not permitted to sign our home care orders, and it slows 
down a patient's availability of services.
    [The prepared statement of Ms. Lear follows:]

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    Senator Casey. Thanks very much. You did a good job staying 
within the time, and I know, as I said before, your whole 
testimony will be part of the record.
    Connie? Thank you very much.

 STATEMENT OF CONNIE KREIDER, DIRECT CARE WORKER, COLUMBIA, PA

    Ms. Kreider. Hi. Good morning. What an honor it is to be 
here today, and I would like to thank everybody for the 
opportunity.
    I am a direct care worker. I have been in the field for 
roughly 13 years, and my background started in retail, which I 
intended to stay in. But with the overwhelming amount of stress 
and long hours and managing a family, a husband, and family's 
multiple schedules, it got to be harder and harder to stay in 
that field.
    So I decided to look for a career change. Someone I had run 
into had said I should try to get into the nursing field 
because, of course, that is the cutting edge of the future, of 
a growing future. So I went down to the area nursing home, 
which I had never actually entered a nursing home before. So 
this was my first time ever.
    This turned out to be a very rewarding and blessing area 
for me. I believe that people want to provide a positive way of 
life for the elderly. I believe that people want to actually 
give back. It is almost like a sense of giving to others.
    I really am a firm believer of doing unto others as you 
would have them do unto you--the Golden Rule. Treat someone 
with love and respect, and they will treat you back with love 
and respect. If you work in this mindset, everything else 
really falls into place.
    It is really sad that the Federal Government--Federal law 
only requires 75 hours of training in this field when, really, 
that is not near enough. You really need to have additional 
communication skills, compassion training, and good customer 
service, also with multitasking with several things going on at 
the same time.
    On a daily basis, you may have anywhere between 8 to 12 to 
sometimes more residents. The high turnover for nurses aides in 
the first year is roughly 60 percent and in the second year is 
roughly 80 percent. They are not nearly prepared for the 
physical work, the emotional demands, and the stress that comes 
with this line of work.
    So when there is this high turnover rate, who really 
suffers? Well, we all suffer. The residents are very upset that 
someone new has just come in to take care of them. The quality 
of care that is provided to the elderly and to people with 
disabilities is so important that change is very difficult on 
them and also difficult for the family members who have also 
formed a close relationship with the caregivers.
    They form a close relationship with their caregivers and 
become emotionally attached with them. We become a part of 
their lives, and so many caregivers are often thought of as an 
extended member of the family. We are the eyes and the ears of 
the many different places we choose to work from. It takes a 
qualified, adequate, positive caregiver to stay focused on the 
issues. It requires a large amount of teamwork and 
communication and also a great sense of humor to pull this work 
off.
    Direct care workers are roughly 90 percent female, and many 
work more than one job in order to support their families. Many 
do not have adequate healthcare, or if they do, it is so high 
in the cost of things that they really can't afford it. Many 
are great providers of others, but they lack the ability to 
provide for themselves. I can't stress that enough.
    Stress takes a toll of your mind, body, and spirit. It can 
consume you and leave you feeling burned out. This is also seen 
across the board as ``compassion fatigue.'' So who takes care 
of the caregiver? We need to be kind to each other, have a 
peaceful work environment, work as a team.
    I am a member of the Pennsylvania Direct Care Workers 
Association, and we promote compassion and quality care for 
people living with disabilities and the elderly, the 
chronically ill, and the terminally ill. The association 
strengthens the quality of professional personal care for all 
Pennsylvanians by providing education, advocacy, and support 
for the direct care worker profession.
    I am also very proud to be a supportive member of the 
Direct Care Workers Alliance. Vera had talked earlier. The DCA 
provides direct care workers with advocacy and leadership 
training. They support all direct care workers in assisting in 
the development of associations and coalitions with technical 
support and leadership training. They also work toward 
improving the direct care workforce and support initiatives 
like the Direct Care Workforce Empowerment Act.
    So what does this mean for all direct care worker? It means 
a better workplace and a better way of life. We are not alone. 
There are many of you who want to stay connected. We want to 
learn to give of ourselves. We learn to give to ourselves and 
celebrate our successes, love where we work, and work where we 
love.
    So what is a good direct care worker worth these days? 
Anybody have a clue? Just ask your one and only best friend in 
the world, one of your residents, and they will say that you 
are absolutely priceless.
    [The prepared statement of Ms. Kreider follows:]

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    Senator Casey. Connie, thanks so much.
    I was struck by your testimony in a number of ways. One is 
just the language that you used to describe your work and the 
work of so many direct care workers across our Commonwealth and 
across the country. Words like you said at one point earlier in 
your testimony--I am not sure this is part of your prepared 
testimony. You said ``the sense of giving to others. People 
want to provide a positive way of life for others, a way of 
giving back.''
    A little later in your testimony, ``Love and respect, 
compassion.'' You used that word several times ``compassion.'' 
You used that word on page 2 as well.
    We don't often see that language associated with the 
profession and with healthcare. God, we need more of it. We 
need a lot more of that kind of passion for the work that you 
are doing and passion for the care that you and others have 
provided.
    I wanted to ask you about some of the mechanics of how you 
prepare. This has always mystified me, and I know that you 
mentioned it about the 75 hours of training not being enough.
    Now 75 hours of training is not insignificant. That is 
basically two solid weeks of doing nothing but training. So I 
don't want to downgrade it, but it is clearly not enough for 
the work that you have to do and others have had to do to care 
for people where, let us face it, in that long-term care 
setting with that resident, you are providing most of the care. 
Most of the kind of hands-on care, I will say.
    But talk for a moment about that training question because 
I know, for example, in Pennsylvania, in other professions that 
often don't involve as much direct care giving, per se, the 
requirements are much, much higher. Also in professions that 
don't provide any care giving.
    For example, my recollection is to be a barber or a 
beautician in Pennsylvania, you need my recollection is 1,000 
hours, but I could be wrong about that. But it is a lot more 
than 75. It is multiple times higher than 75. My recollection 
was more than 1,000.
    So talk to me about the hours of care--or the hours of 
training. Not just that, but the preparation itself in a 
broader way. Or lack of preparation, as I would characterize 
it.
    Ms. Kreider. Right. You know, the 75 hours gives you the 
basic. Really, your hands-on care and your hours of working 
with a seasoned caregiver is really where your training comes 
from and from having an open line of communication with your 
family members and your residents, also with the required in-
service hours that you put forth in your year of training.
    There is also several programs out there that have 
continuing education that is really essential to tap into also.
    Senator Casey. Connie, I think what causes so many of us to 
be in awe of the work that direct care workers do every day, 
although our policy doesn't always reflect that awe and respect 
that we have, and we need to change that. That is why I and 
others have legislation to move in that direction.
    But we do have a tremendous respect for what you do. We do 
have a sense of awe. It is work that I would like to be able to 
think I could do, but I am not sure I could. I hope I could, 
but I am not sure I could. I think that is true of a lot of 
people.
    What drives someone to enter this field of providing direct 
care and staying with it, despite all of the obstacles, all of 
the ways that our country has not put in place policy to be 
reflective of the care that you give. What motivates people to 
do it and to stay with it?
    Ms. Kreider. Well, that is a very good question. I 
originally went into this field because of the convenience of 
it. But I quickly fell in love with this field. Early on, I 
wanted to think that perhaps it would lead into LPN or an RN 
position, but I quickly changed my mind after a couple of 
weeks.
    I think it has a lot to do with the relationships you have 
with your residents, just to work with them and to get to know 
them and to know their histories. Some of them are vets, and 
some of them have a long history of incredible stories to 
share, and just that relationship that you have with them is 
just priceless. They teach you lessons far beyond any textbook 
or history book you will ever be exposed to.
    So it is really fun, a learning experience. It humbles me 
many, many times because they have so much to offer and so much 
to give because they have seen so much.
    Senator Casey. I remember years ago--I will tell a very 
quick story--my father was in a long-term care setting, and we 
would go to visit him. All four of his sons, when one or more 
of us were in the room, we are all pretty big, all over 6 feet 
tall and should have some degree of strength.
    He would be in the bed, and he would be on one side and, of 
course, would need to be turned. He was at a point where he 
didn't have the strength to turn himself in a way that was 
appropriate, and he was someone who really valued expertise in 
a certain area or certain skill level.
    Once in a while, we thought we could be helpful, and we 
would pull--what seemed like an easy task, pulling the sheets 
or the pads underneath him to try to turn him. Invariably, we 
would do it, and we would do it wrong. So wrong that he would 
look at us like you made the situation worse, but he wouldn't 
complain.
    Then a direct care worker came in the room, and invariably 
almost every one that I remember was a woman. She was a foot 
shorter and hundreds of pounds lighter, and she would pull that 
pad with a skill and expertise to make him feel comfortable. I 
couldn't do it. My three brothers couldn't do. My sisters 
couldn't do it. It looked like we could, but we couldn't.
    So that gave me an insight into just one, tiny--one small 
part of the work that gets done every day. Just to make someone 
feel comfortable in that bed was a big task, and he stopped 
asking us for help in that part of his care. He wanted a 
professional to do it, a direct care worker.
    Melissa, I wanted to ask you a question as well. You 
referred as well to what drove you to get into the business of 
caring for people and providing that kind of help in their 
homes. If you had an opportunity to write a piece of 
legislation or to draft a policy, what do you think is most 
needed as it relates not just to this field more broadly, but 
in particular to the work that you do, what you see every day? 
What do you think is our most pressing need or pressing 
challenge?
    Mr. Lear. Our pressing need is still staff. It is very hard 
to find nurses who want to come to the home care because I 
don't think that they know enough about it. The other huge 
barrier that we have is what I mentioned with the physicians 
being the only ones right now in Pennsylvania who can sign home 
care orders.
    There are lots of wound care clinics that serve 
predominantly geriatric patients who are run by nurse 
practitioners, and their patients can't get access to home care 
without a physician to sign off on it. The nurse practitioner 
is the one who sees the patient. The nurse practitioner is the 
one who should be ordering the home care and signing off on it 
so that we can get out there and do the dressing changes. So it 
is really slowing down that delivery system.
    I think those would be the most important things from a 
nursing standpoint. I am certainly onboard with the training 
for the home health aides and that component. Home health aides 
are near and dear to my heart. I mean, my 75 employees, 90 
percent of them are home health aides.
    To the credit that some facilities have high overturn and 
things like that, we retired our first home health aide last 
year after 10 years of service, recognized two others, and we 
have two more this year who are serving 10 years.
    Senator Casey. I guess, over time, that profession, that 
part of our workforce will be growing substantially, right? As 
more and more people prefer to want to be cared for in the 
home, as more and more public policies incentivize that so you 
are getting in some ways less and less nursing home or 
institutional care, that workforce will become ever more 
important. Isn't that correct?
    Mr. Lear. It is ever more important. But I think it is not 
something that is--you don't see the face of us a lot. We are 
standing next to you in the supermarket, and you don't know who 
we are or what we do because we don't look like other 
healthcare professionals. So I don't think we are drawing 
enough young people into this.
    I frequently get calls for nurses who want to work in home 
care because they are burned out from their hospital setting, 
and they think that--I don't know what they think, that we 
don't see patients. But they want--they are looking for that 
desk job or case management job now that I can't give them. 
People just don't have--I can't think of anyone in my 
graduating class who is working in home care besides me. That 
is kind of sad.
    Senator Casey. You said very little of your training was 
directed at that, huh?
    Mr. Lear. Very little of my?
    Senator Casey. Very little of your own training.
    Mr. Lear. Oh. No, one day. I spent one day in home care and 
hospice, and they shared it. I saw one home care patient, one 
hospice patient.
    Senator Casey. I was noting in your testimony, you didn't 
have a chance to go through all of it, but you had three major 
categories. The first one, in terms of the focus of your 
testimony, meeting the increased need for senior care and 
support was one. The second was preparing a workforce to 
support a growing elderly population. Third was retooling our 
healthcare system, including long-term care.
    Is there anything that you wanted to, any point you wanted 
to make that you didn't have a chance to before in either or 
one of those three areas?
    Mr. Lear. I think maybe two points. I just think that 
somewhere in the Medicare system, it would be nice to fund 
chronic care conditions. Maybe not the traditional 60-day 
payment, well, that I am familiar with. We get one lump sum to 
care for somebody after hospital stay.
    If we could get in there before the hospital stays and 
provide some support, we have had a lot of success in home care 
with HIV patients who are frequent fliers in the hospital, of 
medication management patients who are frequent fliers in the 
hospital because they can't get it right.
    But under the Medicare system, there is no vehicle to pay 
for that. So if we didn't look at maybe traditional Medicare, 
but some kind of a new--and I say that cautiously, some kind of 
a new payment system to manage those chronic care conditions, 
that would be hugely important to keeping people at home.
    Senator Casey. OK. Well, thanks very much. I know we are 
out of time. It is about 5 after 12 p.m. That is a record that 
we are pretty much on time. That is pretty good.
    We will have more questions for both of you. We will submit 
them for the record and ask that you answer them in writing, 
but we are grateful for your testimony and grateful for the 
testimony of all of our panelists.
    For those who were here for the basically 2 hours of 
testimony and discussion, we are grateful. I was saying as I 
was coming in here today, we don't get a chance to do this very 
often. People think this is very common to have hearings like 
this in states like Pennsylvania or across the country. Its 
not, unfortunately it should be more common and even in 
Washington we have lots of hearings but sometimes not enough 
that are as focused as this one is, and has been and we are 
grateful for that. So thanks for your testimony and we are 
adjourned.
    [Whereupon, at 12:08 p.m., the hearing was adjourned.]


                            A P P E N D I X

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         Dr. Heinrich's Responses to Senator Casey's Questions

    Question 1. Pennsylvania has the fourth highest percentage 
of residents over age 65. This gives us a tremendous 
opportunity to play an important role as the nation decides how 
to care for our older citizens. How can we work together to 
allow Pennsylvania to be a model for other states with younger 
populations?
    Answer. We recognize that one of the major health care 
challenges facing the United States is providing appropriate 
care to the increasing number of older Americans with complex 
health needs. The Census Bureau estimates that the number of 
adults age 65 and older will almost double from 2005-2030.\1\ 
HRSA recognizes the need for additional health care providers 
with knowledge and training in the unique health needs of older 
Americans, and has several funding opportunities that support 
geriatric workforce development. Pennsylvania residents and 
institutions (including educational institutions) are eligible 
to apply for the varied funding opportunities that the Federal 
government has relating to elder care. HRSA offers consultation 
and technical assistance to anyone interested in these funding 
opportunities.
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    \1\ 65+ in the United States: 2005, released by the U.S. Census 
Bureau.
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    Question 2. What HHS resources could be made available to 
the Scranton-Wilkes-Barre region to help guide our health 
professions training schools and healthcare providers in taking 
full advantage of the federal grant programs you cite in your 
testimony? How do we ensure that a comprehensive system of 
services and qualified healthcare professionals are available 
to this population, and that all of the programs you mentioned 
are leveraged, and not a few hit or miss?
    Answer. HRSA has an array of resources available to help 
identify grant opportunities to support health professions 
schools and healthcare providers in the Scranton-Wilkes-Barre 
region, as well as all other parts of the nation. The best 
starting place is HRSA's website, http://www.HRSA.gov, which 
has information about HRSA's programs and links to additional 
sources of information. It is also a good place to identify 
additional sources of assistance--toll-free numbers, written 
products, and contact information for federal program staff.
    Question 3. You mentioned in your testimony several federal 
grant programs that are assisting this region or that could 
soon assist this region in improving the healthcare of our 
older adults and their families. In issuing grant guidelines 
for applicants of HHS, HRSA, NIH or AHRQ programs, is there any 
preference afforded to new medical schools? What about a set-
aside of a percentage of funds for new grantees, so repeat 
grant recipients are not the only ones being able to take 
advantage of scarce federal resources?
    Answer. None of HRSA's programs have a statutory preference 
for new medical schools or set-asides for new grantees. We 
cannot address this question as it pertains to NIH or AHRQ.
    Question 4. You referenced several provisions to address 
the challenges we face in training frontline health care 
workers and especially direct care workers. What steps do you 
think a state like Pennsylvania with a high percentage of older 
citizens should do to best respond to these initiatives and 
become a model for other states around the nation?
    Answer. Pennsylvania is clearly a leader among States in 
caring for older Americans and poised to build upon this 
experience. HRSA encourages all qualified applicants to submit 
applications for funding opportunities like the State Health 
Care Workforce Development grant program. This program, created 
by the Affordable Care Act, will enable State partnerships to 
plan and implement innovative strategies to expand their 
primary care workforce by 10 to 25 percent over ten years to 
meet increased demand for primary care services.
    Question 5. Is our nation's current approach to medical 
education sufficient to meet the growing demand for health care 
services? And related to that, what do you think is the best 
way to expand the number of residency slots to meet the 
forthcoming physician shortage?
    Answer. Current projections suggest that there will be a 
shortage of providers, particularly primary care physicians, in 
the years ahead. The Administration has responded to the 
shortage by announcing $250 million for its workforce 
initiative, which is designed to increase the number of health 
care providers and strengthen the primary care workforce. 
Resources, made available by the Affordable Care Act and the 
American Recovery and Reinvestment Act, will support the 
training and development of more than 16,000 new primary care 
providers over the next five years. HRSA plays a key role in 
managing this initiative , and is currently implementing a 
multi-pronged approach to strengthen the numbers of primary 
care providers, including physicians, nurse practitioners and 
physician assistants.
    In addition, the Affordable Care Act funded several new 
grant opportunities for primary care providers, including the 
teaching health center program which will provide GME payments 
to support community-based training. Teaching Health Center GME 
payments will cover the costs of new residency programs in 
community-based ambulatory primary care settings such as health 
centers. This will have a strong positive effect on the number, 
and quality, of primary care physicians in this country.
    Question 6. In many ways new medical schools present a 
clean slate for many of the new models we will be testing and 
utilizing under health care reform. How can we work together 
and with these schools to harness those resources and work to 
develop residency programs that complement what these students 
learn in medical school?
    Answer. HRSA recognizes that new medical schools are 
uniquely poised to create and implement innovative curricula. 
Residency programs and medical school curricula can be molded 
to incorporate competency-based models of care, including 
interprofessional team-based competencies and patient-centered 
medical homes. HRSA training programs for physicians are 
available to support these efforts and we look forward to 
working creatively with you and the medical school community to 
achieve these goals.

                                 
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