Transcript Nursing: Pipeline, Practices and Policies

Improving the Health Care of
America’s Older Adults Through
Social Work
Corinne H. Rieder
Executive Director and Treasurer
The John A. Hartford Foundation
The Leadership Academy in Aging
NYAM/NADD Partnership
Saturday, June 18, 2011
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Overview
I. What are Key Challenges to Overcome in
Meeting the Health Care Needs of Older
Adults?
II. What Steps can Social Work Educators &
Practitioners Take to Improve the Health
Care of Older People?
III. The Hartford Foundation: What is it? Why
Aging?
IV. The Foundation’s Social Work Initiatives:
What are they? What has been
Accomplished?
I. 7 Key Challenges to Overcome
in Meeting the Health Care Needs
of Older Adults
•
•
•
•
•
•
•
Demographic changes
Chronic diseases
Use & cost of health & support services
Inadequate & poorly prepared health care workforce
Failure to deliver care cost-effectively
Discrimination & ageism
Important financial, ideological & ethical issues
3
First, the Demographics
• The growth of older Americans is dramatic.
- Today there are 40 M people 65 & older. By 2050
there will be 85 M.
•
The increase in the number of people 85 & older is
especially large.
- They will increase from 1.5% in 2000 to 5% of the
population by 2050.
- Those 100 & older are projected to grow from
50,000 to 800,000.
4
US Population Pyramids
5
Increases in the Oldest Old
U.S. Population Aged 85+ (in millions)
20.9
15.4
9.6
2.2
1.5
0.1 0.2 0.2 0.3 0.4 0.6 0.9
3.1
4.2
6.1
7.3
00 910 920 930 940 950 960 970 980 990 000 010 020 030 040 050
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1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
Sources of data: U.S. Census Bureau, “65+ in the United States: 2005,” December 2005; U.S. Census
6
Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004.
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Second, the Prevalence of Chronic
Diseases Increases with Age
60%
55%
49%
50%
37%
40%
31%
Heart Disease
Hypertension
27%
30%
24%
Cancers
19%
20%
13%
10%
8%
7%
4%
2%
0%
18-44
45-64
65-74
75+
Age in Years
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Third, the Use & Cost of Health &
Social Services Increases with Age
1. Older adults represent 13% of the population,
yet account for:
• 26% of physician office visits
• 50% of specialty ambulatory care visits
• 46% of patients in critical care
• 50% of hospital days
• 32% of prescriptions
• 70% of home health services
• 90% of residents in nursing facilities
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Third, the Use & Cost of Health & Social
Services Increases with Age (Continued)
2. Medicare beneficiaries with 5 or more
conditions:
• See more than 3X as many physicians (14
different physicians per year)
• Visit physicians more than 4X as often
• Receive almost 5X the number of
prescriptions (on average, 49 per year,
including refills)
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Third, the Use & Cost of Health & Social
Services Increases with Age (Continued)
3. Health Care Spending
• About 95% of all health care spending is for
the chronically ill.
• 64% of all Medicare spending goes to the
10% of beneficiaries with 5 or more chronic
conditions. More attention to the 10%.
• Estimates are that about ¼ of Medicare’s
budget goes to patients in their final year of
life. 40% of that is in the last 30 days. It is
interesting to note that the cost of people age
85 & over is 1/3 lower than for people 65 to
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75 in their final year.
Third, the Use & Cost of Health Care
Services Increase with Technology
(Continued)
4. The development & use of technology in health care
increases health care costs, i.e., medical technology
• Medical technology refers to procedures,
equipment, and processes by which medical care is
delivered.
• New medical & surgical procedures & Units
(angioplasty, joint replacements, ACE units)
• New medical devices (defibrillators)
• New support systems (electronic medical records &
transmission of information, telemedicine)
• New therapies & drugs (statins, beta-blockers)
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Fourth, an Inadequate & Poorly
Prepared Health Care Workforce
– NIA estimates a need for 60,000--70,000 geriatric
social workers by 2020. In 2000, there were only
13,500 geriatric social workers with a median age
of 50 years.
– Of the 240,000 advanced practice nurses only
3,500 are geriatric nurse practitioners. Overall,
the projected shortages in nursing range from
340,000 to 1 M nurses by 2030.
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Fourth, an Inadequate & Poorly Prepared
Health Care Workforce (Continued)
– By 2030 there will be fewer than 8000
geriatricians against a projected need for
30,000 geriatricians.
– Half of all geriatric fellowship positions go
unfilled & half of those filled go to physicians
from other countries who may not be committed
to geriatrics.
– By 2030 there will be only 1,700 geriatric
psychiatrists (1 per 5,700 older Americans with
a mental illness).
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Fourth, an Inadequate & Poorly Prepared
Health Care Workforce (Continued)
– There are 43.5 M unpaid caregivers who provide
care to a person 50 or older. Many of them are
unprepared to deal with chronic diseases & the
geriatric syndromes of old age. This unpaid care
totaled approximately $375 billion in 2007.
– 1 M more direct-care workers will be needed by
2018, according to the latest employment
projections. They are required to receive very
little education, often less than dog groomers &
people that shampoo your hair in salons.
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Fifth, the Failure to Deliver Care CostEffectively
Increasing the numbers & skills of geriatricstrained workers will not be sufficient, as it will not
fix the deficiencies in the way care is delivered or
address inefficiencies.
• The health care system remains focused on
acute care rather than on chronic diseases.
• Specialist care is favored over primary care &
prevention
• The fragmented system challenges
communication between & among providers &
care coordination is infrequent.
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Fifth, the Failure to Deliver Care
Cost-Effectively (Continued)
• Payment policies (fee-for-service) encourage
service volume rather than quality. Capitated &
bundled care is essential to better integrate
health delivery & social services.
• Patients & their caregivers need to be active
partners in their care.
• Health care & social supports need to take
account of patients’ cultural & geographic
diversity.
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Fifth, the Failure to Deliver Care CostEffective (Continued)
• Errors (for the general population between 44,000 &
98,000 deaths per year)
• Hospital infections (for the general population 100,000
deaths per year)
• Unsafe prescribing (1.3 million for the general
population)
• High rates of hospital readmission (20% within 30
days at a cost of $17 B/Y)
• 45% of people in nursing homes have no advanced
directives & 75% of older people will not be able to
make some or all of their end-of-life decisions.
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Fifth, the Failure to Deliver Care CostEffectively (Continued)
• There is poor adherence to guidelines (33%
for geriatric conditions)
• Too many health care expenditures that are
of little value (estimates range from 25 to
30% of all expenditures)
• A 2005 report by the NAE & the IOM found
that 30 to 40% of every $ spent on health
care was associated with overuse, misuses,
duplication, system failures, unnecessary
repetition, poor communication & inefficiency.
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Sixth, the Prevalence of
Discrimination & Ageism
Discrimination & ageism negatively impact:
• The quality of care that older people receive.
• Recruitment of students into geriatric health
professions.
• The educational & training environment, i.e., poor
care becomes standard care.
• There are large numbers of older adults that are
abused (physically, psychologically, financially)
&/or suffer from self-neglect.
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Finally, there are Important
Financial, Ideological & Ethical
Issues
• Medicare expenditures were $524B in fiscal year
2010, representing 15% of federal outlays, 17.6%
of GDP & $14,000/year per Medicare beneficiary).
• + $100B in out of pocket, retiree & supplemental
• A growing concern about the mismatch between
projected costs of health & the ability of the
economy & younger generations to pay for them.
• Ethical issues abound.
• Competing ideological viewpoints, particularly on
the role of government versus that of the private
sector.
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II. Next Steps to Improve the
Health Care of Older People
What is Hartford’s vision?
What is the Foundation doing to achieve that
vision?
What steps can the social work profession
take to improve & integrate health &
supportive services for older people? I will
offer 4 recommendations & what I will call 4
“inconvenient truths.”
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Hartford’s Vision
• Older adults receive quality health care from sufficient
numbers of well-trained health professionals.
• Care for older adults is integrated, patient-centered &
coordinated.
• Health professionals are trained to & work in
interdisciplinary/inter-professional teams & our
country’s financing & delivery systems support them.
• Our health care system takes account of the increasing
social, demographic & geographic diversity of older
adults.
• Health care is seamless across various delivery sites
& all clinicians have immediate access to patients’
health information & communicate with one another.
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Hartford’s Vision (Continued)
• Older people & their families are active partners in
their care & greater attention is paid to & financing
of disease prevention, the adoption of healthy life
styles & the preservation of function.
• Movement away from fee-for-service payment of
physicians toward innovative provider payment &
delivery system reforms, e.g., accountable care
organizations, bundled acute & post-acute care
payment, & patient centered medical homes.
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Hartford’s Work to Achieve this
Vision
• Maintain the Foundation’s national scope
even with reduced assets.
• Maintain a narrow & consistent focus in one
area.
• Maintain our commitment to be strategic in
our grantmaking with clear goals,
objectives, strategies & self-evaluation.
• Increase partnerships & advocacy efforts
with grantees, other foundations &
government entities with the same goals.
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Recommendation #1
The Work Site
• Every practicing social worker is prepared to
provide quality care to older adults through
innovative partnerships with academic
institutions &/or on-the-job education &
training.
• Work sites provide high quality clinical training
& education for students.
• Social workers advocate for patients & clients
& teach patients & families to advocate for
themselves.
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Recommendation #2
Education & Training
• More faculty members are expert in geriatrics.
• Geriatrics is infused into & across the curriculum.
• Students have more, better & a greater variety of
clinical experiences with older people & the
institutions that serve them. Field experience is
elevated within academic programs.
• Schools of Social Work move closer to becoming
more like such professional schools as medicine &
nursing, rather than arts & sciences adjuncts. SW
Schools & their faculty bring together social work’s
unique expertise at the individual & community
level with a greater knowledge base in health care
systems & service delivery.
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Recommendation #2
Education & Training (Continued)
• Barriers to interprofessional training, such as
scheduling, accreditation requirements & financial
impediments need to be removed. Training
together will enable students to see the value of &
work better together in interdisciplinary teams after
graduation.
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Recommendation #3
Team Care
• Team care for older adults with chronic & complex
health & social needs are instituted: teams have a
common purpose, specialization of function, defined
roles & processes for coordinating their efforts.
• Clinicians work at the top of their training & the edge
of their license. Team members are empowered to
perform tasks according to scope of practice,
experience & education. Teams find ways to
incorporate & coordinate the supports already
existing. Patients, families & communities are also
part of the team.*
* Who Will Provide Primary Care & How Will They be Trained?
Josiah Macy, Jr. Foundation, 2010
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Recommendation #4
Partnerships
• Improving the health care of older people
needs both interdisciplinary/inter-professional
& community partnerships. Are there silos or
turf battles that need to be addressed in your
organization &/or community? Have you
utilized the resources of other professions &
your community to advance social work?
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The Inconvenient Truths: Truth #1
• ARE YOU AT THE TABLE OR ON THE MENU?*
Social workers have to be advocates & leaders for change even
without the money to do it.
– You cannot wait for others—politicians, bureaucrats or
academic colleagues in other professions—to “allow” or “invite
you” to join the debate & revitalize & reshape the health care
system & the profession, e.g., join your local or state
Alzheimer’s Association, meet & work with your local & state
elected officials.
– One heartening development is the collaborative work
nationally of 6 healthcare regulatory organizations (Med, SW,
Nursing, Pharmacy, PT & OT) to guide regulatory decision
making with regard to scopes of practice.
*Diane Meier “Be at the Table or Be on the Menu”
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The Inconvenient Truths: Truth #1(Continued)
• What are the dangers & opportunities for social workers & other
health professions with implementation of the Patient Protection
& Affordable Care Act (PPACA or ACA)? The tools of
policymakers are very blunt—changes in payment & regulatory
incentives give great scope to professionals & institutions to
decide how to implement. Take advantage of these funding
opportunities and new delivery & funding structures.
- Hospital Readmission
- ACA programs, e.g., ACOs, Innovation monies
- Reducing health care costs
- Coordination & integration of service delivery
- Disease prevention
- Caring for patients with multiple chronic diseases
- Patient-centered medical homes – how will they be
implemented? Roles for social workers?
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The Inconvenient Truths: Truth #2
• You don’t need to re-invent the wheel. In
education & service delivery there is an
abundance of ideas & materials, &
numerous models waiting to be adopted in
your institution or community.*
* For example, see the IOM Report, Retooling for
an Aging America: Building the Health Care
Workforce (2008) which identifies many evidencebased service models.
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The Inconvenient Truths: Truth
#3
• Social workers need to better define who
they are, what they do, & they need to
make a business case with evidence of
their cost-effectiveness. The general public
& other health professionals are not fully
aware of social work’s real & potential
contributions to improving the health care of
older people.
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The Inconvenient Truths: Truth
#4
• The social work profession is sometimes
hurt by its fragmentation. Who speaks for
social work nationally? The field is
fragmented by its multiple national
associations. This situation reduces its
impact & dilutes the potentially pivotal role
played by its leaders.
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III. The Hartford Foundation
•
•
•
•
•
•
82 year old, $500 million mission-driven
foundation; 30 year history of improving the
health of older people
National in scope; premium on projects that can
be sustained & have a multiplier effect; avoid
duplicating the focus of others; place importance
on partnering with grantees & other funders
Strategic in grantmaking; grants are made
competitively; rarely fund unsolicited proposals
Our narrow & consistent focus is unique for a
foundation our size; peers have multiple foci &
shorter term commitments to a funding area
Committed $430 million to 200 organizations
over the past 30 years
Hartford is one of the largest funders of social
work & nursing outside of state & federal
governments
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The bequest from John A. Hartford, which
established the Foundation, directed future
Hartford trustees
“to do the greatest good for the greatest
number.”
And…”to carve from the whole vast spectrum
of human needs one small band that the heart
and mind together tell you is the area in which
you can make your best contribution.”
The Foundation’s Choice & Its
Importance to Social Work
Given Mr. Hartford’s wishes, what led
the Foundation to choose improving the
health care of older adults as its goal?
1. Respect for Mr. Hartford’s desire to
target a limited area to achieve maximum
impact.
2. The demographics.
3. No other foundation had that area as a
major focus.
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IV. Hartford’s Social Work
Initiative
Goal
All social workers are prepared to
care for older adults
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Hartford’s Objectives
1.
2.
3.
4.
5.
6.
Prepare a geriatrically competent workforce.
Infuse geriatrics in the education programs of all
schools of social work in the country.
Ensure that there are sufficient geriatrics faculty
members.
Develop, test & disseminate innovative, costeffective models of care that improve services to
older adults.
Draw national attention to the importance of social
work in improving the health care of older people.
Communicate the idea that older adults are “a core
business” of health care & its professions.
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Hartford’s Strategies
The Foundation pursues two major
strategies in its social work initiative:
•
Faculty & Leadership Development
•
Curricular Change
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Hartford’s Intermediate
Indicators of Impact
Social Work
1. 50% of MSW programs require
coursework in aging (currently about 25%)
2. 75% of MSW programs adopt the Hartford
Partnership Program for Aging Education
(HPPAE) model (currently about 50%)
3. 60% of programs have more than 2 faculty
members specialized in geriatrics
(currently about 45%).
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Hartford’s Financial Commitments
to Social Work to Achieve
these Objectives
1999-2010
Social Work
• $70 Million authorized
• 36 Major grants approved
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The Foundation’s Specific Accomplishments in
Social Work in the Past Decade
1.
2.
3.
4.
Faculty development
• Faculty Scholars Program --106 scholars in 11 cohorts
• Doctoral Fellows Program--88 doctoral fellows
• Pre-dissertation Awards--80 awardees
• The Leadership Academy in Aging--24 deans
Curriculum
• Grants resulted in new aging curricula being disseminated &
adapted by over 180 schools
• Gero-Ed is a model for the development of additional
competencies (CSWE EPAS)
• Aging-content increased in social work text books.
Providing real-world training for social work students.
• Hartford Partnership Program for Aging Education (HPPAE,
formerly PPP) adopted in 72 schools in 32 states.
Three important books by Barbara Berkman & Nancy Hooyman.
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Hartford’s Leveraging: 2001-2009
Total Funding Brought to Geriatric
Social Work: $208 Million
$138M
Lev'd
$70M
Auth'd
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John A. Hartford Foundation
Total Dollars Leveraged over Five Years by Grant Portfolio
(2002- 2006)
$180M
$180,000,000
Leverage from 2000 - 2006: $492M
IIS*
$160,000,000
$140,000,000
$120,000,000
Five-year Leverage from 2002 - 2006:
- $122M Grants Authorized
- $427M Leveraged
- $3.50 Leveraged for every $1 of Hartford Funding
Social Work
$100,000,000
$91M
$80,000,000
$56M
$60,000,000
$40,000,000
Nursing
IIS*
$37M
Nursing
Social Work
IIS*
Social Work
$59M
IIS*
Nursing
Social Work
IIS*
Nursing
Social Work
$20,000,000
Nursing
Medicine
Medicine
Medicine
Medicine
2004
2005
Medicine
$0
2002
2003
* IIS stands for Integrating and Improving Services grants
2006
Partnerships
•
•
•
•
•
•
•
•
•
•
•
•
The Archstone Foundation
The Atlantic Philanthropies
The Hearst Foundations
The Jacob and Valeria Langeloth Foundation
The Helen Bader Foundation
Veterans Administration
National Institutes of Health
National Association of Social Workers
AARP Andrus Foundation
The Louis and Samuel Silberman Fund
The Administration on Aging
Plus more than 50 local funders
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Conclusion
• There has never been a time in history for social
workers to make a more important difference to the
care of older people than now.
• What do I want you to do when you leave this
meeting?
-- A commitment next Monday to begin implementing
at least one of these recommendations & to start a
discussion in your institution or organization on these
“inconvenient truths” or others of your choice.
Hartford has many available resources & tools that
can help you implement these recommendations.
-- If this is not done, all of us in this room & older
people everywhere, will not have the health care they
need & deserve. Thank you very much.
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