Transcript Nursing: Pipeline, Practices and Policies

Improving the Health Care of America’s
Older Adults Through
Social Work
The John A. Hartford Foundation
Corinne H. Rieder
Executive Director and Treasurer
National Association of Deans and Directors of Social Work
Spring 2009 Conference
Scottsdale, Arizona
March 16, 2009
1
Overview
I. What are key problems in meeting the health care
needs of our rapidly aging population?
II. The Hartford Foundation: What is it? Why Aging?
Why is this important to Social Work?
III. What was the state of geriatric social work in 1999
when Hartford began its grantmaking & what has
been accomplished?
IV.Observations & opportunities for promoting aging
in social work.
2
I. Key Problems in Meeting the Health
Care Needs of our Rapidly Aging
Population
A. Work Force Shortages
•
There are too few geriatrics specialists,
including academics, in social work, nursing &
medicine
B. Deficiencies in Health Care Delivery & Quality
•
Quality of care is often unacceptable
•
Systems of care may be inefficient & not well
coordinated.
•
Patients & families not active partners in care
provision
3
A. Work Force Shortages
1. Social Work
•
NIA estimated the need for 70,000 geriatric
social workers by 2020.
•
Currently only 4% of students specialize in
geriatrics despite the fact that 73% work
with older adults & between 8% & 10% of
social workers are employed in long-term
care.
4
A. Work Force Shortages
1. Social Work (Continued)
• The number of programs is also decreasing.
In the 1980s, 50% of MSW programs offered
an aging specialization; by the early 1990s
this had dropped to 33%, & as of 2003, only
29% offered an aging specialization.
• Of the 2000 doctorates awarded nationally
since 1995, only 289 (14%) focused on aging
topics.
5
A. Work Force Shortages
2. Medicine & Psychiatry
•
In medicine, certified geriatricians have
declined from 8,000 in 1998 to 7,000 in 2004,
or 1 geriatrician for every 2,500 older
Americans.
•
Assuming current growth rates, by 2030 there
will be only 7,750 geriatricians or 1 for every
4,250 older people despite a projected need
for 30,000 geriatricians.
6
A. Workforce Shortages
2. Medicine & Psychiatry (Continued)
• Currently there are less than 1,600 certified
geriatric psychiatrists. At the present
graduation rate, there will be only 1,700
geriatric psychiatrists in 2030, or 1 per 5,700
older Americans with a psychiatric disorder.
7
A. Work Force Shortages
3. Nurses
• The most recent projections of the nursing
shortage range from 340,000 to 1 million
nurses.
• Of the 240,000 advanced practice nurses only
3,500 are geriatric nurse practitioners.
8
B. Deficiencies in Health Care Delivery to
Older Adults
1. The quality of care is often unacceptable
• The health care workforce receives very little
geriatric training.
• The health care needs of older adults are
frequently neither comprehensively addressed
nor patient-centered.
• Too little attention is paid to providing preventive
services & coordinating the treatment of chronic
& acute care conditions.
9
B. Deficiencies in Health Care Delivery to
Older Adults (Continued)
2. Services are often not provided efficiently.
• Providers need to be trained to work in
interdisciplinary teams & financing & delivery
systems need to support these teams.
• Care coordination is essential & patient
transitions need to be facilitated across
various delivery sites. All providers need
access to patient information.
• A number of new cost-effective models have
been developed & tested which improve
patient outcomes, which should be widely
10
adopted & adapted.
B. Deficiencies in Health Care Delivery to
Older Adults (Continued)
3. Patients & their families are too often not
active partners in patient care or supported.
• These partnerships need to include the
adoption of healthy lifestyles, selfmanagement of chronic conditions &
increased participation of patients & their
families in decision making.
• The 33 million caregivers providing help to
adults over 50 need support and training.
11
But it Doesn’t Have to be this Way!
I Can Envision a Time When:
• Older adults receive quality health care from sufficient numbers
of well-trained health professionals.
• Care for older adults is comprehensive, patient-centered &
coordinated.
• Health professionals are trained to & work in interdisciplinary
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.
• Older people & their families are active partners in their care &
where there is greater attention to & financing of disease
prevention, the adoption of healthy life styles & the preservation
of function.
12
II. The Hartford Foundation
• 80 year old, $434 million foundation
• 30 year history in improving the health of older people
• Narrow & consistent focus is unique for a foundation our size;
peers multiple foci & shorter term commitments; less than 2%
philanthropic dollars go to aging
• Places importance on partnering: 2 major partners spending
down (Atlantic and Reynolds)
• National in scope; put a premium on projects that can be
sustained & have a multiplier effect, while avoiding
duplicating the efforts of others
• Strategic in grantmaking; rarely fund proposals that come
over the transom
• Committed $400 million to 200 organizations over the past 30
years
13
The Impact of the Current Recession on the
Hartford Foundation
• Independent foundations like Hartford rarely have new money
coming. Depend solely on the growth of investments.
• Nor, obviously, do they have a stream of tuition or research
monies or grateful alums.
• In October 2007, Hartford was a 78 year old Foundation with an
endowment of $750 million instead of $434 million.
• With a $320 million decrease in its endowment, the Foundation
has been forced to cut not only many future grants, but also
current grantees. Something that has been very painful for us to
do.
• Despite the recession Hartford will maintain our commitment to
improving the health care of older people & will increase its
efforts when the stock market recovers & the endowment again
grows.
14
Hartford’s Strategies
The Foundation pursues 3 strategies:
• Education & training
• Improved service delivery
• And, drawing excellent scholars into
aging R&D to advance knowledge and
improve practice.
15
16
17
18
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.”
19
The Foundation’s Choice & Its
Importance to Social Work & to You
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 focus
on a limited area to achieve maximum
impact & to stay within health, his major
area of interest.
2. The demographics.
3. No other foundation had that area as a
major focus.
20
Why are the Demographics Important?
1. The growth of older Americans is dramatic.
2. It is widespread across the country.
3. The increase in the number of people over
85 & 100 years of age is especially large.
4. Chronic diseases increase with age as do
the use of health care services & their
costs.
21
Growth in the Number of Older Adults
• Those over 65 years of age will double between 2000
& 2030, growing from 35 million to over 70 million.
• Much of the growth is attributed to the “baby boom”
generation born between 1946 & 1964.
• 85+ the most rapidly growing group, going from 1.5%
in 2000 to 5% of population in 2050.
• 100+ projected to grow from 50,000 to 800,000 over
the same time period.
22
US Population Pyramids
23
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
9
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
24
Bureau, U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin, 2004.
25
The Prevalence of Chronic Diseases
Increases with Age: Data from 20032005
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
26
The Use of Health Services Also
Increases with Age
Older adults represent 13% of the population,
yet account for:
•
•
•
•
•
46%
50%
50%
70%
90%
of
of
of
of
of
patients in critical care
hospital days
specialty ambulatory care visits
home health services
residents in nursing facilities
27
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What Other Challenges does our
Nation Face in Providing Quality Health
Care & Social Services to Older
Adults?
•
•
Health Care Discrimination & Ageism
The Growing Cost of Health Care & the
Political, Financial & Ethical Issues
Associated with that Growth & the need for, &
difficulty in, achieving fundamental reforms to
health care delivery
29
Why are these important to you & the
Social Workers that you educate?
1. Discrimination & ageism negatively impact:
a. Quality of care that older people receive.
b. Recruitment of students into geriatric health
professions.
c. Educational & training environment, i.e.,
poor care becomes standard care.
d. And, students need to be prepared to
identify & treat older adults that have been
abused &/or suffer from self-neglect.
30
Why are these Important to You?
(Continued)
2. The growing cost of health care & the difficulty
in achieving fundamental reforms to health
care delivery
• Annual Medicare costs are over $400 billion.
• Growing concern about the mismatch
between projected Medicare entitlements &
the ability of the economy to pay for them.
• Complex & divisive ideological & ethical
issues are also at stake.
31
There are also Remarkable
Opportunities to Make a Difference in
Geriatric Social Work
Geriatric Social Work:
• Is the key discipline for coordinating health care & long term
care services for older adults & their families.
• Has primary responsibility for supporting families & informal
caregivers.
• Takes the lead in promoting healthy life styles, reducing the
incidence of chronic diseases & eliminating health disparities
among different segments of the population.
• Actively helps older adults maintain their psychological &
cognitive health, including the promotion of social interaction.
• Is increasingly attractive to philanthropy, business &
governmental leaders.
32
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III. How is Hartford’s Grantmaking in
Social Work Meeting these Challenges?
Are they succeeding?
A. What was the state of geriatric social work
in 1999 when Hartford began its
grantmaking in social work?
B. What has been accomplished through
these efforts?
34
Where was Gerontological Social
Work in 1999 when we began our
efforts?
1. No national aging curriculum models.
2. No focused national recruiting into
geriatric social work.
3. No articulation of competencies in aging to
guide curriculum training.
4. No national training projects to prepare
faculty to teach geriatrics.
5. Minimal resources to train staff or
improve the overall care of older people.
6. No nationwide social work initiatives to
improve care to older clients.
35
Where Were We By the Numbers?
1. Overall, less than 3% of social work
graduates enrolled in geriatric courses.
2.
~95% of students took less than 2 courses
on aging in their social work programs.
3.
73% of social work students report
working with older adults.
36
Hartford’s Social Work Objectives
1.
2.
3.
4.
5.
6.
Prepare a geriatrically competent workforce.
Incorporate geriatrics in the education & training
programs of all social work schools in the country.
Ensure that there are sufficient geriatric social work
faculty members.
Develop, test and disseminate innovative, costeffective models of training & care that improve
social work services to older adults.
Draw national attention to the importance of social
work’s role in improving the health care of older
people.
Communicate the idea that older adults are “a core
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business” of health care & of social work.
Hartford Financial Commitments to
Social Work to Achieve these
Objectives
1999-2008
• $70 Million authorized
($64.5 million in education & $5.5 million for
research and new models)
• $47 Million paid out
• 34 Major grants approved
38
Hartford’s Leveraging: 2001-2007
Total Funding Brought to Geriatric
Social Work: $163 million
$
$108
Million
$55 Million
(authorized)
Other Funding
JAHF Grants
39
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
The Centers for Disease Control
Werner and Elaine Dannheisser Trust
Plus approximately 50 local funders
40
Hartford’s Social Work Initiative
Broadly speaking, Hartford’s Social Work is
organized around 3 themes:
1.
2.
3.
Academic leadership development
• Faculty Scholars Program
• Doctoral Fellows Program
• Pre-dissertation Awards
• The Leadership Academy in Aging
Curriculum for aging
• GeroEd Center (previously GeroRich, SAGE S/W)
Providing real-world training for social work students.
• Hartford Partnership Program for Aging Education
(HPPAE, formerly PPP)
41
What’s Been Accomplished
and Where are We Today?
1.
81 scholars in 8 cohorts. Of the 81 scholars, all
who have applied for tenure received tenure.
These scholars serve on the faculty of 37 schools
in 28 states; they have written 260 book chapters,
21 textbooks, & the 1st 6 cohorts have published
612 articles in top tier journals; overall these
scholars have made 1,605 research presentations
& were awarded 206 grants.
42
What’s been Accomplished and Where
are We Today? (Continued)
2.
69 doctoral fellows have been selected
who show promise to become faculty
leaders in geriatric social work. Of these,
35 former doctoral fellows hold full-time
faculty status or post-doctoral
appointments; almost half (32) are still
engaged in dissertation research.
3. 80 Pre-Dissertation Awardees have been
selected; 16 have gone on to become
doctoral fellows; 8 applied for the August
selection cycle, and 26 more plan to apply
this year.
43
What’s been Accomplished and Where
are We Today? (Continued)
4.
Curriculum grants resulted in new aging curricula
being disseminated & adapted by over 180
schools.
5.
Gero-Ed is a model for the development of
additional competencies (CSWE EPAS).
6. Aging-content is being increased in social work
text books.
7. Geriatric questions have been written for social
work licensing exams.
8.
HPPAE has been adopted in 72 schools in 32
states.
44
What’s been Accomplished and
Where are We Today? (Continued)
9. In January 2006, The Handbook of Social
Work in Health and Aging was published, a
1,000-page reference text edited by Dr. Barbara
Berkman & authored by 33 scholars and 31
program mentors.
10. A national leadership development program
for deans & directors has been established
to strengthen skills & promote
gerontological social work.
11. At this meeting, Dr. Nancy Hooyman, is
unveiling her new book, Transforming Social
Work: The First Decade of the Hartford
Geriatric Social Work Initiative.
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46
IV. Observations & Opportunities for
Promoting Aging in Social Work
A. Observations
B. Recommendations for promoting aging in
social work
47
8 Observations About Social Work
1.
The general public & some health professionals
are not fully aware of social work’s real &
potential contributions to improving the health
care of older people. Nor, do they understand
the expertise that social workers bring to the
table. Within the field, there has been
inadequate attention given to program
evaluation & measuring the cost-effectiveness of
social work services. These factors contribute to
social workers being underutilized & sometimes
feeling that their skills are undervalued.
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Observations (Continued)
2. Who speaks for social work education
nationally? The field of social work is
fragmented by its multiple national
associations. This situation reduces its
impact in a variety of ways & dilutes the
potentially pivotal role played by deans
& directors.
49
Observations (Continued)
3. Social work is a complex & challenging
profession with a commitment to meet the
multiple needs of our country’s diverse
population. While this is a positive, the field
can also become so fragmented that it
overlooks common human needs that cut
across specific population groups, e.g. aging,
income inequality.
50
Observations (Continued)
4. Is there too much separation between policy
& practice within social work programs? Do
social work’s diverse roots in clinical practice
& community organization prevent policy
from being fully integrated into the field’s
curriculum, clinical practice & research
efforts?
51
Observations (Continued)
5. Improving the health care of older
people is an interdisciplinary effort in
practice, policy & R&D. How well
connected are you and your school’s
faculty with counterparts in medicine,
nursing & other health professions? Are
there silos or turf battles that need to be
addressed in your institution? How
much have you exploited the resources
of other professions to advance social
work?
52
Observations (Continued)
6. Social work needs more research
focused on: a) better understanding &
improving service delivery, b) the
assessment & teaching of required
competencies that need to be exercised
in specific care environments, and c)
evaluation & cost-benefit studies of
different interventions. Private funders
ask: Where in social work is the health
services research that we see in
medicine and nursing?
53
Observations (Continued)
7. Some colleges and universities seem
unwilling to assume a responsibility for
meeting national work force needs.
While this tendency may be less in
social work, it still takes its toll on school
& departmental resource allocation
decisions & pressure to bring in
research funding in research intensive
universities. How is this viewed in your
institution? Does it impact your school?
54
OBSERVATIONS (Continued)
8. Some in leadership positions argue that
social work is not sufficiently proactive,
future oriented & strategic. They attribute
this to it being a “helping” profession & the
field’s clinical orientation, thus focusing on &
reacting to specific “here & now” health &
social problems. Are deans & directors, in
your view, honing their strategic skills to
think & plan for the future?
55
One Recommendation
Incorporate Geriatrics into your
School’s Program
56
11 Ways to Incorporate Geriatrics into
your School’s Program
1.
2.
Infuse geriatrics across the curriculum in existing
non-geriatric courses & increase stand-alone
courses. Exercise your leadership to include
geriatric competencies & content in state licensing
exams. To assist you, access the extensive
teaching & curricular resources through
WWW.Gero-EdCenter.org.
Exert your influence to ensure that the new EPAS
emphasis on context, e.g. demographics, is applied
in reaffirmation/accreditation processes. The GeroEd and HPPAE programs have the best developed
geriatric social work competencies now available.
57
Incorporating Geriatrics (Continued)
3.
Increase the number, quality & variety of clinical
experiences that students experience with older
people & the institutions that serve them. Also,
educate social workers to measurably improve
the health outcomes of family caregivers.
Again, HPPAE is an excellent model to adopt.
4.
Increase the number of social workers focused
on geriatrics at all levels of social work including
health, substance use & mental health
specializations (Gero-Ed Center Masters
Advanced Curriculum Project—MAC).
58
Incorporating Geriatrics (Continued)
5.
Hire more faculty members with expertise in
gerontology. Help faculty re-train in geriatrics
when possible.
6.
Increase efforts to obtain government,
corporate & philanthropic support to expand
aging social work programs, especially
important are monies for financial assistance
to master’s & doctoral level students. Given
social work salaries relative to those of other
health professionals, it is critical that deans &
directors advocate for & speak up on state &
federal legislation providing student financial
assistance, including proposals for loan
forgiveness.
59
Incorporating Geriatrics (Continued)
7.
Deans & directors are eager that faculty
members apply for & receive Hartford & other
funding, but they also need to support faculty
with sufficient in-kind resources & additional
funding beyond that which foundations provide.
8. Support the adoption & adaptation of existing
evidence-based social worker models, such as
the Hartford Partnership Program in Aging
Education (HPPAE), that improve the education
of trainees and the delivery of health care
services to older patients.
60
Incorporating Geriatrics (Continued)
9. Initiate interdisciplinary teaching
programs so graduates are better able
to work in interdisciplinary teams,
especially serving frail older adults.
10. Have your school take a leadership role
in critical geriatric areas where there is
insufficient attention, strategies, models
& creativity. Among those that stand
out are: 1) prevention & public health, &
2) mental health, both diseases and
social isolation.
61
Incorporating Geriatrics (Continued)
11. Increase educational, research &
practice relationships with non-social
work schools in your institution to better
prepare social workers to assume
managerial, policy & leadership roles
within & outside social work programs
& academic health centers. Social
work leaders also need to strengthen
their partnerships with community
leaders to provide better services to
older adults.
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By KATIE THOMAS
Published: February 11, 2009
Owners of Older Dogs Revel in Westminster Winner: 10-Year-Old
Spaniel Completes Comeback
Stump
At 10 years old, Stump the Sussex spaniel should be well into his dotage. Instead, the dog who
technically retired four years ago took home Best in Show on Tuesday, February 10th at the 133rd Annual
Westminster Kennel Club show at Madison Square Garden, becoming the oldest to win the award.
Many handlers and owners believe that elderly dogs even have a few advantages, because they
are seasoned competitors who are more likely to perform predictably.
“It’s like the same patina you get from a very elegant mature person. They have a certain
posture and confidence that you only get with age.”
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