 |
 |
|
|
|
|
|
|
|
||||
|
||||
 |
|
|
| Personnel for Health Needs of the Elderly Through Year 2020: Chapter III: Estimates of Personnel and Training Needs | ||
|
||
 |
||
|
September 1987 Report to Congress U.S. Department of Health and Human Services September , 1987 |
||
|
PART A: MEDICAL PERSONNEL The larger population of older adults will be seeking increasing amounts of services from physicians in future years. At the same time, the supply of physicians will be expanding substantially. The needs of the elderly population are likely to challenge the skills and capacities of practicing medical personnel. The number of active physicians is projected to grow about 2 percent a year between the years l985 and 2000. This rate is slightly greater than the anticipated increase in these years of the population 65 years of age and older. As indicated in Table l, the number of active MDs and DOs is expected to increase to more than 700,000 in 2000 from fewer than 540,000 in l985. If enrollment of medical students does not decrease substantially, the number of active physicians in the year 2020 will probably approximate 850,000. Under these conditions, the annual rate of increase of physician supply between l985 and 2020 would be slightly less than the comparable growth rate of the elderly population during the period. Older adults are likely to be utilizing considerably more ambulatory care from physicians in the coming years. Recent trends suggest that such utilization may increase markedly. Between l98l and l985 the total number of ambulatory visits to physicians by persons 65 years of age and older increased about 20 percent, or more than 4 percent a year. Between l978 and l985 the total number of such visits increased about 40 percent, or more than 5 percent a year (Table 2). Similarly, there have been even greater increases in the number of ambulatory care visits to physicians by persons aged 75 and over. The number of such visits increased more than 25 percent between l98l and l985, and about 60 percent between l978 and l985 (Table 3). About half of the ambulatory visits to physicians by older adults in l985 were made to physicians in internal medicine and general or family practice. General and family physicians provided the largest share of these services, about 30 percent. However, in recent years the proportion of all ambulatory care visits by these types of practitioners has declined while the share provided by other medical specialists has increased. In l985 persons over the age of 65 accounted for more than 20 percent of all ambulatory care visits to physicians. The share has increased from l98l, when it was l8.4 percent, and from l978, when it was l6.l percent. The proportions of the practices of different medical specialties that are devoted to serving older adults vary considerably, as indicated in Table 4. For example, in l985 about half of the ambulatory care visits to cardiologists were made by elderly people. Similarly, visits by older adults accounted for very large portions of the practices of ophthalmologists, urologists, and internists. For all the medical specialties listed in Table 4, the proportion of their practices related to the care of older persons increased between l98l and l985. Thus, if these patterns continue, almost all medical specialties will be devoting substantial shares of their efforts to providing services to older adults. Currently only a small number of physicians report geriatric medicine as their major field of interest and activity. About 900 physicians indicated such emphasis in a l985 survey of the American Medical Association. Even physicians who report a major focus in geriatric medicine often do not devote all their efforts to this area. Nevertheless, an increasing number of physicians are beginning to concentrate their activities in geriatric medicine. Some are in academic positions with major teaching and research responsibilities; others are providing clinical services and offering geriatric consultation services within the medical community. Recent estimates of the number of physicians who are full-time faculty members in geriatrics, after completion of a geriatric fellowship program, range from about l20 to 250. No more than 450 physicians are estimated to have completed fellowships in geriatric medicine and geriatric psychiatry. An increasing number of physicians in all specialties, particularly in primary care, are expected to expand their levels of expertise and skills in geriatric medicine. In recognition of these developments, the American Board of Internal Medicine and the American Board of Family Practice plan to certify physicians who have achieved added competence in geriatric medicine. To take the examination to obtain such a certificate, a physician must have been certified in either internal medicine or family practice and completed additional approved training in geriatric medicine. The first examination is scheduled to be given in the spring of l988. The American Board of Psychiatry and Neurology is establishing a similar category for special qualification in geriatric psychiatry. By focusing efforts within the mainstream of these and other medical specialties, it is anticipated that geriatric medicine will have a major impact throughout the field of medicine.
Personnel Needs Future needs for physicians to serve older adults may be grouped in three categories as follows.
A perspective on the potential magnitude of physician personnel needs is offered by applying methodologies developed for the l980 study, "Geriatrics in the United States: Manpower Projections and Training Considerations", by the Rand Corporation. The analyses were designed to provide a range of estimates of potential needs. They considered a number of possible future roles and responsibilities for geriatricians (i.e., physicians with extended preparation in geriatric medicine) as a) academic leaders, b) consulting specialists, and c) primary care practitioners. They also reviewed the potential implications of such developments for other medical specialists, particularly primary care physicians. Each option was further analyzed to identify the effects of greater degrees of delegation to other health professionals, such as nurse practitioners and physician assistants. The Rand study also considered the implications of improvements in the level of ambulatory care provided to older adults. The analyses, based on data from the mid-l970s, found that the average period of contact between physicians and older patients was several minutes shorter than for middle-aged patients. Further, elderly people underutilized services to a slight degree when their level of illness was considered; elderly persons had somewhat fewer non-hospital visits than middle-aged persons. On the assumption that that longer amounts of time spent with patients represent better care, an additional set of estimates of potential future needs was calculated which corrected the perceived underutilization by elderly patients. This adjustment was made by assuming for older persons the increased usage that would result if the length of encounters with physicians equaled that of middle-aged patients. The results of an application of the Rand methodologies for this study to the years 2000 and 2020 are shown in Tables 5 and 6. The tables also indicate separately the potential impact on personnel needs of improved levels of care. These estimates may illustrate general levels of magnitude of prospective future needs, even though the specific estimates are constrained by the fact that they are based on patterns of practice prevalent in the l970s. The lower estimates tend to assume substantial use of nurse practitioners and physician assistants. The estimate of the number of needed academic leaders in geriatric medicine is based on the assumption that at least two to three physicians with specialized expertise in geriatric medicine are needed in each medical school to guide undergraduate and graduate programs. In addition, at least two medical educators are needed in major teaching hospitals to direct residency programs in primary care. These individuals will also be responsible for the continuing education of practicing physicians and for the planning and conduct of research efforts. A recent report of the Institute of Medicine called for at least 2,l00 such academic leaders. Other estimates also have projected needs for large increases in the number of academic leaders in geriatric medicine. For example, the Association of Program Directors in Internal Medicine estimated that at least l,600 academic geriatricians are needed so that there will be the equivalent of two geriatricians for each of approximately 800 internal medicine and family practice residency programs. The American Academy of Family Physicians foresees the need for at least 400 qualified faculty members to serve existing residency programs and 800 to match anticipated expansions. If future geriatricians also assume responsibilities as consulting specialists, they would provide consultation to other health care providers for complex treatment problems and care for certain patients on referral. Under this approach, the number of geriatricians needed might range from l0,000-2l,000 in the year 2000 and from l4,000-29,000 in the year 2020, depending on the scope of their efforts, the amount of delegation to other caregivers, and the levels of services. (These figures combine estimates in columns l and 2 of Tables 5 and 6.) Some future geriatricians may also undertake responsibilities as the physician of first contact and the coordination of care for certain elderly patients. Depending on the scope of such responsibilities and the extent of improvements in care, the estimate for this case might expand to about 3l,000 geriatricians in the year 2000 and 44,000 in 2020. (These figures also combine estimates in columns l and 2 of Tables 5 and 6.) The higher estimates are about 50 percent greater than the estimates that assume continuation of past levels of utilization. Primary care practitioners in family medicine and internal medicine are most likely to continue to provide the major share of medical care to elderly adults in the future. The estimated needs for full-time equivalents (FTE) in these categories, utilizing the Rand methodologies, range up to 28,000 in the year 2000 and 40,000 in 2020, depending on the scope of their activities and the degree of delegation. Actions to improve the levels of care might increase the estimate to about 32,000 in 2000 and 47,000 in 2020. Because primary care practitioners will usually also serve a substantial proportion of younger patients in their practices, the total number of primary care physicians who will be substantially involved in the care of older persons and who will need preparation in geriatric medicine will be much greater than the number of FTEs cited above. To illustrate this point, the foregoing FTE estimate can be translated into the total number of individual practitioners of these types who are likely to be serving older adults. For example, if primary care physicians average about 25 percent of their time in caring for person 65 years of age and older, then the FTE estimates for the year 2000 (i.e., 28,000 and 32,000) translate to about ll2,000 and l28,000 individual practitioners. Similarly, the FTEs for the year 2020 (i.e., 40,000 and 47,000) translate to l60,000 and l88,000 individual practitioners. Thus, the number of primary care practitioners who are estimated in this case to be substantially involved in the care of older persons equals well over half of the total number of practitioners in these specialties anticipated to be practicing in the years 2000 and 2020. The amount of time primary care practitioners devote to the care of elderly persons would probably be somewhat less if some future geriatricians undertake responsibilities of first contact. (This relationship is indicated in Tables 5 and 6, column 3, lines 3 and 6.) The impact might be up to 20-25 percent, depending on the extent to which geriatricians assume expanded roles. Even under those conditions, however, primary care physicians would probably continue to provide the majority of physician care to older persons. Turning to another medical specialty, it is likely that geropsychiatrists will be needed to provide leadership in education and training as well as to offer consultative services and limited amounts of direct service. As noted in Chapter II, epidemiological studies indicate that l8-28 percent of the elderly population have significant psychiatric symptoms. Although other physicians and health care personnel will provide some of these services, especially for mildly depressed patients, specialized training in psychiatry is needed to care for severely depressed patients as well as for demented individuals with significant behavioral disorders. The provision of psychiatric care to the elderly population has been seriously constrained by limits on payments from Medicare and other public and private health care financing programs. Changes in these policies would probably greatly increase needs for personnel to provide such care. In addition, the future elderly population may be increasingly interested in such care in view of attitudes and experiences developed in earlier years. In order to provide leadership in education, training, and research programs, there is a need for 400-500 geropsychiatrists. An estimate of needs for other geropsychiatrists active in patient care (based on l per l0,000 older adults) would be at least 3,000-4,000 in the year 2000 and 4,000-6,000 in 2020. Another medical specialty that is likely to have an increasingly important role in the care of older persons in the future are physiatrists, that is, physicians specializing in physical medicine and rehabilitation. These physicians provide direct care to older people and leadership to other health personnel in treating and training patients to reach their maximum functional capacities. In l983 about 2,900 physicians designated themselves as physiatrists, an increase of about 8 percent from l982 and 30 percent from l980. The latest supply projections developed by the Bureau of Health Professions anticipated about 3,600 such practitioners in 2000 and 4,600 in 2020. The Graduate Medical Education National Advisory Committee in the early l980s identified this as one of the medical specialties that might experience substantial shortages in the future. About 650,000 allopathic physicians are forecasted to be practicing in the year 2000. This estimate includes about l25,000 specialists in internal medicine and 85,000 in general and family practice. If it is assumed that essentially all geriatricians and primary care practitioners included in Table 5 are from these two groups, the maximum estimate of FTEs equals about 25 percent of these specialties. If enrollment in medical schools remains about level, the number of allopathic physicians in the year 2020 will be about 800,000, including l30,000 specialists in internal medicine and 95,000 in general and family practice. Under the assumption that essentially all geriatricians and primary care physicians would be from these two categories, the maximum number of FTEs estimated for the provision of services in 2020 to the elderly population equals about one third of the expected supply of these specialists. However, as discussed above, a much larger percentage--perhaps three quarters or more--of the total number of individual practitioners in family medicine and internal medicine may be responsible for the care of a substantial number of older persons.
Training Needs In view of the foregoing discussion of potential medical personnel estimates, three types of training needs for physicians to serve the future elderly population can be identified as follows:
The expanded curriculum in geriatric medicine should give attention to both knowledge and skill components. Care of chronically ill frail elderly persons should be emphasized. Certain areas deserve special attention:
In order to develop broader understanding and competence in geriatric medicine, educational experiences should encompass a variety of clinical settings. Participation in required rotations in the following types of settings will be beneficial:
Continuing medical education activities are critical to ensure that the latest knowledge and techniques are provided in daily practice. The importance of these efforts is underscored by the fact that new medical school graduates will not compose half of the number of practicing physicians until after the year 20l0.
Current Status Educational programs in geriatric medicine have expanded a great deal in recent years. More efforts are underway throughout the country in medical schools, in residency programs, and through continuing medical education activities. However, the scope and extent of these programs are still relatively modest. In most cases, their development has been constrained by the severe shortage of faculty members who have adequate preparation in geriatric medicine. A l983 survey of medical schools found that almost all of the schools had strengthened their activities in geriatric medicine, with about 90 percent indicating some effort in this area. Required curriculum is usually included in the first or second year whereas such activity in the fourth year is generally elective. While hospitals and nursing homes are the most common training sites, more programs are using outpatient facilities, homes, and other community sites. A l984 survey of medical schools identified the scope of clinical programs in geriatric medicine offered by departments of family practice, internal medicine, and psychiatry. Slightly more than 50 percent of the schools had programs in at least one of the three departments, and about l5 percent (l9 schools) had programs in all three departments. No geriatric medicine clinical programs were reported in these departments for about l8 percent of the schools (22). Although the number of efforts has more than doubled since l980, the majority are elective and less than 5 percent of senior medical students report active participation. Only 40 percent of medical residencies offer geriatric rotations and few residents choose them. In medical residency programs, emphasis on geriatric medicine has also increased in recent years. For example, the essentials for residency training in family practice require a longitudinal curriculum component in geriatric medicine in all residency programs (Appendix F); many programs have 4- to 8-week required or elective block rotations in geriatric medicine. One of the eight components included in the American Board of Family Practice's certifying examination concentrates on geriatric medicine. Similarly, the American Board of Internal Medicine's certifying examination includes questions relating to geriatric diagnosis and care. Several other efforts are also under way to expand education and training activities in geriatric medicine. Although data on the scope of these efforts are incomplete, the following information is indicative:
Examples of other activities to increase the number of faculty members with expertise in geriatric medicine are the following programs:
Medical schools have substantially expanded their relationships with and training activities in nursing homes. A l986 survey found that 90 percent of the schools report such affiliations and more than 50 percent have teaching programs in such settings. Continuing medical education in geriatrics for practicing physicians has also increased but is still modest. Some medical specialty groups are offering additional programs on these subjects to their members. For example, the American Academy of Family Physicians, in cooperation with the Society of Teachers of Family Medicine, is extending its activities to bring new research and clinical information to practicing family physicians. However, a recent review estimated that no more than 8,000 (of more than 450,000) practicing physicians attended at least one day of continuing education devoted solely to geriatric medicine during the years l984 and l985. Public Law 99-660, enacted in November l986, authorized a new program within the Public Health Service, effective in fiscal year l988, for federal support of additional projects to train physicians who plan to teach geriatric medicine. Assistance will be awarded to schools of medicine and osteopathy, teaching hospitals, and graduate medical education programs for two purposes. One is to help support one-year retraining programs in geriatric medicine for faculty members in departments of internal medicine, family medicine, gynecology, and psychiatry. The other purpose is to add one- and two-year fellowships in internal medicine or family medicine which emphasize geriatric medicine and are designed to provide training in its clinical and research aspects. An additional $4 million was authorized for these activities and related geriatric dentistry training projects. The president's FY l988 budget proposed that this authority not be implemented.
Strategies for Meeting Needs for Medical Personnel The preparation of additional faculty members to guide and conduct education and training programs in geriatric medicine is a most critical need. Almost all schools are experiencing a shortage of such personnel. These leaders are essential to provide the foundation for the expanded educational efforts that are needed at the undergraduate and graduate levels as well as in continuing medical education programs. The following actions are indicated to help meet anticipated needs:
PART B: DENTAL PERSONNEL The oral health status of older adults is improving. This trend has been documented in a number of recent national surveys. Yet there are still major differences between older and younger adults. A nationwide effort to promote and maintain the oral health of mature and older adults is being developed, emphasizing the reduction of risks associated with the loss of teeth. Such an effort could lead to much improved dental status among older adults in the future. For example, a national oral health survey among employed adults and retired persons at senior centers, conducted by the National Institute of Dental Research during 1985-86, found that 4 percent of the employed adults and about 42 percent of the older persons had lost all their permanent teeth. There were similar differences in dental caries and periodontal disease status between the two groups. These findings are consistent with earlier studies that found over half of persons aged 65 and older were I edentulous. As the younger groups age, they are tending to retain more of their teeth. In addition to retaining more of their teeth, older persons are tending to have higher expectations for oral I health. Demand for dental care by older persons is increasing. Between 1978 and 1983, the number of dental visits by persons 65 years of age and older increased by more than 40 percent (Table 7). The number of older persons who visited a dentist within the last year expanded at almost the same rate. The average number of visits by older persons during a year increased about 25 percent during the five-year period, from 1.2 to 1.5 visits a year. The 1985-86 national survey, described above, also found that utilization patterns were different among persons 65 years of age and older who had teeth and who did not. More than half (55 percent) of the dentate older individuals reported visiting a dentist during the past year compared to 13 percent of edentulous older persons. Demand for a wider range of dental services by older persons is anticipated for the future. Extractions and removable prostheses should decrease while there should be an increase in preventive, restorative, periodontic, endodontic, and fixed prosthetic services. For example, in the 1985-86 national survey, half of the older persons with teeth indicated that the main reason for their last visit to a dentist was a checkup and preventive care. Although most older persons will have oral needs similar to those of the adult population generally, a small portion are likely to experience complicated dental conditions requiring intensive and sophisticated care. As with other special-care populations, many of these individuals will have multiple medical problems with associated drug therapy; both factors may seriously affect their oral conditions and related treatment. These persons may either be living at home or in long-term care institutions, conditions that complicate the management of care delivery to these patients. To address these issues, a cadre of dental professionals is required with a thorough understanding of organ systems affected by multiple systemic conditions and the knowledge and skills to deliver appropriate care to these patients. Furthermore, individual differences are greater among older persons, with respect to both dental conditions and complicating medical problems. Therefore, individualized approaches to dental (as well as medical) needs are essential. Personnel Needs At present the large majority of dental care is provided in the community, in the offices of private practitioners. According to the American Dental Association, about 20 percent of dentists also provide some care in long-term care settings. This proportion may increase as needs for care increase, especially among the frail old, and more services are required in homes, hospices, nursing homes, and other long-term care settings. According to the data in the Fifth Report to the President and Congress on the Status of Health Personnel in the United States, the supply of dentists and dental hygienists is expected to increase in coming years. As indicated in Table 8, the number of active dentists is projected to increase from about 140,000 in 1985 to about 160,000 in 2000, an annual growth rate of about one percent a year. The number of dental hygienists is expected to increase from about 46,000 in 1985 to about 57,000 in 2000, about 2 percent a year. Dental services for the future elderly population are anticipated to be of two general types:
The former group is likely to include the majority of older persons. They will receive most, perhaps all, of their dental care in ways similar to those used by younger people. Accordingly, almost all dental practitioners will be serving an increasing number and proportion of older patients. The latter group will require most of their care from dental practitioners with specialized advanced training in geriatric dentistry. Such practitioners can be expected to devote most, perhaps all, of their professional practice to serving older patients. Accordingly, it is anticipated that three types of practitioners will be critical in providing services to the elderly in the future, as follows. Essentially all dentists--and all dental hygienists and dental assistants--will be serving a substantial number of older persons as part of their regular practice. A small proportion of dentists will be concentrating on serving functionally dependent elderly persons. A leadership cadre will be responsible for educational and research activities as well as specialized consultation. Recent projections by the American Association of Dental Schools and the American Society for Geriatric Dentistry were developed on the assumptions that a) about 40 percent of the elderly will fall into the special needs patient group; b) about 50 percent will actively seek professional care; and c) dentists with advanced training in geriatric dentistry will serve an average of about 1,000 older individuals with an anticipated utilization rate of 50 percent, in addition to caring for functionally independent patients. Under these three assumptions, there will be a need for about 7,500 dental practitioners with advanced preparation in the year 2000 and 10,000 in 2020. In light of the uncertainties of the assumptions, needs for the year 2000 might be viewed to be in the range of 6,000-8,000, and needs for the year 2020 in the range of 8,000-12,000. Further, a proportion of the future dentists with advanced preparation in geriatric dentistry will devote the major portion of their efforts to teaching, research, and consultation. It is estimated that the leadership cadre may be about 20 percent of the group with advanced education in geriatric dentistry. They may number about 1,500 in 2000 and 2,000 in 2020. The leadership cadre will usually be located at dental schools and teaching hospitals. Thus, the number of dentists requiring advanced education in geriatric dentistry will comprise only a small proportion of all practicing dentists. On the basis of the projections noted above, it appears that dentists with such advanced preparation will make up about 5 percent of all practicing dentists. In light of the changes in dental conditions and needs discussed above, dental hygienists are also likely to have increasingly important roles in providing services to the elderly, especially the well elderly. Their contributions will be especially important in extending preventive practices and services. These estimates of personnel needs are based on the best available information. However, periodic monitoring of the oral health status of U.S. adults is essential in order to assess changing conditions that may require adjustment in estimates of the types and numbers of dental personnel needed to meet the future needs of the increasing number of older persons. Training Needs All dentists, dental hygienists, and dental assistants should receive education concerning the special conditions and needs of the elderly population. This preparation should be an integral part of basic professional education. Such training should also receive major attention in the continuing education of all current and future practitioners. To prepare dentists capable of serving functionally dependent older persons, advanced postdoctoral training will be required. Residency programs with a dental geriatric emphasis will develop needed additional competencies in managing the dental needs of patients with a variety of complicating medical, behavioral, and social conditions. These programs can also provide necessary experiences in a multiplicity of service settings, including the provision of care in homes and nursing homes. To develop competencies for the leadership group, formal programs of at least two years duration are required. Fellowship programs are essential to recruit and support the preparation of such leaders, including programs that lead to Ph.D. degrees. Emphasis must be placed on preparing individuals in this group for both academic and research responsibilities. The addition of a third year focused on research to existing fellowship programs would begin to address this need. Additional attention will also be needed in the training of dental hygienists concerning the care of older persons. As note above, these approaches will emphasize the extension of preventive practices and settings; such services can be provided by appropriately trained personnel in a variety of community settings. Current Status Important progress has been made in recent years in extending geriatric educational efforts as part of predoctoral and postdoctoral dental programs. A 1984 survey of dental schools found that there has been an increase in the teaching of geriatric dentistry topics in dental schools. Curriculum guidelines published in 1982 by the American Association of Dental Schools and learning modules developed in 1979 by the American Dental Hygienists Association have aided these efforts (Appendix F). However, substantial work is still needed to improve and integrate geriatric topics in dental school curricula. Further analysis of the 1984 survey report shows that the development of geriatric dentistry in the curricula of dental schools is uneven. Moreover, the number of dental schools requiring geriatric experiences as an integral part of their didactic and clinical programs is still small. There are currently 270 general practice residency programs, with about 1,000 first-year positions. While care of geriatric patients is not necessarily a primary objective of many of these programs, dental residents learn to manage patients with more complicated conditions, especially hospitalized patients. Federal funding from the Bureau of Health Professions of the Health Resources and Services Administration has helped to expand and maintain the number of general practice residency programs. Ten geriatric dentistry academic awards of five years duration were made between 1980 and 1984 by the National Institute on Aging. Their purpose was to assist the preparation of researchers and leaders in academic dentistry and to help develop and strengthen curricula in geriatrics. Several of these programs are still receiving support but no new awards are being made. The two-year Dentist Geriatric Fellowship program of the Veterans Administration has been preparing five fellows per year since 1982. Most of these individuals, 13 of the 15 to date, remain with the VA in clinical and research positions. They also hold academic appointments at affiliated dental schools. At this time, eight dentists are graduating from formal training programs in geriatric dentistry annually, five from Veterans Administration programs, and three from other programs. To meet the needs discussed above, the total number would need to be increased to about 75 graduates per year. There are currently only 20-25 dentists in the nation fully trained in geriodontics. Most are located in dental schools and with Veterans Administration medical centers. Dental faculty, as well as others, are being prepared, through short-term intensive experiences, in the Geriatric Education Centers funded by the Bureau of Health Professions. Of the 22 funded centers in 1986, 20 had dental components of which 19 are dental schools. A review of the continuing education courses being offered or listed by the American Dental Association in 1986 revealed that less than half of one percent are directly relevant to geriatric dentistry. In 1979 the Bureau of Health Professions awarded grants to two dental schools and the American Dental Hygiene Association to develop model curricula in geriatrics for dentists and dental hygienists (Appendix F). In November 1986, Public Law 99-660 authorized a new program to train faculty who teach or plan to teach geriatric dentistry; the president's 1988 budget proposed that this authority not be implemented. Strategies for Meeting Needs for Dental Personnel The highest priority should be given to the preparation of additional dental school faculty with advanced training in geriatrics. This step is essential to provide the foundation for expanded educational, clinical, and research efforts. Additional fellowship support for advanced dental training is required to meet this need. Other important steps that should be considered include the following actions: 1. Integration of dental geriatric teaching materials, resources, and learning experiences into the curricula of all schools of dentistry, dental hygiene, and dental assisting; 2. Development of new dental teaching materials and techniques, especially to take advantage of new technologies and research advances; 3. Greater emphasis on preventive measures to maintain the oral health of older persons; 4. Strengthening attention to geriatrics in general dental practice residency and advanced general dentistry programs; 5. Adding geriatric components to advanced general residency programs; 6. Development of dental residency programs with a specific emphasis on geriatrics; 7. Assessment of the continuing education needs of current dental practitioners with respect to geriatrics; 8. Expansion of continuing education programs for dentists and dental hygienists to give more attention to the particular needs and conditions of older persons; and 9. Development of research training programs for personnel needed for field and laboratory research in geriatric dentistry.
PART C: NURSING PERSONNEL Nurses provide services to elderly persons in many settings, including their homes, doctors' offices, community health clinics, nursing homes, and hospitals. In most situations, nursing personnel are the largest segment of formal caregivers. In 1984 about 1.5 million registered nurses (RN) were employed (Table 9). About one-third of nurses work part-time. Thus, the full-time equivalent (FTE) workforce equaled about 1.25 million. Analysis of RNs by workplace indicated that approximately 33 percent of the efforts of the FTE supply are devoted to the care of persons 65 years of age and older. About 540,000 licensed, practical/vocational nurses (LPN) were working in 1983, as indicated in Table 10. About one quarter were employed on a part-time basis. Thus, the FTE supply was about 470,000. Analysis of their workplaces suggests that about 44 percent of the efforts of the FTE supply are focused on the care of older adults. According to data in the Fifth Report to the President and Conqress on the Status of Health Personnel in the United States in 1986, the supply of nurses is projected to continue to grow, but at a slower rate, through the year 2000. An available supply of about 2.1 million RNs and about 860,000 LPNs was projected for that year. On an FTE basis, the respective numbers are about 1.75 million and 756,000. The projected increases of FTEs include annual rates of growth of over 2 percent for RNs and 3 percent for LPNs. In the next decade or so, a decline in the number of annual graduations and an increase in the age of new graduates are anticipated. These factors will result in a declining rate of growth in the nurse population, a higher age level among those in the population, and a decrease in the "activity rate"--that is, the proportion of registered nurses who are employed. About 79 percent of the RN population was employed in 1984; it is estimated that about 72 percent may be employed in 2000. On the assumption that annual graduations of RNs will either stabilize or decrease somewhat between 2000 and 2020, it may be anticipated that the RN population may continue to grow but at a slower rate each year. The size of the nurse population may begin to level off about 2020. In terms of the supply of nurses available for employment, the increasing age level of nurses leading to a related decline in the activity rate could result in a constant number by 2020. It is more difficult to estimate the supply of LPNs in 2020 because of a number of uncertainties. Two important sources of uncertainty are the potential impact on enrollments of reduced employment opportunities for LPNs in hospitals and possible changes in educational levels and licensure requirements in the nursing profession. Personnel Needs Future needs for nursing personnel have been projected on the basis of two approaches: An historical trend-based model that uses past and current trends in service and resource utilization, modified by assumptions regarding likely changes in these trends; and A criteria-based model that uses professional judgments about appropriate resources necessary to achieve health care goals. One set of criteria, the so-called lower bound, is defined as a level which all States can achieve; another set of criteria, the so-called upper bound, is a level some States will achieve and towards which other States will work. As indicated in Tables 11 and 12, according to the latest projections (presented in the Fifth Report) utilizing the historical trend-based model, the estimated requirements for the year 2000 would be about 1.7 million FTE RNs and about 720,000 FTE LPNs. Taking into account only those segments of the projection of demand for services that are attributed to older age groups, without considering differentials in the amount of nursing care which may be required, about 35 percent of the efforts of the FTE RNs and 50 percent of the efforts of the FTE LPNs would be needed to provide services to persons 65 years of age and older in 2000. The higher proportion of LPNs required for the care of older persons is due to the fact that a larger proportion of that group is expected to work in nursing homes--more than 40 percent compared to about 15 percent of the RNs. The conclusions in the criteria-based model are based on the expertise of a planning group, which developed staffing and service utilization ratios to accomplish established health care goals. As reported in the Fifth Report, in the summer of 1984 a group composed of experts in various areas of nursing practice and representatives of several nursing and health care service associations revised previous established criteria in light of health care goals and needs for the years 1990 and 2000, taking into account new and revised forms of care delivery as well as concerns about costs. In their review of criteria for staffing nursing homes, the panel attempted to strike a balance among various factors, e.g., economic constraints, current staffing patterns, and the need to move from primarily custodial care to care that provides a more therapeutic environment. The panel recognized that a number of important changes are likely to affect nursing home care in the future. Examples of these are: Increasing intensity of institutional care; Increased responsibilities to provide extended and recuperative care after hospital discharge; Higher average age of patients; and More sophisticated levels of care for many patients, including a great deal of new technology. These changes indicate that an increase in nursing hours per resident day is warranted. Although the panel tempered the use of higher skilled nurses to take account of anticipated economic constraints, members felt that the criteria established represent important gains over the 7-12 minutes of RN care per resident day currently provided. The panel also anticipated a definite increase in the use of various forms of community health care, which would stem from the current trend of deinstitutionalizing persons with a number of types of disability. A sharp increase in the proportion of those discharged from hospitals who will require home health care is likely. The aging of the population and the increased number of older persons living alone will add to requirements for home health care. Because the lower-bound estimates reflect the level established by the panel for the country as a whole these estimates are considered here. Based on the criteria-based model, more than 2.3 million FTE RNs, about 423,000 FTE LPNs, and about 1.5 million FTE nursing aides would be required for the year 2000. Services to persons 65 and over would involve about 46 percent of the efforts of RNs, 70 percent of the work of LPNs, and 66 percent of the work of nursing aides. For nursing homes, these requirements reflect the provision of 3.5 direct care nursing hours per resident day, of which one third is RN care and about 17 percent LPN care. The remaining 50 percent is care provided by nursing aides. With respect to home health services, the criteria used reflect RN home health visits to about 2 percent of the population aged 65-74, 5 percent of those aged 75-84, and 10 percent of those aged 85 and over. They also included more visits for those in the older age categories. In addition to the RN care required in the home health area, the panel envisioned a need for four home health aides to each RN needed. The panel also paid particular attention to the need for RNs with specialized practice. For nursing homes they estimate needs for one clinical specialist for every 100 residents and for 10 percent of the RNs providing direct care to be nurse practitioners. Tables 11 and 12 reveal important differences in requirement estimates between the historical trend-based model and the criteria-based model. Particularly striking are the projections for nursing home employment in the year 2000. Whereas in 1984 about 92,000 FTE RNs were employed in nursing homes, projected requirements in 2000 range from 260,000 in the historical trend-based model to over one million in the upper-bound criteria model. These differences underscore the considerable uncertainties that prevail about future developments in the nursing home industry. Further, the conclusions drawn by both modeling efforts need to be seen within the context of the major changes that the health care system is undergoing, as noted in Chapter II, and the lack of sufficient data to be able to capture the impact that these changes will have on resource requirements. Perhaps neither past trends nor current judgments about care needs and delivery reasonably reflect future conditions and needs. It may be some time before clear indications of things to come will emerge. These constraints are particularly relevant in looking forward to 2020. Because the numbers and types of nursing personnel required are directly related to the setting and types of services provided, shifts in the ways in which health care is delivered will affect the overall numbers of nursing personnel required. The movement toward non-institutional care, coupled with an assumption of improvements in the health status of the 65-74 age group over that of that age cohort in 2000, might lead to a decrease in nursing requirements to provide care for that group. In addition, while the age 75-and-over population will increase in 2020 over their numbers in 2000, the increase for 2020 is lower than that leading to the year 2000. Thus, while this group might still require relatively high levels of nursing care, the decrease in the requirements for the 65-74 year-old cohort, coupled with the revised delivery system, might offset increases required for the older age population. Therefore, with respect to the criteria-based model, if the criteria established for 2000 were to apply to 2020, then the overall effect might be that the estimated requirements for 2020 would remain about the same as for 2000. Under the historical model assumptions, however, there might be an increase in requirements for RNs and a decrease in requirements for LPNs between 2000 and 2020 due to the fact that utilization rates have tended to move toward the rates established for the criteria model. Geriatric nurse specialists include geriatric nurse practitioners (GNP), gerontological clinical specialists, geropsychiatric specialists, and RNs prepared in long-term care administration. Adult and family nurse practitioners are also prepared to serve the elderly population. In 1984 there were only about 6,200 adult and family nurse practitioners and 200 GNPs certified by the American Nurses Association. GNPs are working not only in nursing homes but also in ambulatory care programs, home care programs, rehabilitation, and other hospital-based activities. In 1984 there were approximately 750 nurse practitioners specifically prepared in geriatrics. Their employment has often been limited by restrictive payment policies. The modification of payment policies by health care financing agencies with respect to the services of GNPs, particularly relating to care delivered in the homes of older persons and in nursing homes, would be an important factor in increasing their future utilization and stimulating the education of such personnel. For example, the Rand Corporation report in 1981 projected a potential need for 12,000-20,000 GNPs by 2010, depending on the amount and scope of their responsibilities. Two groups that have analyzed opportunities for strengthening care in nursing homes (Middle Atlantic Regional Nursing Association and Mountain states Health Corporation) have recommended that one geriatric nurse specialist should be available for every 100-125 residents. On this basis there would be needs for up to 8,000 GNPs in 1990, 19,000 in 2000, and 25,000 in 2020. Educational Needs and Current status Although the overall projected supply of RNs appears to be generally in balance with projected needs, there are significant imbalances with respect to the educational preparation of nurses. In 1984 about 400,000 of the 1.5 million employed RNs had a baccalaureate degree and 90,000 had a master's or doctoral degree. The expert panel that established the criteria reported in the Fifth Report projected requirements for RNs with a baccalaureate degree in 2000 at about twice the projected supply (1.1 million FTEs compared to about .5 million). For nurses with graduate degrees the projected requirement is about three times the projected supply (515,000 FTEs compared to 171,000). Although the panel recognized that the major revision in the educational system that would be required is unlikely to be achieved by 2000, the expression of the goals provides a direction for change. The report on Nursing and Nursinq Education from the Institute of Medicine in 1983 noted that the lack of focus on older persons during the years of educational preparation may be one reason that many licensed nurses are not attracted to geriatric care. The committee pointed out: "If nursing education were to provide special preparation in the many aspects of geriatric care, licensed nurses would gain an understanding of the special needs, challenges and rewards of caring for the elderly and thus become more attracted to employment in all the settings where those people receive care--at home, in clinics, in hospitals, and in long-term care facilities." Additional attention needs to be devoted to the preparation of all nurses who will be responsible for providing nursing and health care to the growing number of older persons. There is a major need to increase the geriatric content in undergraduate programs, to increase enrollment in masters- level graduate programs preparing various types of geriatric nurse specialists, and to increase the number of doctorally prepared faculty for teaching and research in this field. In addition, continuing education of current practitioners needs to be greatly expanded to ensure that the latest knowledge and practice are incorporated into the daily practices of institutional and community programs. The current status of efforts and needs for changes in basic, graduate, and continuing education programs are addressed in the following three subsections. Basic Education Historically, professional nursing students in basic education programs have found limited content focused on the care of aged persons. Many course offerings were disease-specific and oriented to the medical model of care. As the population of older persons has increased, schools of nursing have increased the quantity of didactic content dealing with geriatrics in their curricula. A 1984 study of generic baccalaureate programs reported that 71 percent of the 197 responding schools had integrated gerontological contents into their curricula and another 11 percent had specific courses on gerontological nursing. However, there was wide variation in the placement and scope of such content. Further, a substantial number, about 20 percent, did not report any specific attention focused on aging issues. Students' opportunities for clinical experiences with older patients have increased dramatically with the larger number of aged persons in acute care settings. The rising number of frail elderly individuals in the community has also provided additional clinical experiences for students in community health nursing. Respondents to the above survey indicated about half of the students had experiences with acutely ill elderly persons, and about two thirds had experiences with well elderly persons. Involvement in home health programs, ambulatory care centers, health maintenance organizations, and long-term care settings hold promise for expanded clinical experiences for students in basic programs. Innovative educational patterns which closely relate didactic education and clinical practice with older persons need to be designed and tested. Graduate Education Graduate education programs, which prepare nurses for leadership roles in various specialty areas, currently include a relatively small number of nurses specializing in geriatric nursing. For example, in the 1984 Sample Survey, only about 1,100 nurses (1 percent) of the 109,000 nurses with masters or doctoral degrees identified geriatric clinical practice as the primary focus of the degree. The shortages of faculty, administrators, clinicians, and researchers in gerontological nursing are substantial. For example, less than 3 percent of current faculty members have attained masters level preparation and less than 1 percent doctoral level preparation in gerontological nursing; another 4 percent report isolated course work in gerontology. Thus, less than 10 percent of nurse faculty members have special preparation in this field. (However, other nurses specialize in adult and family nursing, which have strong threads of geriatric content within the curricula.) A cadre of well-prepared leadership is essential to exert positive influence on the education of nurses with respect to health care for the elderly. To help address these critical needs, the Division of Nursing of the Bureau of Health Professions supported 10 advanced nurse education programs with a specific focus on geriatrics during fiscal year 1986. Nurse practitioner programs in gerontological nursing also offer advanced preparation to RNs. These programs stress physical assessment and case management. They have tended to move from continuing education certificate offerings to graduate programs that award a masters degree. Twenty-two graduate programs and 13 other programs currently prepare geriatric nurse practitioners; 11 graduate programs received support from the Division of Nursing in fiscal year 1986. About 150 nurses graduate or receive certificates in the field annually. The Veterans Administration provides funds for the clinical training of master’s-level clinical nurse specialists in geriatrics, rehabilitation, and psychiatry/mental health. Annually, about 100 students complete their clinical practicum at 29 VA medical centers. A Gerontological Nurse Fellowship Program was recently established for doctoral level nursing students; plans call for four fellows at two sites within the next few years. Continuinq Education Updating the knowledge and skills of practicing nurses who a work with the older population is vital, yet continuing s education offerings in this specialty are limited. Particularly underserved are nurses who work in inner city hospitals, nursing homes, and community health. Continuing education programs should be made available, accessible, and affordable nationwide for nurses involved in providing care to the older population (Appendix F). In response to the need, 12 Nursing Special Projects are being supported nationwide by grants from the Division of Nursing to assist practicing nurses and other nursing personnel to gain needed knowledge and skills in caring for older persons. Several grantees are developing modules for self study; others are using cable television networks and video programming in addition to the more traditional workshop formats. Many have targeted particular groups, including nurse managers, paraprofessional nursing personnel who work in Native American nursing homes, faculty in schools of nursing, and nurses who work in community settings. Many programs include clinical experiences where the participants practice newly learned assessment skills or teach health promotion. Preparation of Other Nursinq Personnel Much of the hands-on care of older persons is delivered by nonprofessional nursing personnel, nursing aides and orderlies and nursing assistants. The roles of aides and assistants varies by practice setting; they are major sources of care for nursing homes residents, as discussed in Chapter IV. In nursing homes and home health agencies, unlicensed aides generally outnumber licensed nursing personnel. Hiring requirements for aides are usually minimal, neither a high school diploma nor previous work experience being necessary in most cases. This situation is beginning to change, however, as a growing number of States require that nursing aides complete approved training courses, either before starting to work or after they are hired. The typical nursing aide training program, which lasts 240 hours, covers body mechanic, nutrition, anatomy and physiology, infection control, and communications skills. English-language proficiency requirements are beginning to appear as well. Aides and orderlies rely largely on in-service and orientation programs sponsored by employers. Orientation and skill training programs vary greatly in length and sophistication. Areas that need particular attention include skills in assisting older persons in activities of daily living, communication and interpersonal relationships, and the skilled use of technical devices. Efforts to develop model training programs merit study and replication. Because much of the direct care of older persons is the responsibility of this large cadre of personnel, much more attention needs to be given to improving their knowledge and skills. Strengthening Curriculum Content for Geriatric Nursing Research-based curriculum content in geriatric nursing at all levels of nursing education is inadequate. Little systematic study has been given to nursing care and related educational activities concerning either well or chronically impaired elderly persons. For example, only recently has research been initiated specifically focused on the provision of constructive nursing care to older persons who are incontinent; because urinary incontinence is one of the primary reasons for institutionalization, education concerning prevention and management of this condition would be enhanced by greater emphasis on available research findings and further research. Care of patients who have suffered strokes is another relatively neglected area; such patients consume large amounts of skilled nursing care. Little research on which to base education and training activities has been conducted to identify coping strategies utilized by older persons who successfully live in the community; such studies would provide a sounder basis of knowledge to stress health promotion and disease prevention approaches. Similarly, tools to carry out accurate functional assessments are in short supply and only scattered nursing research studies are being targeted to the psychosocial problems of the elderly population. Findings from such research, focused on both physical and psychosocial problems, can have a major impact on the quality of future geriatric nursing curriculum content. The National Institute on Aging, the National Center for Nursing Research, and other programs of the National Institutes of Health are supporting studies in these fields. Strategies for Meeting Needs for Nursing Personnel Needed actions to strengthen the education of nurses who serve older adults include the following: Faculty development-- 1. Expand efforts to update knowledge and skills of current school of nursing faculty members; and 2. Encourage advanced nursing education students to specialize in gerontological nursing. Curriculum development-- 3. Develop research and demonstration activities with older populations that will both strengthen curricula in schools of nursing and improve patient care; 4. Stress attention to health promotion and nutrition content in nurse-client interactions with frail elderly persons; 5. Enhance education concerning the coordination of services provided by nurses and interdisciplinary caregivers; 6. Increase clinical experiences for all levels of nursing students in both institutional and community settings; 7. Expand research efforts to identify more effective ways of providing nursing services to older patients, such as the care of patients with cardiovascular accidents; and 8. Include more emphasis on functional assessments and the maintenance and restoration of functional capacities in older persons as part of basic and continuing education programs. Advanced and continuing education-- 9. Provide for educational development of nurse leaders in long-term care nursing administration; 10. Increase the quantity and quality of continuing education offerings focused on health care of both well and ill older persons for all levels and types of nursing personnel; 11. Provide more part-time, flexible educational programs to increase opportunities for career mobility for nurses in geriatric practice; 12. Formalize and extend in-service and continuing education programs for LPNs and nurse aides and orderlies who work in hospitals, nursing homes, and home health agencies, with particular emphasis on direct patient care; and 13. Develop more instructional materials for nonprofessional nursing personnel that will assist them in providing care to older persons who are at home and in nursing homes.
PART D: SOCIAL WORK PERSONNEL Social work personnel provide a multiplicity of services to older persons and their families as part of health, mental health, and social programs. They have major roles, both as individual practitioners and as members of multidisciplinary teams, in hospitals, clinics, long-term care facilities, and many community-based programs. High-risk groups of older persons residing in the community have special needs for social work services. These include many frail elderly persons, mentally ill/retarded persons, individuals from low-income and minority groups, and the families of these persons. One of the most vulnerable groups includes people living alone, who are predominantly widows, often among the oldest old, frequently in poor health and living on very low incomes. Another special group is composed of older persons living with an aged spouse or other relative, who are often stressed and require assistance to obtain the support necessary to maintain independent living. In recent years services to chronically impaired groups have increased substantially. Social workers held 335,000 jobs in 1984, according to the Bureau of Labor statistics (BLS). Based chiefly on the assumption that the social services industry will continue to expand more rapidly than the economy as a whole, BLS projects demands for 438,000 social work jobs in 1995, an average annual growth rate of 1.8 percent for the 1984-95 period. If that rate of growth persists, employment of social workers would rise to nearly 450,000 by the year 2000 and 640,000 in 2020. Between one-half to two-thirds of persons in social work positions are estimated to have completed formal professional programs in social work education. This condition reflects the wide variation in hiring requirements for entry-level jobs. A bachelor’s degree--not a social work degree--is the minimum requirement for many professional positions in this field. In addition to persons with degrees of bachelors in social work (BSW), undergraduate majors in psychology, sociology, human services, and related fields satisfy hiring requirements in many agencies. A master's degree in social work (MSW) is generally required for positions in hospitals and mental health settings and is almost always necessary for supervisory, administrative, or research jobs. Enrollments in accredited BSW and MSW programs peaked in the late 1970s and have declined since then, with a sharper drop in BSW than MSW programs. In 1984 there were fewer than 15,000 graduates from about 450 social work degree programs. In view of past trends in the proportion of bachelors and masters students majoring in social work, together with the impending decrease in the college age population, it seems unlikely that the supply of formally prepared social workers will keep pace with anticipated growth in positions. This condition does not mean necessarily a shortage in social workers, in view of the abundant supply of new college graduates, career changers, and re-entrants who have the requisite education or experience. Nevertheless, it does suggest that fewer social service professionals may have received systematic preparation in social work methods, putting a greater burden on employers to provide in-service education and training. The National Association of Social Workers (NASW) estimates that about 20 percent of the current efforts of NASW members (103,000 in 1986) serve persons 65 years of age and older. This estimate is based on assumptions that about 10 percent of the caseloads of family service agencies and outpatient facilities and 33-50 percent of the work of hospital social work personnel are concerned with older adults. Only about 5,000 NASW members (less than 5 percent of the total) consider work with older persons to be their primary field of practice. In some communities, however, the proportion of social work services for older adults is much higher. Few social work personnel have had education and training concerning the special conditions and needs of older persons and their families. For instance, the large majority of personnel in social work positions in nursing homes have not had any professional training in social work. Further, most professionally trained social workers who serve older adults have not had any specialized training in geriatric or gerontologic social work. Personnel Needs Social work personnel will be needed in the future to work with older persons and their families in a wide range of programs and places. They may assume direct services or management responsibilities in such activities as these: homemaking and home health programs day programs family service associations community mental health centers senior centers respite programs hospice programs care management activities information and referral programs advocacy and legal service programs protective social services nutrition programs nursing homes and homes for the aged acute care and mental hospitals discharge planning activities Area Agencies on Aging state and local surveillance and licensure programs. Many of these activities and programs are likely to have greatly expanded needs for geriatric social work services. For example, care management and other coordinating activities in family service agencies, outpatient mental health facilities, and other community-based programs for older adults may increase substantially. Care management activities are already expanding in many communities. These efforts are directed at achieving the most appropriate care and rehabilitation services for older persons and making the most effective use of available resources. Professionally trained social workers are frequently responsible for planning and guiding these efforts, in collaboration with many other health and human services professionals. The extent of growth of social service programs for older persons in the years ahead is uncertain. The volume and variety of social services for older adults will continue to reflect resource allocation decisions by individuals, families, and all levels of government. It may be that social work jobs created by private purchases of social services will experience rapid growth, while those associated with publicly funded programs will expand at a more modest rate. InterStudy, with support from the Retirement Research Foundation, is conducting a study that examines this issue and other consequences of the rapid growth of private geriatric management firms. The number of full-time equivalent professionally trained social workers needed to serve older persons and their families has been estimated to be in the ranges of 40,000- 50,000 in the year 2000 and 60,000-70,000 in 2020. These estimates are many times the current levels of adequately trained personnel and the capacities of training programs. Under any conditions, the number of social workers needed to work with older persons and their families is greatly in excess of the current number of prepared personnel in the field. Training Needs Social work personnel must be prepared to meet the diverse social service needs of older persons and their families. To do so they need specialized knowledge of the aging process and the conditions and interpersonal dynamics of aged individuals and their families, as well as an understanding of how the systems providing health care and other services for aging persons operate. They must be prepared to work with various family structures and be sensitive to many different cultural influences and practices. They should have skills to carry out responsibilities as individual practitioners, members of multidisciplinary teams, and program managers. In view of the increasing needs for various social services among older persons and their families, all social services personnel should receive education and training concerning the special conditions and needs of the elderly population. Such preparation should be an integral part of their basic preparation in undergraduate and graduate degree programs. It should also be emphasized in advanced degree and continuing education programs. A substantially greater number of social work educators and practitioners specializing in geriatric social work is needed. These leaders are prepared in graduate degree programs. In addition, continuing education programs can help prepare faculty members and current practitioners for career shifts in order to meet the expanding needs anticipated in the next few years. Integration of more content on geriatric social work into the regular curricula of BSW and MSW programs can help to overcome the reluctance (reported by most students) to concentrate on the needs of older populations and their families. Additional specialized curricula in geriatric social work in undergraduate and graduate degree programs will ensure personnel with greater depth and breadth of knowledge and skills concerning the conditions of elderly persons and their families. Additional education and training efforts of this nature can help to develop an adequate cadre of social work practitioners specifically prepared to focus on the problems of the increasing older population. A critical constraint to the expansion of geriatric and gerontological programs in schools of social work is the serious shortage of faculty members with substantial expertise in these subjects, according to analyses of the National Committee for Gerontology in Social Work Education. Less than 10 percent of the approximately 4,000 full-time faculty of such schools have any formal training in aging issues. To develop a nucleus of faculty members with expertise in these subjects in the approximately 450 schools with BSW and MSW degree programs will require a faculty leadership cadre of 600-1,000 educators. Thus, a substantial increase in the number of faculty members who are highly qualified in geriatrics/gerontology is the highest priority training need. Current Status The number of undergraduate programs in social work that give attention to aging issues and the number of graduate programs that offer a concentration in the field have increased in recent years. Also, related continuing education activities have been expanded with more interdisciplinary content. Current efforts are still very modest, however, compared to the needs of the growing elderly population. Despite the progress to date, there are schools of social work in which there is no systematic attention to the preparation of students for careers in the field of aging. Even among schools where courses and field work are offered, the range and quality of students’ experiences are very uneven. A survey of BSW programs for the 1985-6 academic year, sponsored by the Council on Social Work Education, found that over 75 percent of the approximately 360 programs included gerontologic content in their basic curricula. Additionally, a majority of programs offered electives in aging; about 20 percent of the students chose such courses. About 13 percent of practicum settings were primarily in the field of aging, and a similar proportion of recent graduates were reported to have taken jobs involving substantial services to older persons and their families. These data suggest a growing interest among students in working with older persons; half of the responding schools reported increasing interests in the field of aging among their students. Similarly, about 35 percent of faculty members expressed increased interest. However, only 10 percent of all BSW faculty reported any special preparation in the field of aging. A 1984 survey of MSW programs indicated that 51 of 89 responding programs offered a concentration or specialization in aging. However, the programs vary greatly in scope and intensity. More than 60 percent anticipated further expansion in their geriatric social work curricula. The mean number of faculty with a specialized interest in geriatric content, among schools offering such specialization, was 2.4, but only about half had any specialized training the field. About half of the 50 doctoral programs in social work offer a specialization in the field of gerontology. In 1983 approximately 80 of 1,800 full- and part-time doctoral students (less than 5 percent) were either enrolled in a gerontological concentration or an individualized course of study in this field. A 1985 survey of practicing MSW social workers identified the following topics as being among the major needs in continuing education: Working with older persons in such settings as hospitals, nursing homes, home care programs, and hospices; Cultural differences within the elderly population; Working with Alzheimer disease patients and their families; Prevention of physical and emotional problems; Working with intergenerational families; and Care management and discharge planning. These findings indicate greater awareness among social work practitioners that aging issues need more attention. Several projects have been undertaken in recent years to strengthen social work education in the field of aging. For example, the Council on Social Work Education, with grant support from the Administration on Aging, has surveyed the status of gerontology in social work schools and produced a series of curriculum models. Publications have addressed the integration of gerontology in social work education, a curriculum concentration in gerontology for graduate social work education, faculty development, and continuing education (Appendix F). The National Institute of Mental Health has also aided the expansion of activities in this field. Three major programs have been made available to schools of social work as follows: The Faculty Development Award, which is designed to prepare teachers of geriatric mental health in clinical training centers where no local resource faculty currently exist; Postgraduate Specialty Training in Academic Geriatric Mental Health, which is designed to further develop training programs that are already active in the dissemination of mental health skills and knowledge, by increasing the pool of potential faculty members though specialty training; the training programs may include a range of other postgraduate training experiences; and Geriatric Training Models, which are designed to provide training experiences to the nonspecialist in geriatric care and to stimulate the development of model materials and curricula for the incorporation of geriatric mental health skills and knowledge into the general training of the four core disciplines, psychiatry, psychology, nursing, and social work. The Geriatric Education Centers, sponsored by the Bureau of Health Professions, are also assisting the preparation of social work educators in geriatric social work as part of their multidisciplinary approaches. The Veterans Administration provides training support for a number of students in associated health fields, including master's level social work students from affiliated schools. In 1986, 204 of the 656 students receiving such support in 136 VA medical centers were in geriatric social work. A special allocation in 1986 also aided the training of another 123 masters level social work students. Strategies for Meeting Needs for social Work Personnel A series of actions aimed at the following objectives can help to expand the number of social work personnel who are well prepared to serve older persons and their families in the future. 1. Expansion and integration of knowledge about the aging process and the older population and their families into the core curriculum of all schools of social work; 2. Substantial increases in the number of social work faculty members with adequate preparation and expertise in aging issues who will provide leadership in undergraduate, graduate, and continuing education programs; 3. Encouragement of many more undergraduate and graduate students to select and complete concentrations in gerontologic social work; 4. Recruitment and training of more students and practitioners from minority groups; 5. More opportunities for students to obtain practical experiences in diverse service settings and as members of multidisciplinary teams; 6. Expansion of continuing education programs to advance the knowledge and skills of current practitioners (including both professionally trained and other social service personnel) and to encourage career shifts to concentrate more on geriatric social work; and 7. Extension of research to expand knowledge for teaching and service about the social problems of older persons and their families and more effective ways of meeting these needs.
PART E: OTHER HEALTH PERSONNEL A very large number of other types of health personnel are increasingly involved in the care of older persons. Many different occupations and specialties make critical contributions to the care and well-being of older persons. They provide essential services and support in community programs and home visits as well as in hospitals and long-term care settings. They contribute importantly to the provision of personal assistance and care and to the effective implementation of many technological advances. The multiplicity of health problems of many older persons, particularly frail elderly individuals, often calls for multidisciplinary and interdisciplinary approaches and activities. Diverse competencies and skills are required to respond effectively to their complex conditions and needs. The appropriate utilization of well-prepared allied health professional and other health personnel can make it possible to maintain a greater number of older persons at home with maximum functional independence. Use of the full potential and resources of the health care system can help to ensure the highest possible degree of well-being among older persons and assist them in overcoming disabilities. Table 13 illustrates the many different types of allied health professional and other health personnel who currently contribute directly to the care of older adults. Some work primarily in the community, while others work principally in institutions; most work in both types of settings. The scope and diversity of employment in the health field is evident from analyses of wage and salary workers in the health industry prepared by the Bureau of Labor Statistics. The Bureau identified more than 7 million such workers in 185 occupations in 1984. The analyses anticipated that the number of wage and salary workers in the health industry will continue to grow in future years, partly because of the need to serve increasing numbers of older persons. The projected number of such workers for 1995 is about 9.1 million, an increase of 26 percent over the 1984 figure. Alternative projections for 1995 range from 7.3 million to 10.5 million. Approximately 500,000 additional workers will be employed in nursing homes by 1995, according to the Bureau's base projections, and more than 400,000 additional jobs are expected in offices of physicians. The most rapid growth, however, is expected in offices of other health care practitioners (including nurse practitioners, physical therapists, psychologists, and so forth), outpatient care facilities, and home health agencies. This chapter focuses on only a few types of other health personnel because of limitations of data and time. The following types of personnel suggest the broad scope of health services that can enhance the functioning and well-being of older adults. These personnel also play some of the best-defined roles in the care of older persons: Occupational therapy personnel Physical therapy personnel Audiologists Speech-language pathologists Dietitians and nutritionists Optometrists Pharmacists Physician assistants Podiatrists Psychologists The first six types are discussed below; the last four are discussed at the end of this section. Personnel and training needs for some other personnel, particularly aides, are also discussed in Chapter IV. The focus on these fields is not meant to detract from the valuable and necessary roles played by other health personnel. Additional analyses of personnel and training needs of other health personnel are encouraged. Some professional associations that have reported along these lines are: American Association of Colleges of Pharmacy American Association for Counseling and Development American Association for Respiratory Care American Occupational Therapy Association American Optometric Association American Psychological Association American Society for Allied Health Professions American Speech-Language-Hearing Association Association for Gerontology in Higher Education Although the projections presented below are the best possible, given resource and data constraints, a number of qualifications should be noted. As discussed in Chapter II, the number and kinds of personnel needed to meet future health care needs of the elderly population will be determined by the interplay of many factors: demographic, clinical, social, economic, and political. The reasonableness of long-term projections of personnel ultimately rests on the soundness of assumptions about future developments not only in the rapidly changing health care system but also in the broader society and economy of which that system is a part. Projections of the quantity and mix of personnel required to provide a given amount of health care are highly problematic. They should be viewed with great caution. straight-line projections, based on increases in the numbers of elderly persons and other factors, assume that the current numbers and mix of health professional are appropriate to the needs of the population and do not adjust for improvements in productivity, quality, and efficiency of the health care delivery system. Additionally, projections of need 35 years into the future cannot take into consideration such factors such as cost containment (which may shift care settings and payment policies), the growth in home care, future technological innovations, as well as changes in morbidity and mortality. The following subsections review needs for allied and other health personnel who directly provide rehabilitation services to older persons. The analysis emphasizes the opportunities and needs for fuller involvement of allied and other health personnel in meeting the rehabilitation needs of older persons. Rehabilitation Personnel Rehabilitation approaches are at the heart of geriatric care. Such activities can provide immeasurable benefits enhancing the quality of life of chronically disabled persons and their families. They can also reduce needs for other ongoing support services in the community and institutions. In addition to physiatrists, the primary allied health professionals actively involved in rehabilitation services are occupational therapists, physical therapists, audiologists, and speech-language pathologists. Other allied health personnel--such as dietitians and nutritionists, optometrists, prosthetitians, orthotists, respiratory therapists, and radiology personnel--also have important roles in rehabilitation. Numerous technical-level personnel also contribute to the availability of such services. Occupational Therapy Personnel Occupational therapy personnel are concerned not only with work and therapeutic activities but also with adaptations between physically and mentally impaired patients and their environments. Patients may be trained to mitigate or overcome a disability or the immediate environment may be modified with specialized aids. Both approaches are often employed simultaneously. Uncommon conditions and multiple disabilities experienced by many older persons, especially frail elderly individuals, challenge the skills of therapists. If the patient is to achieve optimal rehabilitation, the therapists must be prepared to participate fully in case management. Currently, however, relatively few occupational therapists are prepared for this role, nor is sufficient research being done to explore the potential contributions to be made by these types of personnel to the health of older adults. Occupational therapists have traditionally provided services to elderly persons in hospitals and long-term care institutions; they are expanding their efforts in other settings such as outpatient facilities, comprehensive rehabilitation centers, adult day care centers, and home health programs. It is estimated that in 1982 about 17 percent of the work of occupational therapists was devoted to services to elderly persons. When this proportion is converted to full-time equivalents (FTE), it is estimated that about 5,000 FTE occupational therapist personnel are engaged in the treatment of the population 65 years of age and over. About 40 percent of the services provided by occupational therapists to older persons are delivered in nursing homes and 20 percent in hospitals. The remainder is delivered in settings such as rehabilitation centers, home health programs, and private practitioners’ offices. Deficiencies in current services are illustrated by a recent study indicating that only 10 percent of nursing home residents received occupational therapy services; it was estimated that about 35 percent of the patients would have benefited from such services. (Medicare coverage of these services was extended by the Omnibus Budget Reconciliation Act of 1986, effective July 1, 1987.) Projections of future needs for occupational therapists have been based on anticipated increases in the number of elderly persons, the number with limitations in activities of daily living, and the number projected to be in short-stay hospitals and nursing homes in the future. Using this approach it is estimated that a minimum of 7,200 FTE occupational therapist personnel would be needed to serve persons 65 and older in the year 2000, and a minimum of 10,200 FTEs would be needed in 2020. The minimum estimate of need in 2020 is more than twice the level of service currently provided. The estimate could increase by as much as 50 percent, to 15,300 FTEs in 2020, if the proportion of time spent by occupational therapists in treating older persons were to increase. An estimate based on total occupational therapy services, including both occupational therapists and their assistants, needed to treat elderly persons in all settings in the year 2000 is from 11,800 to 13,300 FTE personnel. The range for 2020 is from 15,800 to 17,800 FTE personnel. Phvsical Therapy Personnel The importance of physical activity to the restoration and maintenance of health is increasingly recognized, and the potential contributions of physical therapy to the well-being of older adults are being more appreciated. Postoperative rehabilitation of hospitalized patients has received the most attention. The potential benefits to poststroke, arthritic, and other chronically disabled older persons are not yet fully realized, however. These services also have considerable cost-saving potential through improvements in physical and mental states of patients and deferral of institutional care. Physical therapists spend about 25 percent of their efforts in serving older persons, according to available data. On an FTE basis, it is estimated that about 8,800 physical therapy personnel are involved in treating individuals 65 years of age and older. About 40 percent of these efforts are in hospitals, 30 percent in nursing homes, and the balance in other settings such as rehabilitation centers, home health programs, and private practitioners' offices. An estimate of future needs, based on assuming the continuation of current patterns of service, indicates need for a minimum of 12,600 FTE physical therapy personnel to serve older adults in the year 2000 and 18,000 FTE in 2020. Thus, at least a doubling of the number of physical therapists would be needed to serve the elderly in the latter year. The estimate could increase by as much as 50 percent, to 27,000 FTEs in 2020, if the proportion of time spent by physical therapists in treating older persons were to increase. Audiologists Sensory deprivation in older adults is an important contributor to the dissociation and impaired mental states that hasten institutional admission. As with vision, the maintenance of hearing has not only immediate and obvious benefits but also contributes to individuals’ well-being and self-maintenance in ways difficult to document but nevertheless critical. As health care financing and provider groups recognize these benefits, greatly increased attention is likely to be given to maintaining the hearing of older persons. An estimate of future needs for audiologists' services among older persons may be based on the reported prevalence of hearing disability among the noninstitutionalized elderly population and current professional practice patterns. Currently, audiologists spend about one third of their time in providing service to elderly persons. In the year 2000, it is projected that a minimum of 8,300 FTE audiology personnel would be required to serve people 65 years of age and older. By 2020, the number of audiologists calculated as needed to serve this population group will be at least 11,800, an increase of more than 40 percent over the 2000 figure. The estimate could increase by as much as 50 percent, to 17,700 FTEs in 2020, if the proportion of time spent by audiologists in treating older persons were to increase. Speech-language Pathologists Loss of the ability to communicate greatly complicates the provision of health and custodial care to patients and contributes to deterioration of individuals' mental state. Speech problems are common in older persons due to the prevalence of stroke. Although in many cases the prospects for total rehabilitation are poor, the benefits of any improvement in the ability to communicate, both to the individual and to caregivers, warrant increased efforts. Estimates of future numbers of speech-language pathologists needed to serve persons 65 years of age and over are based on reported current prevalence rates of speech-language impairment as well as recent patterns of practice. Currently, speech-language pathologists devote about 15 percent of their time to care of elderly persons. By the year 2000, it is projected that at least 10,900 FTE speech-language pathology personnel would be needed to serve older persons. The number is projected to increase to at least 15,800 by 2020. The estimate could increase by as much as 50 percent, to 23,700 FTEs in 2020, if the proportion of time spent by these personnel in treating older persons were to increase. Dieticians and Nutritionists The incidence of inadequate diet and poor nutrition in many elderly persons and the debilitating and costly consequences of such experiences are well documented. As the number of aged persons increase and a smaller proportion are maintained in institutions, the importance of more attention to diet and nutrition becomes even greater. The ready availability of a larger variety of foods and the development of convenience foods present new problems and opportunities to devise and prescribe diets that are appropriate and feasible for independent older persons. with recognition of the wisdom of providing individual consultation and assistance in diet as a method of deferring costly institutional care, the preparation and availability of personnel to meet these needs will have to be expanded. Optometrists The preservation of vision is important to maintaining the independence of older persons. Diseases and health conditions common among them--e.g., hypertension, glaucoma, diabetes--require vigilance on the part of ophthalmologists and optometrists. Physical limitations, including incontinence, sometimes make it difficult for elderly people to obtain care from conventional sources. Further, mental disabilities can complicate diagnosis, refraction and the use of vision aids. Maintenance of vision in aged persons requires, therefore, special forethought, planning, and modifications in the delivery of services. Prior to the enactment of Medicare more than 60 percent of the population aged 65 and over received primary eye/vision care from optometrists. Although this proportion still holds for the total u.s. population, the effect of Medicare has been to reduce the proportion of eye/vision care provided to older persons by optometrists to approximately 35 percent. This proportion may increase substantially, however, with the enactment of Public Law 99-509, which allows for payment under Medicare for vision care services performed by optometrists, if the services are among those already covered by Medicare when furnished by a physician and if the optometrist is authorized by State law to provide the service. As a consequence, personnel and training needs among optometrists to serve older persons are likely to increase. According to a recent report of the American Optometric Association, the total requirements for primary eye/vision care will increase at a much faster rate by the years 2000 and 2020 than in earlier years due to the fact that the population aged 65 and older will require much more care than other segments of the population. A major factor is that prevalence of eye disease and vision conditions significantly increases with age. Training Needs for Rehabilitation Personnel The foregoing discussion indicates that a multitude of health professionals are likely to be called upon to provide a substantial amount of rehabilitation services to older persons in the future. To ensure that current and future personnel are adequately prepared to carry out these responsibilities in an appropriate and effective manner, it is critical that all future rehabilitation personnel receive education and training in aging and geriatrics as part of their basic professional education programs providing competency-based skills. Similarly, information and materials on geriatrics must be emphasized in continuing education activities for current and future personnel of these types. Training efforts should include specific skills needed to work most effectively in different settings. The provision of care in acute, tertiary, ambulatory, and home care settings calls for differing levels of skills. For example, practices that work well in acute care settings where equipment and other professionals are readily accessible are unrealistic when working in long-term care facilities and homes. Additional skills, sometimes called transprofessional skills, must also be developed as well as the ability to work as members of interdisciplinary teams. Training should also provide experiences in a variety of settings, such as rehabilitation centers, geriatric assessment units, ambulatory care facilities, and home health programs. Placements should also ensure exposure to a range of older persons, rather than solely to those who are chron1cally ill, in order to prevent students from stereotyping elderly persons and to give them broader understanding of the diversity of conditions among older adults. Current Status of Training Rehabilitation Personnel Geriatrics and gerontological issues are being given more attention in recent years in education programs for rehabilitation personnel. For example, a recent survey of entry-level occupational therapy education programs found a moderate emphasis on aging issues; about one half the programs provided some gerontological instruction and about one third required fieldwork placement in geriatrics for all of their students. However, major emphasis was given to aging issues in less than 10 percent of the I programs and only about 15 percent of faculty members had special training in aging. Expansion of these activities is constrained by the serious shortage of faculty members with special preparation in aging. A curriculum guideline for continuing education, "The Role of Occupational Therapy with the Elderly," has been developed and disseminated by the American Occupational Therapy Association, with assistance from the Administration on Aging (Appendix F). Additional teaching materials for entry-level programs are being developed and regional workshops are being conducted to assist faculty in integrating geriatric information into established curricula. Seven post-professional graduate programs offer specialization in gerontological occupational therapy. Continuing education programs for both current faculty members and practitioners are also being expanded. Teaching materials on speech, language, and hearing problems among the elderly population have also been developed in recent years. A booklet, "Communication Problems and Behaviors of the Older American", and a text, Gerontologv and Communication Disorders, have also been published recently (Appendix F). The American Speech-Language-Hearing Association has developed a manual for independent or group study, titled Gerontological Training in Speech-Language Therapy and Audiology, with assistance from the Administration on Aging. In the field of optometry, three one-year residencies in geriatrics have been initiated in recent years, in collaboration with the Veterans Administration. Additionally, 10 residencies in rehabilitative optometry give considerable attention to older patients. A number of schools and colleges of optometry offer specific courses in geriatric optometry; the Association of Schools and Colleges of Optometry is reviewing existing curricula in order to strengthen activities in aging among its members. The Administration on Aging has supported the development of education and training programs in a number of fields. For example, as discussed above, assistance has been made available to the American Occupational Therapy Association, the American Optometric Association, and the American Speech-Language-Hearing Association to assess current and potential roles and responsibilities, to develop curriculum material and training products, and to extend education activities, especially continuing education. Other awards have aided particular programs in pharmacy and occupational therapy as well as multidisciplinary activities. The 11 Long-term Care Gerontology Centers that have been aided by the Administration on Aging have also offered education opportunities to many types of health personnel. The Bureau of Health Professions has assisted the establishment of 22 Geriatric Education Centers between 1984 and 1986, which offer educational experiences to faculty members and practitioners in many health fields. These regional resources also assist information dissemination, curriculum development, and technical assistance in geriatric education. The Veterans Administration has also aided the development of a wide range of health personnel in geriatrics. In Fiscal Year 1986, for example, about 103 associated health students received financial support from the VA at 47 selected medical centers (in 10 GRECCs and 37 other facilities) with special programs for the care of older veterans in the following disciplines: occupational therapy, optometry, audiology, speech pathology, clinical pharmacy, and psychology. Of special importance to the integration of various disciplines in geriatric care is the program for Interdisciplinary Team Training in Geriatrics, which is conducted at 12 model sites in the VA; about 200 students a year participate in this training activity. Strateqies for Meetinq Needs for Rehabilitation Personnel The development of full-time career-dedicated faculty members with special preparation in aging is a critical need in order to increase the number and training of rehabilitation personnel in geriatrics. Effective faculty role models, including leaders who practice in the community and in nursing homes, are needed in all educational programs preparing future personnel. One important approach to extending the effectiveness of faculty members prepared in geriatrics is the development of cooperative arrangements among health professions schools so that resources are shared on a regional basis. This approach can also further the expansion of multidisciplinary educational activities. The Geriatric Education Centers, described above, are an example of this method. Fellowships to support interests in geriatrics among both current and future faculty members and students are a high priority need. Release of faculty members for intensive training experiences needs to be expanded and supported. Talented students should be encouraged and aided as potential future faculty leaders. Expansion of continuing education activities to improve the transfer of new knowledge on the care and management of older patients to current practitioners also requires special attention. Systematic assessments of needs and the content of current courses are essential steps to this end. Pharmacists The number and variety of therapeutic drugs is steadily increasing. Not only do these drugs have numerous side effects and interactions, their effects and effective dosages may vary with the age and condition of patients. Complicating this situation are the problems of compliance with medication regimens (which occur at all ages) and the added uncertainty about whether forgetful or impaired older persons will without close supervision follow often complicated therapeutic drug regimens. As a result of multiple physical problems common in this population, drugs are frequently prescribed by a number of medical specialists who may not have full knowledge of the Patient’s total drug regimen, who often are not furnished with complete and timely knowledge of patient reactions, and who may not be well informed about pharmacologies and drug interactions in aged persons. Therefore, pharmacological problems may contribute to disease and impairment in patients. Prevention of these outcomes is the function of clinical pharmacists, who are trained to analyze and evaluate complicated drug therapies to a degree not possible by other health professionals. However, rarely do clinical pharmacists have opportunities to contribute to case management. Effective care of elderly persons calls for broader use of the potential of clinical pharmacy. Pharmacists can play crucial roles in assisting elderly people to understand their prescriptions and the importance of adhering to instructions and also to monitor for possible ill effects of drug interactions when, as is common, multiple medications are prescribed for older patients. The population 65 years of age and older uses more than 25 percent of all prescribed drugs; this percentage will probably continue to increase as the population ages. However, few data have been developed that specifically address the issue of how the aging of the population will affect needs for pharmacists. Inasmuch as data related to needs for pharmacists in the entire population have not been updated since the 1970s, it is not now possible to generate needs estimates in pharmacy specific to the elderly population. Current Status The American Association of Colleges of Pharmacy introduced in 1985 a geriatric curriculum, Pharmacy Practice for the Geriatric Patient (Appendix F) .The curriculum includes data on specific conditions and drug therapies and also on socio-behavioral aspects of the aging process. Almost all schools and colleges of pharmacy are reported to be utilizing the curriculum, either as a separate course or integrated into portions of other course work. Several nontraditional postgraduate education programs in geriatric pharmacy have been developed in cooperation with pharmacy schools. Continuing education programs in geriatric pharmacy are also being expanded. Strategies for Meetinq Needs Expansion of efforts to increase the number of faculty members in Colleges of Pharmacy with expertise in aging and geriatrics deserves major emphasis. Such leadership would provide the impetus for strengthening attention to aging issues in undergraduate and postgraduate programs as well as in continuing education efforts. Physician Assistants Physician assistants (PA) are among the health care personnel to whom physicians may delegate increasing responsibilities in the future. PAs provide adjunct care for physician-directed services in conjunction with physicians. There are currently about 18,000 graduates of such programs; approximately 1,300 graduate annually. The majority of PAs, 57 percent, practice in family medicine and internal medicine. However, almost every medical specialty is likely to have some PA support. As with physicians, only a small percentage of PAs indicate that their specialty is "geriatrics"--only 2.4 percent of respondents to a 1984 survey of the American Academy of Physician Assistants, which was funded by the Administration on Aging. There are several reasons why so few PAs identify themselves as geriatric specialists. First, most PAs see a range of patients in their practice. Second, PA services have not been covered through Medicare Part B, except where waivers have been granted or where PAs are practicing in remote rural areas. Third, State practice acts sometimes restrict the practice of clinical skills by PAs in the absence of a physician on site; because nursing homes usually have only consulting physicians, this restriction virtually eliminates PA participation in nursing homes in these States. Despite the limitations on PA practice in geriatric settings, more emphasis is being given to the potential of these personnel in providing services to older people. For example, PAs can take health and social histories, perform physical examinations with particular attention to altered presentation of diseases among elderly patients, identify appropriate laboratory and screening tests to assess physical and mental functional status, evaluate the results of such tests and make an initial diagnosis, and design a treatment plan. As health care team members, they carry out a variety of tasks, including discharge planning, coordinating referrals, and participating in community screening and outreach programs. In addition, some PAs are becoming involved in rehabilitation programs for older adults. Personnel Needs As primary care practitioners with appropriate clinical experience in geriatric care, PAs can serve the future needs of the older population on a regular basis at senior centers, long-term care facilities, and other settings where both well and ill older adults congregate. This assistance may be of special importance to homebound elderly persons in rural and some urban areas, who may have inadequate health services and experience social isolation that negatively affects their health. Mid-level practitioners, such as PAs, are especially affected by changes in state laws, payment policies, and other modifications in the health care system. Current trends toward the provision of services in more cost-effective ways favor expanded roles for PAs in many health care organizations, such as inpatient facilities and health maintenance organizations. In addition, recent amendments in the Omnibus Budget Reconciliation Act of 1986 allow Medicare Part B reimbursement of PA services under the supervision of a physician in a hospital, skilled nursing facility, or intermediate care facility, effective January 1, 1987. The American Academy of Physician Assistants estimated that the numbers of PAs may expand to 35,000 in the year 2000 and to 55,000 in 2020. The Academy is currently engaged in an analysis of future PA roles and related training needs. In practice, the number of PAs needed will depend on the degree of delegation by physicians. One example cited in the 1980 Rand Corporation study, Geriatrics in the U.S.: Manpower Projections and Training Considerations, indicates that, in caring for the elderly population in 2030, 22,000 geriatricians with maximal PA delegation may be an effective alternative to 38,000 geriatricians without PA participation. Traininq Needs The training of PAs needs to be expanded in order to give further emphasis to the preparation of graduates to serve older adults. In current curricula, emphasis is mainly on the disease processes of older persons, drug management, psychosocial issues, health promotion, prevention, and nutrition. Additional learning segments should include more instruction in functionally oriented, comprehensive health assessments for older adults, home health care assessment techniques, rehabilitation, and long-term care issues. Required clinical rotations should include experiences with healthy and ill older adults in various settings, ranging from senior centers to skilled nursing facilities. Geriatric assessment and evaluation units should be included as well as acute care settings and the homes of older persons. Current status Geriatric and gerontological components of PA training programs are a relatively recent development. A 1986 survey of 36 programs, funded by the Bureau of Health Professions, found that 83 percent included some geriatric content in their didactic or clinical curricula. These efforts are the result of a federal initiative to encourage geriatric training. Geriatric and home health curricula in PA programs are expected to accelerate as a result of legislation in fiscal year 1986 that directed all PA programs funded under section 783 of the Public Health Service Act to incorporate these components in their training activities. The development of PA training programs has been assisted by two publications prepared with funds from the Administration on Aging. One is a curriculum package (Appendix F). The other is a report that assesses and identifies activities for PAs that will improve geriatric knowledge and skills. An intense, short-term educational effort on major facets of care for the elderly for 21 PA faculty was conducted in 1986 by the Bureau of Health Professions: the resulting Geriatric Curriculum Resource Package, developed by Stanford University, is available to PA faculty nationwide (Appendix F) .In addition, in cooperation with the American Academy of Physician Assistants, the Bureau completed a study to determine potential roles for PAs in geriatric care. A model geriatric clerkship for PAs will be developed in 1987. In order to maintain certification, PAs must complete 100 hours of continuing education every two years. Because the majority of PAs were trained prior to incorporation of geriatrics/gerontology into the curricula of training programs, continuing education is especially needed by PAs who are working with older persons but who have not had any formal instruction in geriatrics/gerontology. Practicing PAs have indicated training deficiencies in psychosocial aspects of aging, polypharmacy, and practice with the multiproblem patient. Pain control, home and institution-based rehabilitation, functional assessment, and geriatric gynecology have also been identified as topics for continuing education. Strategies for Meeting Needs The key factor in the development of training programs to prepare PAs to provide quality health care to older adults is the development of more faculty members who are appropriately trained and committed to teaching geriatrics. At least one faculty member at each PA training program should receive such special training. Training for special geriatrics roles is now accomplished primarily in work settings. Educational needs for specialized geriatric roles are not sufficiently focused to warrant the development of specialty-oriented geriatric educational programs; training programs should continue their primary care focus which includes geriatric training. Inasmuch as PA training programs are the primary providers of continuing education for PAs, strong faculty competence in geriatrics will also have a positive impact on continuing education curricula for current practitioners.
|
 |
back to top | |
|
||
|
||
 Copyright © Practicing Physician Education in Geriatrics |