Public Health Work Force Not Prepared for Aging Population
Increasing number of seniors on horizon
second in an in-depth series on healthy aging in conjunction with APHAs National Public Health Week, which was held April 4-10, and focused on “Empowering Americans to Live Stronger, Longer!” Visit
WHILE preparedness is a fundamental component of public health – from bioterrorism readiness to immunizations to disaster relief- some advocates say there is one major issue for which the health work force is woefully underprepared: the aging of America.
In 25 years, about one-fifth of all Americans will be ages 65 or older and, presumably, all will need a variety of health care services. In fact, older adults use more health care services than any other age group, making up half of physicians’ visits and half of all hospital stays, according to the Centers for Disease Control and Prevention. Not only will the demand for health services begin to overwhelm the supply in coming decades, health care spending is also expected to soar as more people become eligible for Medicare and Medicaid and depend more heavily on their private insurance providers.
But even though demand is expected to rise, few public health professionals are choosing to meet the challenge. A 2004 CDC report on the “State of Aging and Health in America” found that out of 650,000 practicing physicians in the United States, fewer than 9,000 are geriatricians and that number is expected to drop to 6,000 in coming years. On the education front, “geriatricians compromise only one-half of 1 percent of all medical educators in the (United States), which represents the largest education training gap in any field,” the report stated. In addition to knowledge gaps, experts are also predicting shortages among workers such as home health and nursing home aides even as the demand for long-term care increases. For example, according to the National Governors Association, “by 2025, Texas alone will need over 55,000 additional paraprofessional health care aides to maintain current levels of care.”
More public health workers will be needed in coming years to advise older adults on issues such as nutrition and medication.
Although chronic disease prevention and health promotion will be key to sustaining quality of life in later years, advocates worry that a serious dearth in geriatric knowledge among health professionals will limit the number of positive outcomes. For example, it’s well-known that regular physical exercise can delay or prevent the onset of chronic disease, increase independence and confidence and provides mental health benefits. However, because older people are under-represented in many clinical trials and research programs, relatively little is known about what motivates older people to exercise, what keeps them exercising regularly and what exercise methods are best for those with certain conditions, such as arthritis.
“In schools of public health, in medical schools and nursing schools, people don’t learn enough about how to care for the aging population,” said APHA member Nancy Alfred Persily, MPH, associate dean at the University of Albany School of Public Health. “(Public health) focused on (maternal and child health) for a long time, but we didn’t think about what we need to really prevent more disability in aging populations. We’re not educating people to look at aging as a special area that we need in public health.”
According to Persily, taking on the work force shortage will require education and government efforts, from infusing aging issues into curriculums to examining how Medicare reimbursement rates affect worker recruitment and retention. She also said the long- term care field lacks strong leaders.
“We have leaders that look academically at the scientific part of aging…but we don’t have that cadre of people who really have been educated in management, strategic planning and elder care to be able to lead the country, lead organizations and sit at the table with the other people in health care to focus on what we can do for the aging,” Persily told The Nation’s Health.
The coming boom in older Americans, Persily added, is compounded even more by predictions that many health professionals will be retiring at about the same time the demand for health care services in rising. According to the U.S. Health Resources and Services Administration, the ability to attract more workers to the aging field to replace retirees is questionable, as the proportion of people ages 18 to 30 is declining. With the exception of a few states, most don’t seem to be addressing health care work force shortages or retention problems, HRSA has reported, and many that are addressing the problems are only doing so with “modest” efforts. However, a number of nonprofit organizations have stepped up to the plate.
“We really need to be looking at 2015 and beyond because it takes at least 10 years to produce a physician,” said Edward Salsberg, MPA, director of the Center for Workforce Studies at the Association of American Medical Colleges. “Currently, I do not think we’re adequately prepared, both in terms of the number and the skill sets.”
The Center for Workforce Studies was created a year ago to collect data and conduct studies around the supply and demand of physicians and to advise the training community about the future need for physicians, Salsberg said. And the need to train more physicians isn’t only directed toward geriatricians – “the reality is that for almost all specialties…a large percent of their patients are over 65, so we’re going to need all sorts of more physicians,” he noted. According to the center, about 2,800 additional medical school graduates will be needed annually to meet predicted demand, although Salsberg predicted “we’re going to need a lot more than that.”
Graduating more physicians with knowledge of aging issues is a multi-faceted problem that will require creative solutions. Although there has been work to increase geriatric curriculums in medical schools, the demands on medical students are so high given the always increasing body of knowledge, that the challenge is finding the time for additional education. In turn, the solution is not to simply add on aging curriculum, but to “infuse the current curriculum with more information and skills around the needs of the elderly,” Salsberg told The Nation’s Health.
To keep the aging population healthy, health workers will need to be well-versed in disease prevention methods such as exercise.
“The issue of curriculum reform is really across the spectrum of all medical education and training and I think we’re still assessing our understanding of the best role for geriatricians,” he said.
The health care system isn’t designed well for geriatricians, Salsberg noted. For example, people build relationships with their health care providers over many years and are unlikely to switch their primary care to a geriatrician simply because they’ve grown older. The question arises, Salsberg said, whether is it better to have a geriatrician take over a person’s lead care or to use geriatricians as consultants. Of course, one of the best ways to prepare for an aging America and limit the impact of a work force shortage is to step up prevention, he said.
“I think the wisest investment would probably be in prevention,” Salsberg said. “It strikes me as foolish to just focus on needing more doctors and not simultaneously say ‘let’s do what we can to keep the elderly healthy.’”
Unfortunately, there’s relatively little investment at national agencies, such as CDC, in aging issues and for the average public health department, such health concerns aren’t “really on the radar screen,” according to Robyn Stone, DrPH, executive director of the Institute for the Future of Aging Services at the American Association of Homes and Services for the Aging.
“I think we are a very much aging-adverse society and it plays out in our health care systems,” Stone told The Nation’s Health.
Stone said the work force gap begins with “pervasive ageism” in the United States – that our fear of growing old, or even talking about growing old, has affected how society values those who care for the elderly.
“Our society really doesn’t value those jobs, so there’s not the same monetary value attached to (them),” she said.
There are two major issues, according to Stone: shortages and preparation of quality professionals. While much of the labor shortage for front-line caregivers is determined by competition in local economies, the “ongoing problem of preparing and retaining a quality work force is the more fundamental problem,” she said. Stone predicted that the nation has about a 20-year window to prepare itself to meet the demands of older residents.
“We’ve got to shift the paradigm of teaching to understand that our primary client will be the elderly,” Stone said.
To help prepare the nation, the Institute for the Future of Aging Services runs the Better Jobs Better Care program, a four-year, multi-million dollar research and demonstration program funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies. The program aims to create changes in long-term care policy and workplace practices, among other goals, said Debra Lipson, MHSA, deputy director of BetterJobs Better Care. In the arena of long- term care, not only do many workers not have the proper training, but the pool of workers who traditionally filled such jobs is decreasing. According to Lipson, the long-term care work force has traditionally consisted of middle-aged women with little education, but that population is shrinking as more women go on to higher education and fewer women are available to stay at home as caregivers for elderly relatives.
Also, the average wage for a nursing home aide is about $8.90 per hour, often with health benefits, while the average for a home care worker is only about $7.80, even though most people want to be taken care of in their homes, Lipson said. Adding to problems is the fact that about two-thirds of all nursing home residents have their bills paid for by state Medicaid programs, and with health care costs busting state budgets, state legislators do their best to keep pay rates low.
“You get what you pay for, and in this case, (some states) are buying services on the cheap,” Lipson told The Nation’s Health. “There will ultimately have to be some sort of publicly subsidized insurance program or something else that provides real protection from the catastrophic cost of long-term care so that it doesn’t fall on the states.”
To increase the quality of long-term care, Better Jobs Better Care awarded grants to five demonstration projects in 2003 to projects in Vermont, Pennsylvania, North Carolina, Iowa and Oregon. For example, in North Carolina, the grantee is setting up a process through which long-term care employers can apply for special licensures after having met standards for areas such as supervisory practices and safe workloads. Ideally, such employers will be able to use the licensures in their efforts to recruit more qualified workers and as part of their client marketing campaigns. In turn, a better prepared and more knowledgeable work force will hopefully result in better wages and benefits and higher retention rates, according to Lipson.
Another project at Better Jobs Better Care is looking at how to recruit non-traditional labor pools such as people ages 55 to 65 as well as those who have experience caring for an elderly family member.
“(Such workers) are not health professionals by definition and yet they are critical to the quality of care for people who need longterm care,” Lipson said.
Approximately one-fifth of all Americans will be ages 65 and older in 25 years.
However, before people reach the stage of long-term care, there are many opportunities for health promotion and the delay of chronic disease and disability that are missed, said APHA member Fox Wetle, PhD, associate dean of Medicine for Public Health and Public Policy at Brown University. The research into how to change older people’s health behavior is minimal, and when effective methods are found, oftentimes there isn’t enough funding to implement them, Wetle said.
“We’re hitting a crisis situation among public health professionals who have special expertise in healthy aging,” she told The Nation’s Health.
To begin reversing the work force trend, health curriculums must begin adjusting and national investments must be made to encourage students to study aging, she said.
“It’s very important that these investments be made,” Wetle said. “We either make the investment now or we pay big-time later.”
For more information on the health work force and aging, visit
– Kirn Krisberg
Copyright American Public Health Association May 2005