Care Delivery in the Future: The Role of the Health Care Workforce – Caring for an Aging Population

SARAH DASH: I am delighted now to turn it over to Marcus Escobedo, who is a senior program officer and communications director for the John A. Hartford Foundation. He will be moderating our final panel on caring for an aging population. Thank you, Marcus.   MARCUS ESCOBEDO:  Thank you. Really a pleasure to be here. Welcome to our panelists. This is very exciting for me, getting to be with an esteemed group of experts in improving care of older adults. It’s a mission of our foundation at the John A. Hartford Foundation. So, let me start with introductions and then we will get right into the questions and have us a lively discussion today.   First, we have Claire Luz, who is assistant professor in the Department of Family Medicine at Michigan State University, in their Geriatrics and Gerontology Program. She has 40 years of experience as a gerontologist, the majority of her research has been related to workforce developments, particularly labor conditions and training of direct care workers, which we will talk a lot about today.   We also have with us today, Joanne Lynn, who is the Director of the Center for Elder Care and Advanced Illness at the Altarum Institute. Joanne is one of the first Hospice physicians in the United States. She is the author of more than 250 articles, and several books on palliative end of life care, and she’s been a medical officer for the Centers for Medicare and Medicaid Services.   Then we have Tom Edes, who is Director of Geriatrics and Extended Care for Clinical Operations for the Department of Veteran’s Affairs. And Dr. Edes’ national responsibility for operations and management of the VA’s spectrum of services across all settings of care, and I do want to note that Tom has also been a past president of the American Academy of Home Care Physicians, and I think we will be talking a little bit about that area today as well.   Thank you all for being here. Let me start by going back in time a little bit. I’m going to go all the way back to 2008. It was just a couple of years after I had started my work at the John A. Hartford Foundation, and a report came out called “Retooling for an Aging America:  Building the Healthcare Workforce.” It was an exhaustive study examining and asking the question:  Is our workforce in healthcare prepared for the rapidly growing aging population? It’s in the context of not only a doubling of the elderly adult population in a relatively short period of time, but with that coming of course, the higher rates of multiple chronic conditions, the rise of serious illnesses and conditions like Alzheimer’s disease and dementia. The fact that 70% of us, if we reach the age of 65, will at some point need assistance with daily activities on average for three years. All of that really creates what the committee at that time felt was a really important need to examine the workforce and ask that question:  Are we prepared? So, I will quote Jack Roe, the esteemed leader of the committee at the time who responded to the Senate, No, we are woefully unprepared. Woefully unprepared, was his remark.   I want to come now to today, and I want to pose a question to the panelists. Given what the Eldercare Workforce Alliance, who is a co-sponsor today, has been talking about in their work that we are still woefully unprepared, I wanted to ask the panelists, how do you see the state of the workforce as it relates to the aging population today? Keep this pretty general and broad. And really specifically, where do you think we should be putting our energy, our attention, our action, when it comes to creating that adequate workforce that we need? I’m going to start with Tom at the end, if that’s okay, and we will work our way down.   TOM EDES:   I think “woefully unprepared” is a reasonable description right now. Because we are facing still such a climb. I will be a little bit specific to VA. For example, in the two decades between 2000-2020, the American population over the age of 85, fastest growing sector, was expected to increase 72%. Roughly 70% over 20 years. What happened in the VA, the population of veterans over the age of 85 nearly tripled in half that time, and doubled in five years between 2000 and 2005. So, we’ve been anticipating this, recognizing that the curve is steeper for us, a much sharper magnitude. We’ve been working on this for decades, so we have some success. And so, one of the things, I guess, I would like to bring into this, is the need for opportunities for really robust, interdisciplinary team training. And we have that in a few settings, right? Many geriatric programs do that, or geriatric clinics do that. Our hospice agencies can create that setting if they are connected with training to do that. But in VA, which trains almost two-thirds of the healthcare workforce of all disciplines that practice in geriatrics, we have homebased primary care. Homebased primary care gets into the home. So, it’s focused on nearly 40% of that top five percent of the population accounts for 50% of healthcare costs. And in the VA’s model, we have physician, nurse, social worker, dietician, pharmacist. Really proud of a mental health provider in every team. If I didn’t say rehabilitation therapist, that is a part of the team. So, it’s a very strong team, and it’s a great site for interdisciplinary team training. Really get that experience. That to me, is where — to take care of this population, we really need people trained in every element. Did I social work? I don’t remember? But it’s a very robust encompassing team, and bringing people together who work together, for complex care needs, is something we need to be prepared for.   MARCUS ESCOBEDO:  That’s a great point and a theme that we’ve heard throughout today’s session. Joanne, what is your take on where there are opportunities for action and where you see biggest needs?   JOANNE LYNN:  Well, how many people here want to grow old? Okay, everybody. How many want to have a couple of years of serious disability at the end?  It’s interesting how everybody wants to grow old, no one wants to age. Yet, the average is now a couple of years. Where is that help going to come from? There are almost no geriatricians, the number is going down. The geriatric skills are not actually taught to most primary care doctors. Nobody wants to work with this population. It’s really tough. I mean, it’s the hardest work around. Yet, we don’t even pay a living wage to the care workers. We pay nothing to the family volunteers. Most other countries provide a stipend, provide respite, provide all manner of support. It’s almost as if we set out to see how hard we could make it. And so, what is the upshot when we double the number of people who are old and frail? When I first started working in elder care, in 1978, there were whole states where half or more than half of the people in nursing homes were tied down every day. There were whole facilities with half of the patients having pressure holds. We don’t see that level of horrible care in general anymore, but those weren’t awful people doing that. Those were people who didn’t have the skills, didn’t have the resources, didn’t have the standards set. We could slide back to that in a flash. We could have people die much more quickly because they simply don’t get fed. In Detroit a couple of years ago, I was there, and the wait list for Meals on Wheels was 850 people. Most people died or went to a nursing home before they got fed. We are so blind to what it is we face, and yet, everybody here wants to join this group. I mean, it’s the only minority group to which we all aspire. Yet, we are doing nothing important about financing or training the workers that we need, and generating the skills that we need. It’s as if we somehow think magic is going to happen, and it’s all going to miss us. We are going to get to be 95 and die in the arms of our lover, and fresh off the golf course. Not likely. And to the extent we keep wiping out one disease after another, and doing better at prevention, we make it more likely that we are going to have frailty as our course. Frailty is a uniquely difficult course. The person is sharp, mentally aware, and can’t get out of a chair. We need to change the — we will come back to this later, but I think we need to change the power relationships. We need to change how we value this part of life, and we need to change who has the say over it. It can’t be the surgeon in the hospital whose never been on a home visit. It can’t be the legislature who thinks he’s going to be rich enough to get out of it. We have to get the caregivers involved, and really develop a political force.   MARCUS ESCOBEDO:  That’s very important points, Joanne, that we will dive into, I think, in more detail in a moment. Let me turn to Claire and give your perspective on where we are right now, and where the biggest areas of opportunity might be.   CLARE LUZ:   Well, hear, hear, that was well said. Robin Stone is not here, so I’m going to yell on her behalf. Because up until this moment, most of the discussion this morning has been about clinical care settings and licensed professionals. The shortage in an aging care — there are shortages across the board. We don’t have enough geriatricians, nurse practitioners, social workers. But we really don’t have enough direct care workers. The crisis is already here. It’s not coming, it’s here. There are home care agencies across this entire nation who are dying out there. They are desperate. They don’t have the direct care workers who are the people that allow you to stay at home. I think the end game for a lot of the clinicians and the specialists is high quality care. Right? You want to give the best care possible. But I think you have actually a bigger goal than that. You want your patients and your clients to be able to have a high quality of life at home, for as long as possible, as independently as possible. The only way they are going to do that is with direct care workers — paid direct care workers, and family care givers. Family care givers and direct care workers are the ones that are there day in and day out, doing the hands-on care that gives family members relief, but also provides the care that allows people to stay at home. Now, I, for many years, was a nursing home and home care social worker. Important job. All of these specialties are important jobs. But I would go into a home maybe once a month, set up services, help with the healthcare bills, do some counseling, things like that. But those direct care workers are the ones that are in there every single day, making it possible for people to stay at home. Yet, we undervalue them, under pay them, give them no respect. We are supposed to talk about solutions, I know, so on the positive side, I guess, if you can frame it this way, we’ve seen this coming for decades. We’ve seen the aging of the population coming for decades, right? One of the things that hasn’t changed, is family caregivers still provide the majority of care at home. But, because people are living longer, women are in the workforce, all kinds of reasons, they can’t handle it all. We have the sandwich generation with people working, taking care of older adults, and taking care of younger kids. They are being stretched in all of these different ways. They can’t handle it anymore. So, they turn to paid care. What kind of care do they hire? They hire direct care workers. You know, 80% of paid in-home care is from direct care workers. 80%. And so, I think that if we didn’t have them, home care would actually crumble. People would not be able to stay at home. And they’d go back to nursing home, which we can’t afford. So, the good news I think is that we have seen this coming. We have studied this. Fifteen years ago, I did a study on this. We know what the challenges are to supporting the direct care workforce. We know what the solutions are. We just don’t have the political and social will to make it happen. So, I hope in the next few minutes I have some time to talk about what some of the solutions are.   MARCUS ESCOBEDO:  Let’s stay on the direct care workforce and family care givers for a moment, and have you all talk about them. Let’s put it in the context of, there is interdisciplinary teams that we need for all of us, but especially as we age. Tom, I know in the VA, there is some good work going on around creating those teams as you mentioned. Talk about the direct care workers, and family members as part of those teams and what you are doing.   TOM EDES:  There is certainly a huge emphasis that VA has been moving in for a couple of decades, is shifting care to the home, and you are absolutely right. In order to maintain individuals at home, very often they need direct care workforce to really support that. And we also need to support the family care givers for those who have a family caregiver. There are those who do not. So, we have to think about both of that, and we are in the midst of a very exciting time in the VA, to really examine this. We will probably hear more about this over the next few days as Veteran’s Day is in the news a bit, and we partner with Administration for Community Living, we do somethings like Veteran Directed Home and Community Based Services, where the individual has a budget to really help with this direct care workforce. Who do I choose to do that so they have a budget to work with? Money follows the person, kind of concept. So, those are some things that we are working on. There will be a paper that comes out this week with one of our partners, between the Administration of Community Living and AARP, on a piece of really, around this person-centered care, and how do we expand this and support family caregivers in that role?   JOANNE LYNN:  The VA is doing a marvelous job. The first thing I ask when somebody calls me up and says, what can I do with my dad? Is, “Is he a veteran?” Because that’s the one system that’s really trying to make this work. But we are at such an elementary level. The AARP is very proud of getting the Care Act that passed in a whole bunch of states, and it’s a good act, and I’m glad that it’s there, but it’s really awful that you need to pass an act to get hospitals to notify the caregiver when they are discharging a person who can’t take care of themselves. I mean, sue the bastards, dammit! Don’t just write a statute in the legislature. I mean, why do we ever think that you should do that? Send a person home without telling the caregiver. Without training the caregiver. Without even identifying the caregiver. You know, ONC doesn’t require the caregiver to even be identified in the hospital record. They don’t require that there be a slot. I mean, the most elementary of stuff we’ve skipped over. We don’t provide any honor for the family caregiver.  We don’t provide any respite. We often let them get terribly isolated and thoroughly overburdened. I mean, what are we thinking about? We need volunteers, we need villages movements, we need support for the family caregiver. But most of all, we need a political movement that says, hell now, we will not keep doing this. We need a way for caregivers to have a political voice. In the last election, we got about 25 proposals into state party platforms, to get caregiver issues onto the party platforms. It had never been done. I mean, we really need to rev this up in the 2030s. I mean, the VA has already hit it. But in the 2030s, the whole country will hit that kind of explosion, as all those kiddies we were so proud of in the ‘50s, going off — toddling off to school are now 85. It’s not 65 that hits us, it’s 80 and 85 that hits us. And we need to get the systems in place now, and in order to do that, we need to change the power relationships. We need to have a voice for family caregivers. We have a couple of voices for paid caregivers. We need an act up for old people. The reason that AIDS did well, is because people were willing to stand in the back of rooms like this and say, stop saying sentences with nouns and verbs and periods as if it’s all going to be okay. And paint themselves in the corner and yell. We don’t have that. We don’t have a movement that is actually outraged. And we need to say crazy things, so that these midline proposals that we all calmly present, become reasonable. At the present time, the kinds of proposals that I put forward as seen as thoroughly bizarre. I need someone further out saying:  No, actually, we aren’t going to deal with this anymore. We are going to really raise our voices. So, reasonable proposals with good evidence and all of those sorts of things, become actually talked about.   Anyway, I find it, as you can see, very frustrated. Let’s get Meggie Coon back, we need a great Panther’s movement, raising hell at meetings like this.   CLARE LUZ:   I share your passion and your urgency, and given enough time, I would get revved up, and you would have a hard time shutting me up. Just to sort of convey that urgency — in Michigan alone, we already have a shortage of direct care workers. We anticipate that we are going to need 30,000 more direct care workers by 2020, and that is less than three years away. We think we have a problem now? And the problem is too, we don’t need just more direct care workers. Let’s say we found 30,000 workers somewhere. We don’t want just warm bodies filling these slots, do we? When I hire a direct care worker, I want somebody who’s qualified, who knows what they are doing. Who is trained. Who has the technical skills, but also knows how to deliver them in a person-centered way. Who can provide care with some kindness and respect for the person’s values. Who likes their job and plans to stick around for a while. And who has a good attitude. You know, the turnover rate — we not only have a shortage — the huge problem is the turnover rate. It’s just churning the system up. It destroys continuity of care. And it’s very, very expensive. We have to stabilize this workforce. How do we do that? We need — obviously they have to be paid more. That’s a given. They are paid so low, they need better wages, better benefits. That gets really tricky, because a lot of the work that is done by direct care workers, is paid for by Medicaid. So, you have these reimbursement caps. And every home care agency across the country will tell you, those rates are too low. They are not going to be able to raise wages enough to make a difference, let alone pay for training programs. So, we need different financing. We need higher caps, different financial mechanisms, for wages and training. And why is training important? It reduces the turnover rate, because it increases job satisfaction, for starters. But the work we’ve been doing in Michigan, we’ve been able to actually provide empirical data. There is an association between comprehensive personal care assistant training, and better patient outcomes, including very costly ER visits. Lower ER visits, lower falls. So, it’s not just about the direct care workers. It’s about the economy, it’s about the cost of healthcare. The behavioral group before us. It’s about the cost of housing. It all affects all of these systems. So, more solutions coming.   MARCUS ESCOBEDO:  I’m glad you brought up training, and I want to touch on that a little bit in both for direct care workers, family caregivers, but also let’s go back to the clinicians and health professionals that are out there. What is your sense — and anyone can jump in here, on where we are in terms of the adequacy of our education training programs for healthcare professionals and the entire healthcare workforce, and when it comes to older adults? Where do we need to go?   JOANNE LYNN:  Yeah, it is incredible to me that CMS is the major payer for physicians’ post graduate training for residency and fellowship. And does not require that those trainings teach you about taking care of old people. So, they pay for the cardiologist to learn all kinds of things about interventional cardiology, and not how to make a decision with a patient and family as to whether to do the procedure. And nothing about sort of the behavioral issues and the rehabilitation issues that could be worked into the orthopedic training, and into nephrology training and so on; but we don’t require that. Isn’t that incredible? Our elder care system does not — and disability system — does not require training in elder care and disability for doctors. It’s one of the most glaring of errors in the training systems.   TOM EDES:  So, a few things:  In VA, we have opportunities for interdisciplinary team training, but as you’ve said, there is also no requirement for making house calls, home visits. So, that’s a big gap. And as we think about, in 1900, average age of death was 49. But we are now dealing with a huge American success story. So, fortunately, many of us are living longer and we are going to — one thing we are all going to experience is death, and we’re making some progress in that area. But before that, most of us are going to have a phase in which it’s high cost, high utilization, some disabling conditions, multiple chronic diseases, and we are not preparing our workforce to deal with that. Where I feel really strongly, would be really helpful to have a homebased primary care program, every academic center in the country, so every discipline could have an opportunity for that interdisciplinary team training. There are multiple benefits that really benefits obviously the citizens of that state, and their care. It also then benefits the trainings — all trainings have that interdisciplinary experience that benefits the healthcare system, because they are seen as innovative and they now have a model of care that you can build as a foundation. Other really important models of care that can help this population meet the care needs at lower cost — like hospital in the home, adult foster home, medical foster home concepts. A lot of things that can improve upon that. Then we take a look at it in general, it’s going to also have a benefit to tax payers, because much of what we do, we demonstrate that that will reduce total taxpayer costs. So, it can be a benefit to everyone to get that training out there, and that homebased primary care team is really valuable in getting into the home, seeing things that you won’t see in the clinic, and finding out what the home support system is like. Does the caregiver need some training? How do we help educate that? Then identifying what else do you need? What direct care workers do you need so we can really ramp that up? But that is a challenge, because we face that in the VA. There is a cultural — wait a minute, this is getting really costly. Yeah, when we start really examining, we are putting in a better place — putting in place a better sort of case mix tool to identify not only those who need it, but about how many hours of direct care workforce help they need. It’s really bothering a lot of people, because they are saying, wow, this costs a lot. Well, yeah, but look at the alternative. We are not facing up to the alternative and the need.   MARCUS ESCOBEDO:   I think that raises some good questions. Let me see, Clare when you add to that, also think about these changing models of care that we do have. Different payment systems, different ways of valuing care. And the changing landscape in terms of the delivery of that care. I’m wondering if you can expand on those thoughts and maybe take us into that area as well, Clare.   CLARE LUZ:  Sure. So, to follow up on what you were saying, I work in a medical school. I teach in a medical school. I can attest to the fact that geriatric curriculum is negligible. It’s shocking. I don’t understand it. It’s stunning. How can we not see what is needed here? From a policy standpoint, for a number of years, there were awards — the GACA awards. I don’t know if anybody is familiar with those, but federally funded Geriatric Academic Career Awards to encourage physician clinicians — academic clinicians — to go into geriatric medicine. Those were eliminated. They were just eliminated. So, now there is a push to try to get those back, but in many cases, we seem to be going backwards instead of moving forwards. So, different models of care. I think we have to — there is this false dichotomy between healthcare and long-term care. We talked about the false dichotomy between behavioral health and physical care; we need this continuum of care, with continuity of care, across settings from hospitals to home, where there is a safe handoff. We need to include the direct care workers and the family care workers in the team. We talk about interdisciplinary teams and never talk about the direct care workers, as if they don’t exist. We need training for them. We need to wrap social services around them. You can have the best trained direct care worker in the world, it doesn’t make a bit of difference if they can’t get a job. Or, if they get a job, but don’t have gas money to get there. Most of these people are on the edge — the socio-economic edge. They need supportive services. We have to look at models of care that are more inclusive, and a social model that looks at the total picture.   JOANNE LYNN:  Speaking of models of care, I have become quite drawn to the PACE model. Program All-Inclusive Care of the Elderly.  Unfortunately, it has been thwarted in many different directions and actually growing, but in PACE, everything except housing — housing is the one thing that is not directly covered. Everything that affects this person is covered in the capitation. And the PACE program is at risk for food delivery, it’s at risk for activities, it’s at risk for falls, it’s at risk for medical care and drugs and everything else. From onset to the end of life, you are in a program that makes sense, that has figured it out. It’s almost as good as the VA programs. But it has one advantage that the VA doesn’t have, which is that it’s geographic. So, they are responsible for a geographic area. What an idea! We have this nifty idea that it’s okay for Hospital A to run a homebased primary care program, and for the VA to run one, and for to run one, and for somebody else to run one. They are all running all over town, wasting windshield time. Every other country organizes homecare geographically. We have completely turned our back on the possibility of enormous savings, by organizing homebased care geographically. D.C. has 60 homecare agencies. Any one little apartment building out there could have six Medicaid patients with six different entities, each of which has a three-and-a-half-hour minimum, even if the person only needed 45 minutes. We spend half of our Medicaid home care dollar on maintaining the illusion of competition. Competition didn’t set the rates at all. Competition is not even available on quality issues. So, why don’t we organize something somewhat geographically? But we can’t even talk that way because we are so into competition. But competition isn’t actually yielding what we are looking to do. So, let’s think about some other possibilities. So, PACE has the enormous advantage of radical continuity. Thorough comprehensiveness, and a geographic population. Why don’t we let it grow? Why don’t we get out of its way and let PACE see if in at least a dozen community around the country, it could really be good. The VA can even use it. The VA has an agreement to use PACE. We have a model that works, but almost 20 years in, it serves 40,000 nationwide. There are 40,000 people who need PACE between here and Baltimore. So, let’s get out of its way and let it grow and see what we can do with it.   MARCUS ESCOBEDO:  These models can provide a great training opportunity and a way for infusing the competence and skills that are needed for the workforce caring for this population. I’m going to close in a few minutes, before taking questions, in getting your ideas for specific policy options and recommendations that you think are really critical right now. and if you have any specific policy movement that you think we should be aware of, we are going to ask that. But I do want to pose one quick question that maybe one or two of you can tackle. We heard from project ECHO just a moment ago, so I do want to touch on: Is there a role that you see for technology in assisting the workforce that is needed for the aging population? Any bright spots that you are aware of, or common around technology innovation in that space?   TOM EDES:   Yeah. I talked about different teams we have, whether they are clinic based or home based, we really want to provide better care in the homes of individuals. And the windshield time is a really expensive element of this. If we have a direct care workforce, they can be our eyes and ears. They don’t need to be trained to be diagnosticians, they need to be trained to recognize something is different. And they can let us know. And with technology in the home, a simple screen that we can say, and this is what this person is looking like today. Or, why don’t you talk to this person and ask the questions you need, whatever that is. But to carry technology into the home, we think is hugely valuable. Independence at home, its completed its third year of a Medicare demonstration and hopefully when that becomes a routine Medicare benefit, that will allow the economics for home-based primary care to exist in every academic facility in the country, and spring up. But integrating technology was built into that intentionally, and I just want to say one piece of good news:  The VA has taken a step to put in for authorization, and it’s now through the federal register, and we are just responding to comments now, for VA to have the authority to provide anywhere to anywhere. Care anywhere to anywhere. So that means in our clinic in Baltimore, if we have somebody in Pennsylvania, we can cross that state line with technology. That right now, outside the VA, you cannot do. So, we are anticipating we will be able to move forward with that fairly soon, so we will be able to have providers cross state lines, with the direct care workforce who’s in the home, and right now we can do that clinic to clinic, as ECHO does, but not across state lines into someone’s home. This is a huge move for us, and hopefully then when VA gets that established, it will help move the rest of the country into policy in that direction.   MARCUS ESCOBEDO:  Let’s chat about other important policy options and either specific federal legislation, regulatory action that you see as needed, or even stated local, which we really haven’t had a chance to dive into. What is top of mind for you, Clare?   CLARE LUZ:  Well, several policies/changes come to mind to support the family caregiver. We just have paid family leave for elder care, and other workforce policies that are family friendly, so that they can get some relief without jeopardizing their own wages and employment. For the direct care workers, a policy change that I think is really important is right now you can get nursing home/CNA training paid for through Medicaid. Pre-employment training paid through Medicaid. But you cannot do that for home care. For the personal care workers, you cannot pay for pre-employment training through Medicaid. So, why the difference? Let’s recognize home care. We have this huge movement in the country to re-balancing. To bring people out of nursing homes, into home care. How are we going to do that if we don’t have a trained workforce in home care? So, there are a number of policy changes that could take place.   MARCUS ESCOBEDO: Thank you. Joanne? What about you?   JOANNE LYNN:   Yeah, I mean, we’ve got to pass the Chronic Act. It doesn’t do a whole lot, but it does some really good things, and doesn’t do anything bad. Clearly encourages the use of technology. The Caregiver Core Acts that a couple of people have put forward might well be worthwhile. There are a thousand regulations in the way of good care. The one that I’m focused on at the moment is that the Medicare-only person trying to get into PACE, is the only person in America who does not get the benefit of Part D, and the payment goes from $35 or so a month for your Part D coverage, to as much a $1,000 a month, because you do not get the benefit