By Rani Snyder and Nancy E. Lundebjerg
In 1978, the Institute of Medicine (IOM) grappled with the challenge that an aging America would present to the healthcare workforce. It wrestled with this issue again in 1993. And in 2008. All of the resulting reports called for increased investment in training the workforce to care for older adults (IOM, 1978, 1993, 2008). Yet today, despite almost thirtyseven years of calls from the IOM for increased investment, funding to increase the competence of clinicians and direct care workers to ably care for the nation’s growing population of older adults is a patchwork system of private and public funding streams. And, much like the U.S. healthcare system, those funding streams frequently are uncoordinated, rely on the priorities of disparate parties in private and public communities, and leave knowledge and skills gaps in the healthcare workforce.
Has there been progress on creating a workforce that is ready to care for the growing number of older Americans? A qualified yes. Each report led to incremental additional investments by private and public funders focused on creating a geriatrics and gerontology workforce, and on enhancing the skills and competence of other workforce members. Notable among the private investors in the future workforce is The John A. Hartford Foundation (JAHF) of New York City, which has invested almost $324 million in creating a competent workforce. So too, The Atlantic Philanthropies (AP), at approximately $100 million, and the Donald W. Reynolds Foundation (DWRF), at $221 million, have made significant investments in ensuring that the healthcare workforce is ready to care for older Americans.
On the federal side, the Department of Veterans Affairs (VA) is widely credited with enhancing the pipeline of geriatricians entering the workforce with its 1978 establishment of a geriatrics fellowship. Its support for geriatrics fellowship training and development of advanced fellowship training to support geriatrics health professionals skilled in research, education, and clinical care is ongoing. Similarly, the Health Resources and Services Administration (HRSA) has invested in preparing the workforce under the Title VII Geriatrics Health Professions Programs through the 1982 Congressestablished Geriatric Education Centers (GEC), the Geriatric Academic Career Awards Program (GACA), and, from 1998, the Geriatric Training for Physicians, Dentists, and Behavioral and Mental Health Providers (GTPD) and, in 2002, the geriatrics nursing program under Title VIII. Title VII funding of GACAs has enhanced the faculty pipeline, supporting 363 geriatrics clinician educators during the formative years of their academic careers. The Fiscal Year (FY) 2016 budget for all of the geriatrics health professions programs is $37.8 million.
Finally, the Affordable Care Act (ACA) created additional funding streams for workforce development—particularly the investment in direct care worker training under the Personal and Home Care Aide State Training demonstration grants from HRSA and attention to workforce development in the first round of Health Care Innovations Awards from the Center for Medicare & Medicaid Innovation (CMMI) of the Centers for Medicare & Medicaid Services (CMS).
In the context of the larger funding environment and the growing older adult population, investments that have been made to date are quite small. The $645 million in private foundation funding has been important, but it represents well over twenty years of funding and is dwarfed by the federal investment in Graduate Medical Education (GME), which totals $11.1 billion annually (GAO, 2013). So, too, when comcompared to the annual investment in GME, the $37.8 million spent on the geriatrics and gerontology workforce is fairy dust.
Despite reminders that baby boomers are aging and that the population of adults ages 65 and older is growing, private and federal funding streams are very much in flux as funding priorities shift in both sectors. This article will review the current and near-term future landscapes of private and public funding for the eldercare workforce.
The IOM Retooling report was funded by ten private foundations that, collectively, had recognized very little was being done to prepare the healthcare workforce to deliver the best possible care to older patients (IOM, 2008). Their goal was to shine a light on the issue and create a robust call to action. All private sponsors listed in the report have an interest in assessing and addressing the healthcare needs of Americans older than age 65. Two of the original IOM report funders, JAHF and AP, followed the report with additional funding designed to forward the report’s recommendations for workforce development by helping to create the Eldercare Workforce Alliance (EWA). EWA’s goal is to address the immediate and future workforce crisis in caring for an aging America, and its members’ efforts were instrumental in getting a number of workforce provisions included in the ACA to support geriatrics education (Stone and Barbarotta, 2011). However, not all of the ten original private funders have focused their grant support on workforce development.
Three foundations—JAHF, DWRF, and AP—are well known for funding workforce development specifically for the aging population. Through these three funders, a significant amount of past and current funding has been dedicated to educating our healthcare workforce about geriatrics and how to prepare healthcare staff and caregivers to care for frail older Americans.
JAHF’s long-term goal has been to improve the health of older adults by creating a more skilled workforce and a better designed healthcare system. The Foundation’s Aging and Health program began as early as 1982, and it has been critical to the development of an eldercare workforce ever since. Beginning in 1996, the Foundation expanded beyond physician training to include nursing and, in 1998, to include social work. Therefore, since 1983, JAHF has made grants of almost $324 million specifically to increase academic geriatric capacity in medicine (54 percent of funding), nursing (26 percent), and social work (20 percent).
Compared to JAHF, DWRF was a newcomer on the scene when in 1997 it began its Aging and Quality of Life Program. The Foundation has devoted almost $221 million of its $265 million aging program portfolio to initiatives that improve the training and preparation of the eldercare workforce. Focusing at first only on physician training, the Foundation’s initial goal was to assure that all physicians, regardless of discipline, would better know how to care for their frail, older patients. In 2008, DWRF added grants to its portfolio that focus on nursing and the replication of a caregiver training program for paid and family caregivers serving older adults who are aging in place. Although DWRF has focused the bulk of its funding (89 percent) on medical schools, some of that investment has been geared explicitly toward interdisciplinary team training, including numerous other health disciplines—most notably nursing, pharmacy, and social work. DWRF funding for gerontological nursing and caregiver training represent 2 percent and 9 percent, respectively.
The Atlantic Philanthropies, during its period of “anonymous” grant-making, partnered extensively on some of JAHF’s academic geriatric workforce investments such as the Paul B. Beeson Scholars program. More than others, it has focused most of its workforce grant-making further downstream from that of JAHF or DWRF, including continuing education grants to Boston University’s Institute for Geriatrics Social Work, the Hartford Institute for Geriatric Nursing at NYU, and the American Academy of Family Physicians.
Despite these efforts, the numbers of health professionals specializing in geriatric care have barely changed and show no sign of keeping up with the aging of the population. There remains limited information on the competence of generalist providers, but continuing high rates of potentially unsafe medication prescribing suggest that competence in practice is still low (Agency for Healthcare Research and Quality [AHRQ], 2015).
Unfortunately, private funding sources for the eldercare workforce are changing dramatically. One major funder, JAHF, is in the process of shifting focus away from grants centered on developing a quality healthcare and longterm-care workforce for older adults. JAHF is focusing increasingly on downstream innovations that show promise to transform care through practice change.
Two other key private funders, AP and DWRF, are both spend-down foundations only a few years from sun-setting deadlines. AP already has shifted its spending away from preparing the healthcare workforce for an aging population. DWRF will continue—but not increase—its grant-making to train physicians and interdisciplinary teams, nurses, and paid and family caregivers until it closes its doors at the end of 2017. The loss of funding streams from these foundations will leave a sizeable hole to fill.
The ACA’s passage brought modest enhancements to funding for the eldercare workforce (Dawson, Lundebjerg, and Connelly, 2010) in the form of demonstrations, a temporary Medicare 10 percent pay bump for primary care services, and some eligibility modification to existing Health Resources and Services dministration (HRSA) programs. These gains did not include increased coordination of funding across agencies or increases in funding for those programs that focus specifically on geriatrics and gerontological health professionals.
Post ACA, two major changes bear mentioning that affect how the eldercare workforce of the future will be paid. The first is the reinterpretation of the Fair Labor Standards Act by the U.S. Department of Labor that makes direct care workers, in particular personal care attendants, eligible for minimum wage and overtime protection (U.S. Department of Labor, Wage and Hour Division, 2013). After significant litigation and controversy, the Department began enforcement on November 13, 2015. The second is repeal of the Sustainable Growth Rate (SGR) formula when Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) (U.S. Congress, 2015). Under SGR, geriatrics health professionals, who are paid primarily by Medicare, annually faced an approximate 30 percent cut in reimbursement. Both of these policy changes may be important to recruiting and retaining the eldercare workforce.
Centers for Medicare & Medicaid Services
Among the IOM’s 2008 recommendations was that public and private payers increase support for research and demonstration programs promoting the development of new models of care for older adults, and that funders promote the effective use of the workforce to care for older adults (IOM, 2008). In a 2011 letter to then acting administrator Donald Berwick, EWA called upon CMS to incorporate EWA-developed principles into all pilot and demonstration projects (EWA, 2011). As a result, one of the objectives for the first round of CMMI Health Care Innovation Awards (HCIA) was to identify new models of workforce development, deployment, related training, and education that support new models directly or through new infrastructure. Grants were made in 2013, and the first-year evaluation reports of the HCIA awardees are available on the CMS website (CMS, 2015).
There is no overarching report that provides an overview of grantee progress on the required elements of the proposed project, including new models of workforce development and deployment. Additionally, CMMI engaged six evaluation groups to evaluate each portfolio, but there is no common approach to evaluations, making it difficult to draw conclusions around the workforce component of the intervention (CMS, 2015).
In 2015, with its release of the Funding Opportunity Announcement for the second round of HCIA, CMS eliminated the focus on testing new models of workforce development and deployment as a part of proposed interventions.
Health Resources and Services Administration
Over the past several years, funding for the Title VII and Title VIII Geriatrics Health Professions programs has been relatively level, with some very small increases. Total funding for FY 2016 is $38.7 million and the President has proposed level funding for FY 2017. The net effect is that there has been no increased funding for GACA awards, despite eligibility expansion under the ACA. Other elements of the ACA, such as the National Healthcare Workforce Commission, have not even been implemented.
In 2015, the HRSA made seismic changes to its geriatrics programs, combining funding under Title VII (GEC, GACA, and GTPD programs) and Title VIII (comprehensive geriatric education nursing program) to create the new Geriatrics Workforce Enhancement Program (GWEP; see Busby-Whitehead et al. article on page 122). HRSA encouraged applicants to focus their educational efforts on primary care, required them to partner with community-based organizations, and offered a menu of options for applicants to consider implementing in their proposals (many mirroring the older portfolio of programs). Grantees were announced at the July 2015 White House Conference on Aging, with more than $35 million in awards going to forty-four organizations in twenty-nine states to support quality care for older Americans (grantees are eligible for some $70 million in additional funding through annual non-competing renewals). In December 2015, JAHF made a grant to the American Geriatrics Society (AGS) to serve as the JAHF GWEP Coordinating Center to support the GWEP network so it can fulfill HRSA’s goal of expanding the reach of its Title VII and VIII dollars.
Department of Veterans Affairs
Current estimates of the Veterans Administration (VA) FY 2015 budget to support research, education, and clinical programs that focus on the needs of veterans older than age 65 totaled nearly $27 billion. Approximately $1 billion of this funding supports VA research and education programs focused on the care of older veterans. The jewel in the crown is the twenty Geriatrics Research, Education, and Clinical Centers (GRECC), which receive $42 million in federal funding annually. Eighteen of these centers offer Advanced Geriatric Fellowships that prepare geriatrics health professionals for careers in education and research. From 2010 to 2015, ninety-one advanced fellows were trained by GRECCs. The VA estimates that it provides support to approximately half of geriatrics fellows and two-thirds of geriatric psychiatry fellows who receive some or all of their training in Veterans Health Affairs facilities (U.S. Department of Veterans Affairs, 2015).
Continued Investment Needed
In the face of inflation, the increasing numbers of older adults, and growth in the size of the healthcare workforce, spending to date represents a per capita reduction. The Administration on Aging’s (AOA) website highlights that “people 65+ represented 14.1 percent of the population in the year 2013 but are expected to be 21.7 percent of the population by 2040” (AOA, 2014). Funding remains fragmented, with little coordination between the federal and private sectors.
So, what is needed? At a minimum, we believe that the rate of spending to ensure the healthcare workforce is prepared to care for older Americans should be increased to better match population growth.
Federal spending that could be leveraged by requiring healthcare workforce training to optimize care for older adults includes the following:
- Congress should require that the approximately $15 billion in Medicare dollars supporting post-graduate professional healthcare training and education produce a workforce with the necessary skills and knowledge to care for older adults—regardless of specialty or discipline;
- CMS should prioritize testing and scaling of Alternative Payment Models under MACRA that include a focus on ensuring that the workforce delivering the care is competent to do so; and,
- CMS should require that all funded demonstration projects and innovation awards include and evaluate workforce competence to care for older adults within the framework of the interprofessional competencies created by the Partnership for Health in Aging in 2010 (AGS, 2010).
Further, Congress should reauthorize geriatrics training programs and commit increased, sustained appropriations to expand preparation of a workforce that can meet the healthcare needs of older adults through the following strategies:
- Assigning dedicated, significant federal resources to the GWEP to ensure the geriatrics education pipeline is national in scope and would include the training of health professionals in diverse geographical regions (at a minimum, there should be at least one GWEP in every state);
- Crafting legislative language that reestablishes and expands the free-standing junior and mid-career geriatric academic career awards program; each fiscal year, sufficient funding should be appropriated for a minimum of fifty awards, and HRSA should adopt an annual funding cycle for this grant program; and,
- Making sufficient resources available each fiscal year to the National Health Care Workforce Commission and the National Center for Workforce Analysis to collaborate on tracking and data analysis of health professionals with special training in geriatrics and gerontology.
Existing private funders of aging workforce development should develop programs to partner—formally and informally—with new and existing private foundations to foster their understanding of the issues, with the explicit goal of increasing private sector investments in a geriatrically trained workforce.
Additionally, private funders should do the following:
- Come together to set a collaborative strategic plan for investing in workforce preparation that identifies where funders can work and where funders will work in parallel, given their disparate missions and grant-making styles; and how funders can identify strategic opportunities rather than replace what should be public-sector funding; and,
- Identify opportunities to partner with the federal government (much like JAHF has done) with the goal of coordinating efforts across sectors.
Finally, organizations representing various workforce sectors should modify their privatesector training approaches to ensure they are preparing trainees to care for an aging America and that continuing education and certification deliver content that will meet the needs of an aging population.
The time for incremental additional investments is long past. The population demographics demand nothing less than seismic change.
Rani Snyder, M.P.A., is program director of The John A. Hartford Foundation in New York City. Nancy E. Lundebjerg, M.P.A., is chief executive officer of the American Geriatrics Society in New York City.
Editor’s Note: This article is taken from the Spring 2016 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “America's Eldercare Workforce: Who Will be There to Care?.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.
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