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The number and proportion of older persons in the United States is rapidly increasing. Significant deficiencies are projected in the country’s capacity to deliver the medical, public health, and support services needed for the future frail and ill older population, and the nation is not investing sufficiently in keeping people healthy late in life. Valuable advances are needed in 4 vital directions central to the health and well-being of older persons, especially those at greatest risk owing to medical conditions or social disadvantage.
Patients with multiple comorbidities present special challenges with respect to both clinical management and control of costs. Coordination of all clinicians in setting goals and sharing information is essential to effective care. Evidence-based strategies are available to improve the care management of frail older persons with comorbid conditions, but wide dissemination of these models has often been hindered by organizational limitations, such as reimbursement restrictions and lack of effective coordination and sharing of data and responsibility among clinicians and organizations such as hospitals and clinics. Notable examples include The Transitional Care Model, a nurse-led care coordination proven to yield benefits in quality of care and well-being while reducing expenditures,1 and the Independence at Home program established by the Affordable Care Act and deployed in Medicare and the Veterans Administration, an accountable care organization approach for frail elderly persons.
Among the prominent opportunities to strengthen care delivery for co-occurring chronic conditions are: widespread adoption of high-value, rigorously evidence-based best practices with demonstrated longer-term value that target older adults; new modes of care developed for older adults in such neglected areas as prevention, long-term care, and palliative care; robust metrics of effective care management for vulnerable older adults with particular emphasis on outcomes that matter to patients and their family caregivers; and extending progress under the Elder Justice Act (HR 988) to help prevent elder abuse and neglect.
As pointed out in an Institute of Medicine report on the elder care workforce,2 one of the most important challenges resides in the current and likely future inadequacy of this workforce, including both the numbers of workers and the competency of the primary care workforce in geriatrics.
Training a sufficient number of board-certified geriatricians has long lagged far behind the national goals, and similar deficiencies exist in all other relevant components of the elder care workforce, including nurses, social workers, and other health care and public health providers. While there are many reasons for this, it is hard to ignore the role of compensation. For instance, the income of geriatricians is well below that of general internists or family physicians, despite the additional training required to become certified in geriatrics. Nursing also has a shortage in geriatrics; less than 1% of registered nurses and less than 3% of advanced practice registered nurses are certified in geriatrics.
Perhaps of greater significance than the dearth of trained specialists in geriatrics is the lack of sufficient training and demonstrated competence of all health care and public health practitioners who care for older patients or populations and provide diagnosis and management of common geriatric problems.
In addition, more than 1 million direct care workers, including certified nursing assistants, home health aides, and home care and personal care aides, deliver most of the paid care to older adults in numerous settings.3 Even though demand is projected to increase by nearly 50% between 2010 and 2020, the pressures on recruitment are aggravated by retention issues, as annual turnover rates for such workers often exceed 50%. Of the several factors driving the shortage, low wages (median hourly wages of certified nursing assistants, home health aides, and personal care workers in 2014 were $12.06, $10.28, and $9.83 respectively),4 inadequate training and supervision, and the perception that these are “dead-end” jobs lead the list.
Among the prominent opportunities to strengthen the elder care workforce are demonstration of competence in the care of older adults as a criterion for licensure, certification, and maintenance of certification for health care professionals; enhancement of reimbursement for clinical services delivered to older adults by practitioners with certification of expertise in geriatrics; provision of graduate medical education payments extended to public health physician and nurse training in geriatric care and health promotion; increase in training time requirements to 120 hours for certified nursing assistants and home health aides; compensation of direct care workforce at a wage commensurate with the skills and knowledge required to perform high-quality work; and establishment of state and the federal programs for loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists.
Social factors are widely recognized as major determinants of well-being at all ages, but there has been inadequate attention to the importance of social engagement, through either participation in the labor force or volunteer activities. Regarding the well-being of older persons, a major source of concern is the strong trend in national surveys toward a reduction in engagement over the past 20 years. The federal government’s Corporation for National and Community Service, which includes several programs such as Senior Corps, Foster Grandparents, and Senior Companions, while well intentioned, are considered to require much more resources to meet the need. Other volunteerism efforts, such as Experience Corps, which connects retirees with schoolchildren, have shown remarkable benefits but remain dependent on private support and require greater dissemination.
Among the prominent opportunities to foster social engagement in late life are strengthening on-the-job and community college training programs for middle- and later-life workers transitioning to new types of jobs; making older workers less costly for employers by Medicare serving as primary payer for health insurance claims for all older workers; and reengineering volunteer programs that benefit youth and seniors (eg, Foster Grandparents, Retired and Senior Volunteers, Senior Companions, Experience Corps) to serve a much larger portion of the potential beneficiaries.
In 2014, the Institute of Medicine report Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life5 called for broad improvements in advanced illness and end-of-life care. Specific areas for strengthening include care planning and coordination, communication strategies between and among patients and clinicians, and especially in enhancing the competence of the overall health care workforce in dealing with the challenges these patients present.
Among the prominent opportunities to strengthen advanced illness and end of life care are payment for care tailored to the complex needs of those with advanced serious illness near the end of life; assurance of skilled palliative care for those with advanced serious illness, wherever they receive care; establishment and payment for standards for advance-care planning that are measurable, actionable, and evidence-based; and appropriate training, certification, or licensure requirements for those who provide care for patients for advanced serious illness as they near the end of life.
Although many opportunities exist for improving the health and health care of current and future older persons, 4 distinct vital directions are identified that require immediate attention and will yield significant benefits, including
Develop new models of care delivery. Existing strategies for care delivery that add value require broader dissemination and new approaches are needed that address the clinical and financial challenges presented by multiply impaired frail patients.
Augment the elder care workforce. The cadre of specialists in geriatric medicine, across all health professions including public health, must be strengthened to conduct research, provide specialized care as needed, and, perhaps most important, lead educational efforts to enhance the geriatric competence of all health care practitioners who manage the care of older persons or populations.
Promote the social engagement of older persons. Enhancement of public and private programs to incent engagement of older persons in the labor force and in volunteerism will yield substantial benefits in health and well-being. Specific efforts are needed to reverse the decades-long trend toward disengagement of older individuals.
Transform advanced illness and care at the end of life. Current widespread weaknesses in the care received by people with advanced illness, especially those near death, can be improved through the use of available evidence-based approaches. Such efforts will maintain dignity and improve care quality while reducing the waste of precious resources.
These realistic and affordable recommendations blend greater dissemination of existing proven strategies with development of targeted new approaches. Given the substantial increases in the number and proportion of older persons in the United States, this is a critical task, and the health care system and the nation cannot afford to fail.
Corresponding Author: John W. Rowe, MD, Robert N. Butler Columbia Aging Center, Columbia University Mailman School of Public Health, 722 W 168th St, New York, NY 10032 (email@example.com).
Published Online: September 26, 2016. doi:10.1001/jama.2016.12335
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: The National Academy of Medicine’s Vital Directions initiative is sponsored by the California Health Care Foundation, The John A. Hartford Foundation, the Robert Wood Johnson Foundation, and the National Academy of Medicine’s Harvey V. Fineberg Impact Fund.
Disclaimer: This Viewpoint on recommendations for improving the health and health care of older persons in the United States provides a summary of a discussion paper developed as part of the National Academy of Medicine’s initiative on Vital Directions for Health & Health Care (http://nam.edu/vitaldirections). Discussion papers presented in this initiative reflect the views of leading authorities on the important issues engaged, and do not represent formal consensus positions of the National Academy of Medicine or the organizations of the participating authors.
Additional Contributions: Coauthors of the National Academy of Medicine discussion paper included Lisa Berkman, PhD (Harvard University), James Jackson, PhD (University of Michigan), Mary Naylor, PhD, RN (University of Pennsylvania), William Novelli (Georgetown University), S. Jay Olshansky, PhD (University of Illinois at Chicago), and Robyn Stone, PhD (Leading Age). Elizabeth Finkelman, MPP (National Academy of Medicine), served as the initiative director.
Rowe JW, Fulmer T, Fried L. Preparing for Better Health and Health Care for an Aging Population. JAMA. Published online September 26, 2016. doi:10.1001/jama.2016.12335