SUPPLY AND DISTRIBUTION
The number of professional workers directly involved in the care of older adults is difficult to quantify, for a number of reasons: changes in employment status, differing measures (e.g., licensed vs. active professionals), and the presence of ill-defined and overlapping titles for many occupations. Furthermore, many professionals treat older patients without being identified as geriatric providers either by title or certification. Health care-related careers, including medical assistants, physician assistants, physical therapists, mental health counselors, pharmacy technicians, and dental hygienists, account for about half of the country’s 30 fastest-growing occupations (BLS, 2007a). Despite the rapid growth, however, the supply of health care workers does not satisfy current demands and will certainly fall short of the increased demands expected in the future. In fact, the United States will need an additional 3.5 million health care providers by 2030 just to maintain the current ratio of health care workers to population (Table 4-1).
Number of Providers in 2005 and Projected Number Needed in 2030 to Maintain Current Provider-to-Population Ratios (in Thousands).
While the general need for professionals who care for older patients is high, the particular need for geriatric specialists is even greater. For example, geriatricians1 are the physicians who are specially trained in care of the elderly population as a subspecialty of internal or family medicine. These specialists account for only a very small portion of the total physician workforce—just 7,128 physicians are certified geriatricians, or one geriatrician for every 2,546 older Americans (ADGAP, 2007b). By 2030, assuming current rates of growth and attrition, one estimate shows that this number will increase to only 7,750 (one for every 4,254 older Americans), far short of the total predicted need of 36,000 (ADGAP, 2007b; Alliance for Aging Research, 2002). In fact, some argue that there could be a net decrease in geriatricians because of the decreasing number of physicians entering training programs as well as the decreasing number of geriatricians who choose to recertify (Gawande, 2007). Geriatric psychiatry faces a similar shortage. Only 1,596 physicians are currently certified in geriatric psychiatry, or one for every 11,372 older Americans, and by 2030 that total is predicted to rise to only 1,659, which would then be only one for every 20,195 older Americans (ADGAP, 2007b).
Other professions have similarly low numbers of geriatric specialists. For example, just 4 percent of social workers and less than 1 percent of physician assistants identify themselves as specializing in geriatrics (AAPA, 2007; Center for Health Workforce Studies, 2006). Less than 1 percent of registered nurses (Kovner et al., 2002) and pharmacists2 are certified in geriatrics. In short, dramatic increases in the number of geriatric specialists are needed in all health professions. Even with tremendous effort, it is unlikely that we can completely fulfill the projected needs, but, still, much can be done to begin to close the gaps.
Aside from concerns about the total numbers of health care workers with geriatric competencies, the composition and distribution of the health care workforce for older Americans should also be considered. This includes racial and ethnic diversity as well as the geographic distribution of professionals trained to provide care to older adults.
Racial and Ethnic Diversity
The committee commissioned a paper on the increasing diversity of older populations (Yeo, 2007) and found that the diversity of the workforce is important for several reasons. First, minority patients often prefer to be treated by health care professionals of the same ethnic background (Acosta and Olsen, 2006; IOM, 2004; Mitchell and Lassiter, 2006; Tarn et al., 2005). Second, a provider from a patient’s own background may have better understanding of culturally appropriate demonstrations of respect for older populations and may also be more likely to speak the same language (in the case of bilingual providers). Finally, providers from minority populations often account for most of the services provided to underserved populations (HRSA, 2006a). For example, while only 3.4 percent of dentists are black, they treat almost two-thirds (62 percent) of black patients (Mitchell and Lassiter, 2006).
While older adults are more diverse than ever before, the younger generations training to care for them are even more diverse (see Chapter 2). The pattern of this diversity, however, will not necessarily match up with the pattern of diversity among older Americans. Table 4-2 demonstrates, for example, that there is significant diversity among resident physicians in geriatrics, but the percentage of white residents (39 percent) is much lower than the percentage of whites in the elderly population, and the percentage of Asian residents (42 percent) is much higher that the percentage of Asians in the elderly population.
Race and Ethnic Origin of Residents in Geriatric Medicine and Psychiatry, 2006.
The distribution of both professionals and older adults varies widely across the country. Since both of these populations may be unevenly distributed across regions, states, and local communities, different areas may have different workforce needs. The committee commissioned a paper on state profiles of the U.S. health care workforce (Mather, 2007). This report showed there is an average of 443 dentists per 100,000 population aged 65 and older in the United States, but this ratio varies widely among the states. There are 759 dentists per 100,000 older adults in New Hampshire, but only 104 dentists per 100,000 older adults in Kansas. This variance must be caused by a variety of factors, since these states do not have similar distributions in the numbers of other types of professionals. New Hampshire has a lower-than-average number of pharmacists per population of older adults, for example, while Kansas has a higher-than-average number of registered nurses. The need for health care workers with geriatric skills can also vary according to the distribution of older adults. For example, as discussed in Chapter 2, older adults make up 16.8 percent of Florida’s total population, while they account for only 6.8 percent of Alaska’s population (U.S. Census Bureau, 2008). Differences by community are likely to also vary widely. Therefore, the needed distribution of the health care workforce for older American can vary by both the state and the individual profession.
The recruitment and retention of health care professionals in rural areas is especially challenging (IOM, 2005), and this is an important factor when discussing the health care needs of the geriatric population, since older adults are disproportionately over-represented in rural areas (Hawes et al., 2005). Older adults that live in rural areas tend to be less healthy than those in urban areas and to have a higher rate of difficulty with activities of daily living (ADLs) (Brand, 2007; Magilvy and Congdon, 2000), while their access to health services is limited by the relatively small number of providers (especially specialists) that choose to work in rural areas. Because of the relatively small number of specialists, physician assistants and nurse practitioners play significant roles in providing health services to the rural aging population (Henry and Hooker, 2007). Among the challenges in recruiting any type of professional to rural areas are professional isolation, heavy call schedules, and few job opportunities for the spouses of the health care professionals. The best strategies for recruitment and retention may be those that focus on the training of existing rural providers in geriatric skills via distance education in conjunction with the use of remote technologies to increase the availability of outside geriatric experts for rural elderly populations.
THE CURRENT STATE OF GERIATRIC EDUCATION AND TRAINING
For more than 30 years the IOM (IOM, 1978, 1993) and others (LaMascus et al., 2005; Olson et al., 2003) have called for improvements in the geriatric education and training of virtually all types of health care providers. While progress is evident, many formal training programs still do not include robust coursework in geriatrics (Berman et al., 2005; Eleazer et al., 2005; Linnebur et al., 2005; Scharlach et al., 2000). Among the barriers to increased education and training in geriatrics for all professions are the lack of faculty, lack of funding, lack of time in already-busy curricula, and the lack of recognition of the importance of geriatric training (Bragg et al., 2006; Hash et al., 2007; Hazzard, 2003; Rubin et al., 2003; Simon et al., 2003; Thomas et al., 2003; Warshaw et al., 2006). Furthermore, very little is known about the best methods to improve the knowledge and skills of professionals in caring for older adults (Gill, 2005).
It is not possible to discuss every profession in detail, as virtually every professional cares for older patients to some degree. In the following section, several professions instrumental to the care of older adults are examined. (See Table 4-3 for an overview.) Specifically, the status of geriatric education and training within each profession is discussed. While some professions are discussed more extensively than others, the committee does not intend for this to imply any conclusion about their importance to the care of older adults. Rather, this is a reflection of the amount of data available and the extensiveness of the existing education and training programs in geriatrics. Overall, the breadth and depth of geriatric education and training remains inadequate to prepare all professionals for the health care needs of the future elderly population.
Older Americans account for a disproportionate share of physician services, but a 2002 survey of primary care physicians showed that only half of these physicians believed that their colleagues could adequately treat geriatric conditions (Moore et al., 2004). This section examines the education and training of all physicians in the care of older adults, with a focus on the path for geriatricians.
The geriatric curricula in medical schools has had notable improvements. The percent of medical schools with requirements for “geriatric exposure” has increased from 82 percent in 1985-1986 to 98 percent in 1996-1997 (Eleazer et al., 2005). Still, much of this exposure is inadequate or occurs too late in the educational process to influence which specialities the students select. As noted above, several major public and private initiatives support improvement in the geriatric education of physicians. In May 2001 the Donald W. Reynolds Foundation awarded $19.8 million in grants to 10 institutions in order to develop comprehensive training programs in geriatrics (Donald W. Reynolds Foundation, 2007). Because of the success of this effort, the Donald W. Reynolds Foundation repeated the grants in 2003 and 2005, distributing almost $20 million in each round, and in October 2007 the Donald W. Reynolds Foundation issued a request for proposals for a fourth series of grants. In addition to this effort, the Donald W. Reynolds Foundation has established two departments of geriatric medicine.
The Health Resources and Services Administration (HRSA) distributes grants to support Geriatric Education Centers (GECs), which educate and train individuals in the care of older patients. These centers are often collaborative efforts among several health-profession schools or health care facilities and have a special focus on interdisciplinary training.
In July 2007 the John A. Hartford Foundation and the Association of American Medical Colleges (AAMC) hosted the National Consensus Conference on Geriatric Education. There the participants developed a set of minimum standards for the knowledge, skills, and attitudes of graduating medical students with respect to the care of older patients (Leipzig, 2007). The standards covered a number of domains, including
cognitive and behavioral disorders;
falls, balance, gait disorders;
atypical presentation of disease;
hospital care for older adults; and
health care planning and promotion.
Overview of the Education and Training of Professionals in Geriatrics.
The group then developed a total of 36 competencies based on these domains (AAMC/The John A. Hartford Foundation, 2007). The competencies included
identification of medications to be avoided or used with caution in older adults;
ability to define and distinguish delirium, depression, and dementia;
assessment of ADLs and IADLs;
identification of physiological changes due to aging;
identification of psychological, social, and spiritual needs of patients; and
performance of examination to assess skin pressure ulcer status.
While the coverage of geriatric issues at medical schools is increasing, students still express significant reservations about their abilities to treat older patients. The AAMC’s 2002 Medical School Graduate Questionnaire found 55 percent of graduates perceived inadequate coverage of geriatric issues in medical school; only 68 percent felt adequately prepared to care for older persons in acute-care settings, and only half felt prepared to care for them in long-term care settings (Eleazer et al., 2005). In spite of this, less than 3 percent of medical students take geriatric electives (Moore et al., 2004).
Postdoctoral training of physicians occurs during both residency and fellowship programs. As of 2003, 27 types of medical residency programs (accounting for 70 percent of trainees) included Accreditation Council for Graduate Medical Education (ACGME) requirements for some form of geriatrics training, but the extent of such training is highly variable (Bragg and Warshaw, 2005; Bragg et al., 2006; Simon et al., 2003). One survey showed that only about half of graduating family-practice and internal-medicine residents (48 percent and 52 percent, respectively) felt very prepared to care for elderly patients (Blumenthal et al., 2001). Although a large majority of graduating psychiatry residents felt very prepared to diagnose and treat delirium (71 percent) and major depression (96 percent), only 56 percent felt very prepared to diagnose and treat dementia.
Several specialties that treat large numbers of older patients, including ophthalmology, general surgery, and dermatology, do not include any requirements for geriatric training (Bragg and Warshaw, 2005). Since 1994 the John A. Hartford Foundation has funded the Geriatrics-for-Specialists Initiative, which aims to improve geriatric knowledge of surgical specialists and related medical specialists. Their Geriatrics Education for Specialty Residents Program encourages interaction between directors of specialty residencies and the geriatricians within their facilities.
After completion of a residency in internal medicine, family medicine, or general psychiatry, a physician can pursue a fellowship in geriatric medicine or geriatric psychiatry, which may last one or more years. Fellows may be graduates of allopathic or osteopathic schools of medicine, or they may be international medical graduates (IMGs). This finding is notable in that IMGs have become increasingly relied upon to provide primary care services and care to underserved populations in the United States (Hart et al., 2007).
About half of geriatric-medicine and geriatric-psychiatry fellows (58.2 percent and 44.4 percent, respectively) are female, and about two-thirds of the two types of fellows (64.1 percent and 61.1 percent, respectively) are IMGs (Brotherton and Etzel, 2007). By comparison, across all specialties IMGs make up only 26.9 percent of the entire resident-physician population. As seen in Figures 4-1 and 4-2, while the number of positions available in geriatric-medicine and geriatric-psychiatry fellowship programs has been increasing, the percentage of positions filled has been decreasing. Very few fellows continue past the first year, possibly because of the decrease in the requirement for the length of training that is needed to pursue certification (discussed later in this section).
First-year geriatric medicine fellowship positions, available and filled. SOURCE: ADGAP, 2007b.
First-year geriatric psychiatry fellowship positions, available and filled. SOURCE: ADGAP, 2007b.
The Veterans Administration (VA) plays an important role in the development of geriatric fellowships. In the 1970s, in anticipation of the wave of aging World War II veterans, the VA established Geriatric Research, Education and Clinical Care Centers (GRECCs) to improve geriatric knowledge (Goodwin and Morley, 1994; Warshaw and Bragg, 2003). These centers are still in operation and often educate and train multiple disciplines in geriatric care. At around the same time the VA first established fellowship programs in geriatric medicine and geriatric psychiatry, often in conjunction with a GRECC. Today, about 25 percent of geriatric-medicine fellowship positions and almost 50 percent of geriatric-psychiatry fellowship positions are supported by the VA, and many other geriatric fellows will receive part of their training in VA facilities (VA, 2007a). The VA also funds four fellowships in geriatric neurology (VA, 2007b).
Other branches of the federal government also support the geriatric education and training of physicians. HRSA administers the Title VII Geriatrics Health Professions Program. Although funding was eliminated for fiscal year 2006, it was restored for fiscal year 2007, with $31.5 million for the support of 48 GECs, 88 Geriatric Academic Career Awards (GACAs) for individuals, and 11 Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Professions Program awards given to institutions to prepare faculty for these professions (ADGAP, 2007c). In 2007 Congress approved a fiscal year 2008 Labor-Education-HHS appropriations bill3 that included continuation of the Title VII geriatrics programs at the same funding level as for fiscal year 2007, but President Bush vetoed the bill on November 13, 2007, and the House of Representatives failed to override the veto on November 15, 2007.
Finally, CMS is the major financial supporter of the residency training of all physicians. In fiscal year 2004 it paid $7.9 billion for graduate medical education (GME) (GAO, 2006). Medicare pays for a portion of the cost of GME for physician residents and fellows through direct and indirect medical-education payments. Direct medical education (DME) payments support hospitals’ direct cost of operating a GME program, especially salary support for residents; indirect medical education (IME) payments cover a portion of the added patient care costs associated with teaching hospital settings (MedPAC, 2003). Through GME, Medicare has specifically supported advanced training in geriatrics by counting geriatric fellows as full-time equivalent (FTE) residents, while all other subspecialty fellows count only as one-half of a full-time equivalent. Thus hospitals that train geriatricians receive more GME funding than hospitals that train other types of subspecialists (MedPAC, 2003). Furthermore, when GME updates were frozen in the 1990s, geriatric programs were exempt.
Sites of Training
The training of medical students and residents tends to occur in discrete episodes of care, within single disciplines, and usually only in the hospital or ambulatory setting, which means that residents generally do not have the opportunity to follow patients longitudinally over time and across settings of care. Thus many students and residents lack exposure to alternative sites of care of importance to the geriatric patient—namely, home-care settings, nursing homes, and assisted-living facilities. Deterrents to increasing student clinical experiences in these sites include the need for an on-site supervisor of the same discipline, the need for collaboration with site staff, a lack of student interest, and a lack of time in already crowded programs (Leipzig et al., 2002; Warshaw et al., 2006).
In one national survey, only 27 percent of graduating family-practice residents and only 13 percent of graduating internal-medicine residents felt very prepared to care for nursing-home patients (Blumenthal et al., 2001). Still, clinical experiences in alternative sites of care have increased somewhat from past years (Cheeti and Schor, 2002; Matter et al., 2003). For example, Weill Cornell Medical College implemented a clerkship in which third- and fourth-year medical students accompanied a geriatrics team on home visits to patients living with chronic illness; when interviewed about the experience, 84 percent of recent graduates felt that it had had a positive effect on their delivery of care (Yuen et al., 2006).
Among the obstacles to expanding training sites is a lack of funding to cover the expenses of residents while in non-hospital settings. As described above, Medicare distributes GME funds, primarily to hospitals, to support the training of residents. However, the Balanced Budget Amendment of 1997 allows for other providers, including federally qualified health centers, rural health clinics, and managed care organizations to receive GME funds directly (AAMC, 2007c). Furthermore, since 1987 hospitals have been allowed to count the time that residents spend in settings outside the hospital, such as nursing homes and physician offices, subject to certain agreed-upon conditions between the hospital and the outside entity. Still, this does not happen often enough. Since most care of older patients occurs in non-hospital settings, more needs to be done to ensure that professionals are fully trained in how to care for patients in these settings.
The committee concluded that comprehensive care of older patients should include training in non-hospital settings.
Recommendation 4-1: The committee recommends that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes.
Residency program directors need to ensure that their residents’ schedules include adequate time rotating through these alternative settings, and the directors and hospital administrators need to be willing to collaborate with the outside entities to reach mutually agreeable conditions for partnership.
Physicians may pursue voluntary national board certification in many major specialties and then become certified in the subspecialties of geriatric medicine or geriatric psychiatry. It was in 1988 that the American Board of Family Medicine (ABFM) and the American Board of Internal Medicine (ABIM) first offered a 10-year certificate of added qualifications (CAQ) in the subspecialty of geriatric medicine.4 Originally CAQs were available only to physicians with at least 2 years of specialty geriatric training or to those who had substantial clinical experience (the “practice pathway”). In 1994 the ABIM and ABFM phased out the practice-pathway option, and in 1998 they lowered the training requirement to only 1 year, resulting in a slight upward trend in the recruitment of geriatric fellows. As seen in Figure 4-3, the number of physicians certified annually surged and then sharply decreased when the practice-pathway option was eliminated; only 13.4 percent of all new certifications occurred after the practice-pathway option ended.
Numbers of physicians newly certified in geriatric medicine, 1988-2004. SOURCE: ADGAP, 2005.
Osteopathic physicians may pursue CAQs from the ABIM or ABFM and also from the American Osteopathic Board of Family Physicians (AOBFP) or the American Osteopathic Board of Internal Medicine (AOBIM), which have offered certification since 1991. The AOBIM ended the practice-pathway option in 1994, and the AOBFP ended it in 2002.
The American Board of Psychiatry and Neurology (ABPN) recognized geriatric psychiatry as a subspecialty in 1989 and first awarded 10-year CAQs in 1991 (ABPN, 2007a). In 1996 the ABPN phased out the practice-pathway option and subsequently reduced post-graduate training requirements from 2 years to 1 year. Figure 4-4 shows a similar surge and then a drop in certification related to these events.5 Only 13 percent of all geriatric psychiatrists ever certified became certified after the practice pathway was phased out.
Numbers of physicians newly certified in geriatric psychiatry, 1991-2004. SOURCE: ADGAP, 2005.
As the geriatric certifications expire, many physicians do not pursue recertification; most of these physicians were certified via the practice pathway. Reasons for not recertifying are multifactorial, including retirement, the burden of the process, and the lack of perceived benefit. Table 4-4 shows that only about half of all physicians certified in geriatric medicine or geriatric psychiatry before 1994 have been recertified (ADGAP, 2005). By comparison, 89 percent of physicians who received specialty certificates in other disciplines6 from the ABIM between 1990 and 1995 enrolled in the maintenance of certification process; of those, 81 percent completed the process (ABIM, 2005). The comparable rate of recertification in geriatrics among other health professions is unknown.
Number of Physicians Certified and Recertified in Geriatrics.
Professional nurses7 represent the largest sector of the health care workforce responsible for patient care in most health care settings. The professional nurse workforce consists of registered nurses (RNs) and advanced practice registered nurses (APRNs), who are RNs prepared in master’s degree programs. With few exceptions, almost all professional nurses are involved in the care of older adults. In addition to direct care, professional nurses supervise licensed practical nurses (LPNs)8 and certified nurse aides (CNAs) (discussed in Chapter 5). While the current and impending nursing shortage has received much attention, there have been some improvements; enrollment in baccalaureate programs increased by 5 percent from 2005 to 2006, and the number of graduates increased by 18 percent (AACN, 2006). However, this upswing is tempered by the fact that more than 32,000 qualified applicants to nursing programs (baccalaureate level or higher) were not accepted; about half the schools identified lack of faculty as the main barrier to admitting more students (AACN, 2006; Anderson, 2007). Additionally, men remain underrepresented in the nursing profession and need to be considered for recruitment efforts to allay workforce shortages (see Chapter 5).
Licensed Practical Nurses
LPNs have a more limited scope of practice than RNs, but this scope can vary widely among states, especially in light of the nursing shortage. With about 26 percent of all LPNs working in nursing homes, LPNs are especially important to the care of older adults in long-term care settings (BLS, 2007b). LPNs often provide more hours of care per nursing home resident per day than do RNs (Harrington et al., 2006). LPNs receive about 1 year of training through technical or vocational schools or through junior or community colleges. With experience and training, LPNs may supervise nurse aides. For example, the Institute for the Future of Aging Services is developing a leadership training program to teach LVNs the necessary skills and competencies to be more effective supervisors (IFAS, 2008). Some of the elements of this training include communication, critical thinking, conflict resolution, and cultural competency. Little is known about the geriatric training of LPNs.
As with other professions, nurses generally receive little or no preparation in the principles that underlie geriatric nursing in their basic nursing education. In 2005, 31 percent of new RNs received baccalaureate degrees, but only one-third of the baccalaureate programs required a course focused on geriatrics. Almost all baccalaureate programs include some geriatric content, but the extent of this content is unknown (Berman et al., 2005). While 42 percent of RNs receive their initial education through associate degree nursing programs (HRSA, 2006b), the degree of integration of geriatrics into these programs is also unknown. Given the paucity of geriatric content in programs preparing nurses, it is appropriate to assume that most practicing RNs have little formal preparation in geriatrics.
There exist a number of efforts aimed at ensuring nursing competency in geriatric care. In 2000, for example, the American Association of Colleges of Nursing (AACN) developed guidelines for geriatric competencies in baccalaureate programs. The National Council of State Boards of Nursing (NCSBN) mapped those guidelines against the National Council Licensure Examination (NCLEX), which is required for licensure of all nurses, to ensure adequate testing on geriatric issues (Wendt, 2003). Still, more needs to be done to analyze the depth of this content (Bednash et al., 2003).
As with other professions, there exist various public and private efforts aimed at increasing the geriatric content of nursing programs and developing geriatric nursing leaders. Since 1996 the John A. Hartford Foundation has invested $60 million in the Hartford Geriatric Nursing Initiative, which includes the Institute for Geriatric Nursing and the Centers of Geriatric Nursing Excellence. These programs foster the development of academic leaders and increase geriatric content in the education and training of nurses. In 2002 the Atlantic Philanthropies funded a 5-year initiative to improve nursing competence in treating older adults (Box 4-1). Under the Nurse Reinvestment Act,9 the Comprehensive Geriatric Education Program provides funds for clinical training of nurses in geriatrics, the development and dissemination of geriatric nursing curricula, and the preparation of nursing faculty to teach geriatrics. Funding for this program has remained at around $3.4 million annually since fiscal year 2004 (HRSA, 2007b). The Nurse Education, Expansion, and Development Act of 200710 proposes to offer grants to nursing schools to increase the integration of geriatrics into their core curricula.
Nurse Competence in Aging Initiative. “Nurse Competence in Aging (NCA) is an initiative to improve the quality of health care older adults receive by enhancing the geriatric competence—the knowledge, skills and attitudes—of the (more...)
Similar initiatives have also been developed to support education and training in geropsychiatric nursing. For example, in 2007 the John A. Hartford Foundation awarded $1.2 million to establish the Geropsychiatric Nursing Collaborative. This group will establish a core set of geropsychiatric competencies in order to develop basic curricula for all levels of nurse training (The John A. Hartford Foundation, 2007).
Advanced Practice Registered Nurses
An RN may become an APRN by obtaining a master’s degree and may become certified either through a national certifying examination or through state certification mechanisms. An APRN functions as an independent health care provider, addressing the full range of a patient’s health problems and needs within an area of specialization. There are a number of different types of APRNs, including: nurse practitioners (NPs), who provide primary care; clinical nurse specialists, who typically specialize in a medical or surgical specialty; certified nurse anesthetists; and certified nurse midwives. The pipeline for producing APRNs with a specialization in geriatrics is inadequate to meet the need. As with other types of nurses, the John A. Hartford Foundation has been a key supporter in the development of the geriatric APRN workforce. In particular, the Building Academic Geriatric Nursing Capacity Scholars and Fellows Awards Program targets doctoral and post-doctoral nurses and APRNs who want to redirect their careers toward geriatrics (Fagin et al., 2006).
NPs represent a particularly important component of the workforce caring for older adults because of their ability to provide primary care as well as care for patients prior to, during, and following an acute care hospitalization and also to care for residents in institutional long-term care settings. NPs treat a disproportionate number of older adults—23 percent of office visits and 47 percent of hospital outpatient visits with NPs are made by people 65 and older (Center for Health Workforce Studies, 2005). Furthermore, NPs care for a higher proportion of elderly poor adults than do physicians or physician assistants (Cipher et al., 2006). Finally, NPs have been shown to provide high-quality care and be cost-effective (Hooker et al., 2005; Melin and Bygren, 1992; Mezey et al., 2005).
While APRNs care for large numbers of older adults in ambulatory care, hospitals, and institutional long-term care settings, APRN education programs lack specific geriatric requirements. The AACN publishes a set of competencies called Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care (AACN, 2004), but it does not require that these competencies be incorporated into educational programs. Some of these competencies include
ability to distinguish between illness and normal aging;
assessment of geriatric syndromes;
identification of changes in mental status;
education of patients and their families about prevention and end-of-life care;
assessment of cultural and spiritual concerns; and
collaboration with other health care professionals.
Little is known about on-the-job opportunities for APRNs to gain knowledge and skill in geriatric nursing care.
Oral-Health Care Workers
The oral health needs of older adults are significantly different from the needs of younger people, and older adults face a variety of challenges in meeting these needs. One of the barriers facing older adults who need oral-health services is lack of access to care. This lack of access is often due to the lack of coverage under Medicare for routine services, but it is also the case that many oral-health professionals are reluctant to travel to alternative sites of care (such as community-based settings) or to manage the complicated social and medical challenges associated with older patients. Even though the delivery of basic oral-health services to nursing home patients is supported by government regulation, less than 20 percent of residents of government-certified institutions received dental services in 1997 (MacEntee et al., 2005). In 1987 the National Institute on Aging (NIA) predicted a need for 1,500 geriatric dental academicians and 7,500 dental practitioners with training in geriatric dentistry by the year 2000 (NIA, 1987). By the mid-1990s, however, only about 100 dentists in total had completed advanced training in geriatrics (HRSA, 1995), and little has changed since then.
The availability of geriatric training for dentists has improved over the past few decades. In 1976, only 5 percent of dental schools offered courses in geriatric dentistry and, at that time, more than half of the programs (52 percent) did not foresee geriatric dentistry as part of their future curricula (Mohammad et al., 2003). However, by 1981 about half of all schools had developed geriatric dentistry programs, and an additional 25 percent planned to add geriatric curricula in the near future. As of 2001, all dental schools reported having some curricula related to geriatric dentistry, and almost one-third operated a geriatric clinic (Mohammad et al., 2003). The geriatric content varies greatly among schools. A school may offer only a single elective course, for example, or material information may be imparted via guest lecturers. Additionally, exposure to clinical experiences is lagging behind the didactic requirements. Of the students graduating in 2001, almost 20 percent did not feel prepared to care for the elderly population, and 25 percent felt the geriatric dental curriculum was inadequate (Mohammad et al., 2003).
The American Dental Association currently does not recognize geriatric dentistry as a separate specialty, and none of the 509 residencies recognized by the American Dental Education Association are specifically devoted to the care of geriatric patients; in contrast, specialty recognition and 71 residencies exist for pediatric dentistry. In fiscal year 2005, HRSA supported seven residency programs in pediatric or general dentistry; one program specifically requested funds to improve clinical and didactic curriculum in geriatric dentistry, but the residency is not focused on geriatrics (HRSA, 2005b). The VA’s Advanced Fellowship in Geriatrics program allows dentists (and other health care professionals) to pursue advanced research in geriatrics at one of 16 GRECCs (VA, 2007a). Previous VA fellowships in geriatric dentistry are no longer available. As mentioned previously, HRSA administers the Title VII Geriatrics Health Professions Program, which includes awards to institutions to prepare geriatrics faculty in dentistry, medicine, and behavioral/mental health.
The American Board of General Dentistry (ABGD) offers board certification in general dentistry following completion of a post-graduate residency; exam content does not explicitly require questions on geriatric care or on special-care dentistry, but it does explicitly require knowledge of pediatric dentistry (ABGD, 2007). Also, while the ABGD’s general dentistry certification process has minimum requirements for continuing dental education in several areas (e.g., periodontics, orthodontics, and pediatric dentistry), it has no minimum requirements for “special patient care,” although it is a listed category. The American Society for Geriatric Dentistry (ASGD), part of the Special Care Dentistry Association, offers fellowship status to ASGD members who meet requirements for post-graduate and continuing education and who pass an oral examination. The American Board of Special Care Dentistry further offers diplomate status to ASGD fellows based on time in practice and membership in the SCDA. The American Dental Association, however, does not recognize this specialty board.
Less is known about the geriatric education and training of dental hygienists, although dental hygienists are increasingly important in providing care to special populations, especially those in rural areas and long-term care settings. Dental hygienists usually earn associate degrees, but some programs grant up to a master’s level degree. Dental hygienists are licensed by individual states, must pass written and clinical examinations, and have variable requirements for continuing education. While all schools have in tegrated geriatric content, about half (49.5 percent) consider their geriatric curricula to be inadequate (Tilliss et al., 1998).
There is currently a significant national shortage of pharmacists in the United States, which is due to a number of factors, including increased use of prescription medications, increased workloads, changing sites of service, demographic changes in the workforce, and expanding scopes of work (HRSA, 2000). While the absolute number of pharmacists has grown, supply has not kept up with demand, and wide variations in the numbers of pharmacists per capita exist from state to state (Walton et al., 2007). The current shortage causes problems for older adults, who tend to be heavy users of prescription drugs and to rely on pharmacists for counseling on the proper use of medications and on the monitoring of medication-related problems, such as interactions, duplications, adverse events, and adherence irregularities (Cooksey et al., 2002).
The role of pharmacists in the interdisciplinary care of older patients was reinforced in 1974 when Medicare first mandated drug regimen reviews (now called a Medication Regimen Review) in nursing homes by consultant pharmacists (Levenson and Saffel, 2007). In this setting, the role of the consultant pharmacist includes the provision information and recommendations to physicians regarding medications, identification of improper use of medications or the prescription of incompatible medications, and collaboration with the medical director and other staff to develop proper protocols for response to adverse events. This role has increased importance with the escalation of the number of medications given to the most frail and chronically ill patients. Additionally, with the advent of Medicare Part D, pharmacists potentially have a role in the education of older adults on their plan options and associated implications.
The doctor of pharmacy (PharmD) degree requires 4 years of pharmacy education. The Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree, adopted in 2006, implies that geriatrics should be a part of the pharmacy curriculum but does not explicitly require its inclusion. However, the science foundation of programs must consider populations that have altered pharmacological needs because of physiology or other reasons; this may include geriatric patients. Some of the competencies needed for the care of older patients include knowledge of the influence of aging on drug therapy, provision of medication and wellness counseling, and knowledge of geriatric syndromes (Odegard et al., 2007).
The American Society of Health-System Pharmacists (ASHP) accredits 1-year residencies in pharmacy, community pharmacy, or managed care pharmacy, which are referred to as PGY-1, for Post Graduate Year 1. Pharmacists may pursue a second year of residency training (PGY-2) in a focused area, including geriatric pharmacy. The ASHP currently accredits (or pre-accredits) 351 PGY-2 programs (ASHP, 2007). There are eight accredited programs in geriatric pharmacy, and two other programs are pre-candidates for accreditation. The American College of Clinical Pharmacy offers one fellowship position in geriatrics to prepare pharmacists for academia and independent research; this 2-year fellowship focuses on Alzheimer’s Disease (ACCP, 2007). Viability of these programs has been hindered by inconsistent funding; with the exception of GECs, there are few federal or private-foundation-funded programs or initiatives that support pharmacist education and research training in geriatrics.
Pharmacist licensure, which is performed by individual states and jurisdictions, depends on passing a national examination, and 46 jurisdictions require an additional examination on federal law and state-specific regulations (CCP, 2006). Some states also require laboratory and oral examinations. Re-licensure requires a minimum of continuing education credits. Currently, neither continuing education in geriatrics nor demonstrated geriatric competency is required for pharmacist re-licensure in any state. However, a 2005 survey of state pharmacy laws found that one state requires all pharmacists to participate in 2 hours of continuing education in end-of-life care every 2 years, and two states require all pharmacists working as long-term care consultants to have at least a portion of their continuing education activities focused on the care of older adults (Linnebur et al., 2005).
Physician assistants (PAs) represent an important part of the workforce for the elderly population (Olshansky et al., 2005). PAs work under the supervision of a physician, but they can often work apart from the physician’s direct presence and can prescribe medications and bill for health care services. Unlike some of the other professions described above, the PA workforce tends to be younger and is growing rapidly. About half of PAs work in family medicine or general medicine (Brugna et al., 2007; Hooker and Berlin, 2002). The 65-and-older population accounts for about 32 percent of office visits to PAs (Hachmuth and Hootman, 2001), and 78 percent of PAs report treating at least some patients over the age of 85 (Center for Health Workforce Studies, 2005).
PAs are an especially important source of care in underserved areas, where they often act as the principal care provider in clinics, with physicians attending on an intermittent basis. In this vein, they are a potential source of care to meet the increased need that is projected for long-term care settings. Their use may be a particularly attractive strategy since, as with NPs, the use of PAs has been shown to be cost-effective (Ackermann and Kemle, 1998; Brugna et al., 2007). On the other hand, according to a survey of more than 23,000 PAs, only 5 percent of respondents reported spending any time in a nursing home or other long-term care facility, and less than 1 percent identified their primary practice as geriatrics (AAPA, 2007). Of those respondents who specialize in geriatrics, 67 percent reported working primarily in a nursing home or long-term care facility, and 75 percent reported spending at least some time in those settings. Almost 18 percent of PAs who specialize in geriatrics spend some time caring for patients at home, compared to 1.3 percent of all other types of PAs. And almost 22 percent of PAs specializing in geriatrics are employed by the government, primarily by the VA, while only 9 percent of all other types of PAs work for the government.
The overwhelming majority of the 136 accredited PA programs are located within universities and colleges, but a few exist within hospitals, community colleges, and military institutions (BLS, 2007c). Most of these programs offer a master’s level degree, while others offer bachelor’s and associate-level degrees. Virtually all students in these programs—99 percent—pursue primary-care tracks. Most programs follow traditional curricula of medical schools (Hooker and Berlin, 2002), and while some PAs receive advanced training, the bulk of the advanced programs focus on surgical and emergency care (APPAP, 2008). Accreditation standards require training in geriatrics but do not specify a minimum workload (BLS, 2007c). As is the case with other professions, there have been many calls for increased education and training of PAs in geriatrics (Brugna et al., 2007; Olson et al., 2003; Segal-Gidan, 2002; Woolsey, 2005). Unfortunately, very little has been done to examine the quality and quantity of current geriatric education and training among PA programs. In one survey, PA program administrators who were asked which areas of the curricula needed increased emphasis said that geriatric issues related to pharmacology and mental health deserved the highest priority (Olson et al., 2003).
The need for geriatric social workers has been recognized for decades (NIA, 1987; Saltz, 1997). In 1987 the NIA estimated that there would be a need for 70,000 social workers prepared in geriatrics by 2020, or a 43 percent increase over the needs at that point in time. In spite of this urgency, the number of social workers trained in geriatrics has not kept pace with the need. While 73 percent of social workers report that they work with adults aged 55 and over, and between 7.6 and 9.4 percent of social work ers are employed in long-term care settings, only about 4 percent actually specialize in geriatrics (ASPE, 2006; Center for Health Workforce Studies, 2006). Between 1996 and 2001 the number of students specializing in aging decreased by 15.8 percent (ASPE, 2006). On the other hand, many social workers begin to specialize in the care of older persons after graduation and do so without formal training in geriatrics (Cummings and DeCoster, 2003).
Social workers receive training through either bachelors-level (BSW) or masters-level (MSW) programs, which may be accredited by the Council on Social Work Education. As of 2006, the Council accredited 458 BSW programs and 181 MSW programs; there were also 74 doctoral programs in social work (DSW or PhD) at the time (BLS, 2007d). Combined, BSW and MSW programs graduate about 31,000 students annually (ASPE, 2006). Social workers with BSW degrees are more likely to work in long-term care settings than those with MSW degrees. A 1995 survey showed that 11.5 percent of BSW social workers worked in nursing homes or hospices, compared to 1 percent of MSW holders, and 16.5 percent identified aging services as their primary practice, compared to 3.7 percent of MSW holders (ASPE, 2006).
In spite of the long-recognized need for social workers trained in aging issues, most social work programs contain little or no geriatric content in their curricula. In fact, the proportion of programs offering specialization in aging is decreasing. In the early 1980s almost half of MSW programs offered an aging specialization; by the early 1990s this had dropped to about one-third of programs, and as of 2003 only about 29 percent of MSW programs offered an aging concentration, specialization, or certificate program (Cummings and DeCoster, 2003; Scharlach et al., 2000). Existing aging curricula often have limited content, rarely offering more than one or two elective courses. In 1988 the vast majority of BSW programs—about 80 percent—did not offer specific instruction on aging issues (Lubben et al., 1992). The inadequacy of curricula is compounded by the fact that social-work students show low levels of interest in taking courses on aging and have persistent negative attitudes about working with older people (Hash et al., 2007; Lubben et al., 1992).
In 2000 the Council on Social Work Education, in conjunction with Strengthening Aging and Gerontology Education for Social Work (SAGE-SW), surveyed social workers about the competencies that geriatric social workers and other types of social workers need in order to care for older patients effectively (Rosen et al., 2000). Sixty-five competencies were identified, of which 35 were described by the respondents as being needed by all types of social workers. These competencies included
knowledge of the physical, social, and psychological changes of aging;
knowledge of the diversity of attitudes about aging;
use of case management skills to get access to needed resources;
collaboration with other health professionals;
identification of one’s own biases toward aging; and
respect of diverse cultural and ethnic needs.
Several initiatives aim to promote education and training in geriatric social work:
The Social Work Leadership Institute at the New York Academy of Medicine, funded by the Atlantic Philanthropies and the John A. Hartford Foundation, coordinates the Practicum Partnership Program, an innovative educational model to train masters level social workers in their field work (Box 4-2).
The Atlantic Philanthropies established the Institute for Geriatric Social Work, which, in partnership with the American Society on Aging and other groups, promotes the training of practicing social workers in issues related to the elderly population (IGSW, 2007).
In 2000-2004 the John A. Hartford Foundation supported the Geriatric Enrichment Program (GeroRich) to increase geriatric content in basic social work courses at both the BSW and MSW levels (Hash et al., 2007).
The John A. Hartford Foundation also supports the Council on Social Work Education Gero-Ed Center, which serves as a resource for both faculty and students to become competent in geriatric issues.
The Practicum Partnership Program. “The Practicum Partnership Program sponsored by the New York Academy of Medicine and the Hartford Foundation is in its eighth year. It has trained more than 1,000 social workers to work with older adults using (more...)
Very few social-work trainees do advanced training or field work in aging, and of those who do, most are students in MSW programs. This lack of training is primarily due to a lack of funding for program support or stipends (ASPE, 2006; Scharlach et al., 2000). In partnership with the Social Work Leadership Institute, the John A. Hartford Foundation supports 60 MSW programs in an effort to increase the quality and content of field experiences in aging. The effort aims to increase the numbers of MSW students who go on to specialize in geriatrics.
In 1998 the National Association of Social Workers (NASW), the voluntary professional organization of social workers, created a new specialty section on aging. Recently the NASW has developed three specialty certifications in gerontology available to its members (NASW, 2007).
Allied Health and Other Professions and Occupations
Many other professionals also provide essential health services to older Americans. These professionals are pressed to meet the needs of the growing older population because of shortages of supply, increases in demand, and deficiencies in geriatric education and training that are similar to those already discussed. For example,
HRSA’s 1995 report on the status of geriatric education showed only 17 percent to 19 percent of physical therapy programs had at least 75 percent of their students complete a geriatric internship even though 39 percent of the physical therapy patients were over 65 (HRSA, 1995).
The Emergency Medical Technician—Basic: National Standard Curriculum, developed by the National Highway Traffic Safety Administration, includes modules dedicated to the care of obstetrics and pediatric patients, but none are dedicated to the older adult patient (NHTSA, 1994).
While 84 percent of optometry schools and colleges reported a required geriatrics course, the content of these courses was variable.
Only one of the eight schools of podiatric medicine has a discrete course devoted to the care of geriatric patients, while six list courses specific to the care of pediatric patients (AACPM, 2007).
In a 2004 survey of dietetics and nutrition programs, 22 percent of the undergraduate programs and 44 percent of the graduate programs offered courses in aging (Rhee et al., 2004). In comparison, maternal and child health courses were offered in 31 and 51 percent of the programs, respectively. Thirty-seven percent of graduate programs had no faculty in geriatrics.
None of the following specialties with high volumes of older patients has a subspecialty certificate available in geriatrics: dermatology, emergency medicine, physical medicine and rehabilitation, or surgery. By contrast, all have certification in pediatrics (ABMS, 2007).
Of particular importance are the many occupations that fall under the broad category of “allied health care workers.” This term is ill-defined, and the many definitions that have been developed are often contradictory (Lecca et al., 2003). In general, allied health care workers represent nearly 200 different occupations, including various types of technologists, technicians, therapists, and health-information professionals. Many of the allied health occupations are currently experiencing shortages and are projected to be among the fastest-growing occupations in the United States (BLS, 2007a). These groups face significant increases in need for their services in all care settings (Chapman et al., 2004). The geriatric education and training of the allied health care workforce is highly variable and is usually structured according to the standards of the appropriate accrediting body.
Other Issues in Geriatric Education and Training
In addition to the particular professional concerns discussed in the previous section, there are a number of other overarching issues that all professions face in the geriatric education and training of their practitioners. First, the education and training of all types of professionals depends on the availability of qualified faculty. Second, practitioners should be aware of the unique health care needs of several special elderly populations; these populations include various racial and ethnic groups as well as the growing number of lesbian, gay, and bisexual older adults.11 Third, all practitioners who care for older adults should be educated and trained in the full spectrum of health care needs, from health promotion to palliative care. Finally, as discussed in Chapter 3, interdisciplinary care of older adults shows promise, so students in all professions should be trained on how to be an effective member of an interdisciplinary team.
A well-recognized barrier to geriatric education and training of all health care providers is the inadequate number of available and qualified academic faculty (Berkman et al., 2000; Berman et al., 2005; Cavalieri et al., 1999; Graber et al., 1999; Hazzard, 2003; Kovner et al., 2002; Rhee et al., 2004; Rubin et al., 2003; Simon et al., 2003; Warshaw et al., 2006). Any effort to increase geriatric education will find itself limited by the availability of trained faculty. Furthermore, beyond the need for a greater number of geriatric faculty, all geriatric fields need strong expert leaders to develop new knowledge and recruit new students.
It is a controversial question whether advanced geriatric training programs should be designed to train geriatric specialists for clinical practice or to train them for academic research and leadership. Some argue that, for the sake of the efficient use of scarce resources, geriatric specialists should concentrate on their roles of performing research and training the future health care workforce and should act as clinical consultants in only the most complex cases.
Beyond academics and clinical care, geriatric leaders need to learn the skills to manage staff, promote quality, and create a healthy work environment. For example, the relationship between nursing supervisors and nurse aides plays a significant role in the development of a hospitable work environment that leads to increased job satisfaction (see Chapter 5 for more on job satisfaction and turnover among direct-care workers) (Tellis-Nayak, 2007). In addition, certain management principles, such as providing rewards to nurse aide staff, have been associated with improved patient outcomes (Barry et al., 2005). This relationship will also have increased importance as direct-care workers assume more patient responsibility in the cascading mechanism of job delegation (discussed more later in this chapter).
To increase the number of geriatric leaders, a number of public and private entities have developed programs to promote research and teaching capacities in geriatrics. Examples include the following:
The Hartford Geriatric Social Work Faculty Scholars Program, funded by the John A. Hartford Foundation, aims to develop leaders in geriatric social work through research support, mentoring, skills-based workshops, and nurturing of professional relationships (GSWI, 2007; Maramaldi et al., 2004).
HRSA’s Geriatric Training for Physicians, Dentists, and Behavioral/ Mental Health Professions Program is the country’s sole source of postgraduate training for preparing dentists to teach geriatrics (HRSA, 2005a). In fiscal year 2005 HRSA funded 13 programs with a total of $6.3 million in grants. It is unknown, however, whether all of these programs filled their available dental positions.
The Atlantic Philanthropies and the John A. Hartford Foundation support the Dennis W. Jahnigen Career Development Scholars Awards to develop geriatric academic leaders in surgical and related specialties, such as anesthesiology, ophthalmology, and emergency medicine. The two foundations are also responsible for the establishment and continuation of the T. Frank Williams Research Scholars Award, which supports research by medical subspecialists in geriatrics or aging.
In July 2004 the Donald W. Reynolds Foundation awarded a total of $12 million in grants to four academic health centers for them to train their medical faculty in geriatrics (Donald W. Reynolds Foundation, 2007).
HRSA grants GACAs (Geriatric Academic Career Awards) directly to junior faculty at allopathic and osteopathic medical schools to support teaching (HRSA, 2005a).
The John A. Hartford Foundation’s Centers of Excellence in geriatric medicine, psychiatry, and nursing help to train larger numbers of competent geriatric academicians and also allow specialists to devote time to geriatric research in addition to their work training future clinicians.
Recognizing the scarcity of geriatric leaders, several institutions have developed innovative approaches to spread knowledge of geriatric principles. For example,
In 1997 the Practicing Physician Education Project used geriatric experts to train non-geriatrician physician leaders to educate their peers on various geriatric syndromes (Levine et al., 2007).
Since 1992, the Nurses Improving Care for Health System Elders (NICHE) program has worked with nurses in hospital settings to implement models and protocols that improve the care of geriatric patients. In the Geriatric Resource Nurse (GRN) model, a geriatric APRN trains a staff nurse to be the clinical resource on geriatric issues for other nurses (NICHE, 2008).
The Boston University Medical Center developed the Chief Resident Immersion Training (CRIT) Program in the Care of Older Adults to improve understanding and teaching of geriatric principles among residents in non-geriatric fields (ADGAP, 2007a). The program is being disseminated nationally.
In 2003-2004 the Society of General Internal Medicine and the John A. Hartford Foundation worked in Collaborative Centers for Research and Education in the Care of Older Adults to enhance the ability of general internists to teach geriatrics (Williams et al., 2007).
HRSA administers the National Advisory Council on Nurse Education and Practice, which, in response to the Nursing Reinvestment Act, provided grants for the geriatric education and training of registered nurses so that they can act as leaders and trainers for CNAs and LPNs (HRSA, 2003).
Geriatric experts have tried to infuse geriatrics into training programs for personnel who might not normally gain exposure to geriatric principles. Faculty at Northern Michigan University developed a training program for correctional workers that focused on the needs of the aging prison population (Cianciolo and Zupan, 2004).
Ethnogeriatrics As discussed in Chapter 2, the elderly population of the future will be more diverse than today’s older adults. Thus increased knowledge of different cultural belief systems will be important to the development of comprehensive and effective plans of action. For example, older Asian adults may not disclose their non-Western health beliefs, including the use of herbal medications or alternative health procedures, unless directly asked (McBride et al., 1996). These concerns are especially important considering the potential mismatch between the diversity of the health care workforce and the diversity of the older adult population. For example, the high proportion of IMGs among fellows in geriatric medicine and geriatric psychiatry was demonstrated earlier in this chapter. However, concerns exist for issues of communication and cultural competency in particular when IMGs care for older adults (Howard et al., 2006; Kales et al., 2006).
Several efforts have been started to improve upon the ethnogeriatric education and training of the health care workforce in settings where providers are responsible for taking care of diverse populations. For example, the Collaborative for Ethnogeriatric Education produced a five-module Core Curriculum in Ethnogeriatrics and 11 Ethnic Specific Modules which can be used as resources in different geographic areas to provide content on local populations (www.stanford.edu/group/ethnoger). Box 4-3 lists some of the knowledge and skills needed to properly care for diverse populations.
Knowledge and Skills Needed in Ethnogeriatrics. Knowledge: Differential health risks
Lesbian, gay, and bisexual persons Approximately 1 million to 3 million adults ages 65 and older are gay, lesbian, or bisexual (GLB), and by 2030 that number is expected to rise to 4 million (Cahill et al., 2000). The few existing studies on the health care needs of older GLB patients report similarities to the health care needs of heterosexual older adults, with a few important differences. Many GLB patients do not feel comfortable disclosing their sexual orientation to their health care providers. Surveys reveal that discrimination based on sexual orientation is widespread in health care and other social-service settings, and it often causes GLB persons to avoid seeking health care (Cahill et al., 2000; Ryan and Futterman, 1998; Schatz and O’Hanlan, 1994). The discomfort of revealing sexual orientation to health care providers is heightened for older adults who came of age at a time when society was even less accepting of homosexuality (Brotman et al., 2003).
Knowledge of a patient’s sexuality can be critical to high-quality patient care. A recent study estimated that approximately 100,000 adults ages 50 and older are HIV positive (ASA, 2007). Older adults with HIV/AIDS may be misdiagnosed because health care providers do not perceive HIV/AIDS to be a risk among older adults and because older adults often do not disclose the nature of their sexual activity to health care providers (AIDS InfoNet, 2007; NAHOF, 2007). Additionally, GLB older adults often do not have the same family support systems as heterosexual older adults, particularly since GLB older adults are less likely to have children and are more likely to live alone (Cahill et al., 2000).
The Continuum of Care
Geriatric education is highly variable in its level of comprehensiveness, and it often fails to address the health care needs of older adults across the continuum of care, ranging from preventive to palliative care. Health care professionals should be aware that older adults have a vast range of health care needs. Many students still are not taught about or exposed to older populations at either end of the continuum of care.
Health promotion/disease prevention Health promotion is beneficial for people of all ages and all health conditions, but it may be especially important to the growing cohort of healthy older adults—that is, the 20 percent of older Americans who have no chronic disease and who require only preventive and episodic care. Traditionally, the training of professionals in the care of older adults has focused only on the treatment of disease and has given little attention to the promotion of health. For example, poor nutrition is prevalent among seniors (IOM, 2000), but most professionals are still not trained in the nutritional needs of older adults (Bonnel, 2003; Rhee et al., 2004). Government agencies and professional societies have developed guidelines for health promotion and disease prevention in elderly populations which include goals typically promoted for other populations, including increased physical activity, smoking cessation, and weight management (Fields and Nicastri, 2004). These guidelines are based on research that shows the benefits of health promotion and disease prevention in elderly populations. For example, studies have shown that older persons who practice tai chi experience fewer falls (Li et al., 2002, 2005; Wolf et al., 1996).
Screening guidelines are important in nursing homes for the early detection of depression and pressure ulcers (McElhone et al., 2005). Unfortunately, prevention and screening guidelines often lump all elderly persons into one group (65 years and older), and recommendations are often based on studies performed in younger age groups (Nicastri and Fields, 2004). More research is needed on preventive services for older adults, especially for the “oldest old,” and health care professionals need to be aware of the value of these services for all of their older patients.
The activities of professional groups today reflect a growing awareness of the importance of health promotion and disease prevention for older patients. For example, the Geriatrics Section of the American Physical Therapy Association has an interest group on “Health Promotion & Wellness” that aims to improve the education, clinical practice, and research of physical therapists in health and wellness among older adults (APTA, 2007). The American Geriatrics Society lists “health promotion and disease prevention strategies” among the areas of knowledge needed for the successful preparation of internal medicine physicians who care for older adults (AGS, 2004). The American Dietetic Association includes the provision of nutrition care across the lifespan, “infants through geriatrics,” as one of the core competencies for entry-level dietitians and dietetic technicians (ADA, 2008).
Palliative care Within geriatric education and training programs, palliative care skills are especially important since 80 percent of American deaths occur among those over age 65 (Ersek and Ferrell, 2005). Skills that are particularly important include identification and relief of physical and emotional stress, effective communication, interdisciplinary team work, recognition of the signs and symptoms of imminent death, and support of the bereavement process (National Consensus Project for Quality Palliative Care, 2004). The opportunities for exposure to these topics has improved greatly in recent years; almost all medical schools offer some form of end-of-life care education, and 62 percent of pharmacy schools surveyed reported didactic training in end-of-life care (Billings and Block, 1997; Herndon et al., 2003).
Despite such improvements, however, the overall education and training of the health care workforce in palliative care is deficient (Billings and Block, 1997; Ersek and Ferrell, 2005; Holley et al., 2003; IOM, 1997; Paice et al., 2006; Walsh-Burke and Csikai, 2005). In one survey of medical students, residents, and faculty, less than 20 percent reported that they received formal education in end-of-life care, 39 percent felt unprepared to address patient fears, and almost half felt unprepared to deal with their own feelings about death (Sullivan et al., 2003). Another survey showed that less than half of graduating family medicine and internal medicine residents (41 percent and 43 percent, respectively) felt very prepared to counsel patients on end-of-life issues (Blumenthal et al., 2001). In contrast, a 2005 study showed 70 percent of geriatric medicine fellows reported completing rota tions in palliative care, end-of-life care, or hospice, and only 2.7 percent felt unprepared to care for dying patients (Pan et al., 2005).
In October 2006 the American Board of Medical Specialties (ABMS) announced Hospice and Palliative Medicine as a new subspecialty for ten different specialty boards (ABMS, 2006). The first certifying exams will be administered in October 2008.
Interdisciplinary Team Training
One element common to many models described in Chapter 3 is the use of interdisciplinary teams. The value of interdisciplinary teams for the care of older adults with complex care needs has been increasingly acknowledged in recent years (Dyer et al., 2003; Howe and Sherman, 2006; Inouye et al., 2000; Maurer et al., 2006; Wheeler et al., 2007; Williams et al., 2006). The term “interdisciplinary team” implies an interaction and an interdependence among practitioners with different areas of expertise who are working together to treat a single patient. Still, health care professionals are typically trained separately by discipline, which fosters ideas of hierarchy and responsibility for individual decision making (Hall and Weaver, 2001). As a result, providers may gain little understanding of or appreciation for the expertise of other providers or the skills needed to effectively participate in an interdisciplinary team. However, most health care professions identify interdisciplinary team practice as a necessary competency in the care of older adults.
The field of geriatrics led the movement toward team training in health services. In the 1970s the VA developed the Interdisciplinary Team Training in Geriatrics (ITTG) Program, and in the 1980s HRSA began awarding grants for GECs to teach collaboration and teamwork to health care professionals working in geriatrics (Heinemann and Zeiss, 2002).
In 1997 the John A. Hartford Foundation funded eight national programs to develop geriatric interdisciplinary team training (GITT) programs for students in nursing, social work, and medicine in order to foster the skills needed for effective team care. These programs often included other professionals, such as pharmacists, dentists, and rehabilitation therapists. GITT seeks to train health professionals to work more effectively on geriatric care teams. The announced goals included the creation of a national model to forge partnerships between geriatric care providers and institutions of education, the development of educational curricula for interdisciplinary team training, training health care professionals in team skills, and the testing of new models of training for practicing professionals (Flaherty et al., 2003).
To evaluate this training, several measures have been developed to assess trainees’ knowledge of interdisciplinary geriatric-care planning, their knowledge of team dynamics, their attitudes toward geriatrics and teams, and their skills in team care (Flaherty et al., 2003). One evaluation showed that the most improvement came on measures of attitudes, especially self-reported measures of team skills; no changes were seen in care planning, and few changes were seen in team dynamics, depending on the question and the discipline (Fulmer et al., 2005). Obstacles identified for interdisciplinary training within the GITT programs included differing lengths of rotation among the disciplines, differing levels of experience among the participants, and the inability of clinicians to supervise students from other disciplines (Reuben et al., 2003, 2004). Physicians were the least experienced with and the most averse to sharing responsibilities of patient care. Similar results have been documented in studies of other similar models (Fitzgerald et al., 2006; Leipzig et al., 2002; Williams et al., 2006).
HRSA has been a strong supporter of interdisciplinary training in geriatrics and has stated that interdisciplinary geriatric education should be a core requirement for every health profession (HRSA, 1995). As mentioned above, GECs provide interdisciplinary training of faculty, students, and practitioners in the diagnosis, treatment, and prevention of disease, disability, and other health problems of older adults (HRSA, 2007c). While more and more professionals are gaining experience in interdisciplinary training, little evidence exists to determine which methods are best for imparting the knowledge and skills necessary to work as a team member or to show how such training affects patterns of practice (Cooper et al., 2001; Hall and Weaver, 2001; Remington et al., 2006).
The education and training of professionals in geriatrics has improved because of the expansion of school-based opportunities, increased efforts in interdisciplinary training, and the development of alternative pathways to gaining geriatric knowledge and skills (discussed in more detail later in this chapter). Professional groups, private foundations, and public agencies all support and promote multiple efforts.
Assignment 53 Information
Five scientists, each of them vital to the Alien Aisha Invasion Force lead by Supreme Commander Arlhox VII, have become stranded on distant planets throughout the galaxy. As an ambitious (and expendable) new recruit, the important mission of braving these dangerous planets and rescuing the scientists has fallen to you. So, recruit... Are you up to the task?
You can bet we are!
How to Play
In Assignment 53 you take control of either Eddix or Moxi, Alien Aisha recruits that, coloration aside, are identical. The game can be played in its entirety with the arrow keys, left and right moving your character, up jumping, and down crouching. Alternately, you can use the W, A, S, and D keys to play. To pause the game, however, you must use your mouse to press the button in the bottom-right corner of the screen.
On each planet you visit, your goal is to rescue a scientist from the wreckage of their crashed ship. Planets are split into two acts: the first ending when you reach a signal beacon, and the second ending when you reach the scientist. Along the way you can collect Nerkmids, gross food, and Alien Aisha technology that have fallen from the crashing ships. You will also have to be on the lookout for strange alien lifeforms, as most prove to be hostile and will damage you on contact. Most of these creatures can be defeated by jumping on top of them.
"Strange" may be an understatement...
In the lower-left corner of the screen is a display showing your air supply gauge, your health (represended by three green lights), your lives, and the number of Nerkmids you've collected. This area will also show any power-ups you're currently holding. If you run out of air or health, or fall into a pit, you will lose a life and restart from the last checkpoint you reached. While losing all of your lives represents the failure of your assignment, if you manage to collect enough Nerkmids you will be able to gain extra lives.
You can also gain an extra life by using your arrow keys to input the code Up, Up, Down, Down, Left, Right, Left, Right in the game's main menu.
|Nerkmids are worth 10 points each, but this will only be added to your score when you complete an act. Collecting enough Nerkmids will grant you an extra life.|
|Force Fields render you invulnerable for 15 seconds, allowing you to destroy aliens with a touch. This includes ones that are normally impossible to defeat.|
|Gravity Boots greatly increase your jump height, and grant the ability to perform a wall jump by jumping, coming into contact with a wall, and jumping again. You will lose them if you take damage.|
|Speed Wings increase your speed, allowing you to quickly dash across the planet's surface for 10 seconds. You will lose them if you take damage.|
| ||Gross Foods can be collected to restore one unit of health, and if eaten with full health are worth 100 points. If you're curious as to what each food item is, click on it to view its Item Database entry.|
|These beacons serve as checkpoints when activated, allowing you to start at them rather than at the beginning of a level when you lose a life.|
|These beacons appear at the end of a planet's first act, serving as a checkpoint for the next act.|
There are four ways to increase your score in Assignment 53: collecting Nerkmids, destroying enemies, eating Gross Food, and completing levels quickly. Nerkmids are worth 10 points each, but are only added to your score on completing a level, so don't expect to get points from them if you get a mid-level Game Over. Every enemy destroyed is worth 30 points, and as most only require being jumped on, this is a quick way to earn points.
While eating a piece of Gross Food will restore your health by one unit, if eaten with full health they grant an instant 100 points. Finally, you will receive bonus points depending on how quickly you finish a level, as indicated by your air gauge in the lower-left corner of the screen. While you can get a considerable Air Remaining Bonus in the early levels, later in the game it's more worthwhile to collect Nerkmids and destroy enemies for points, as there are many more of them at this point. If you lose a life, you will also lose all of the points you've earned since the last checkpoint.
The forest-covered first planet in the Wuba system, Wuba Prime is where your assignment begins. Act 1 poses little threat to you, and serves as a tutorial on the basic mechanics of the game. If you jump at the wall to the right of the checkpoint, you will find a secret area leading to a piece of gross food.
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Act 2 features moving platforms and several seed-spitting plants. In order to pass the first moving platform without being knocked off, crouch at the front of it until the plants have spit their seeds.
The second scientist can be found on Octozodi, a rather swampy planet inhabited by slimey, primitive lifeforms. From the start Octozodi is much harder than Wuba Prime was, with a barrage of slug-like creatures that launch projectiles at you. If you watch for openings and crouch where it's safe, you should be able to get through this area without too much trouble.
At the start of Act 2 is a moving platform that will take you to an area filled with Nerkmids, power-ups, and aliens. If you avoid the moving platform, or go to the left when you reach the bottom of the area after using it, you will come across a small ledge with a creature on it. If you jump on the creature for a height boost and press against the left wall, you will find a secret area with twelve Nerkmids.
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Next up is the mountainous Wuba Secundus, the aptly-named second planet in the Wuba system. This is much harder than the previous levels, with tight, alien-filled corridors that require precision and a good sense of timing. If you drop straight down into the first pit after collecting the Gravity Boots, you'll find a Force Field that will make this area considerably easier; you will, however, need to wall-jump to get out.
Act 2 begins with a Speed Wing area in which you can dash through collecting Nerkmids, but unless you've mastered the Speed Wing you will likely take damage trying to do this. It's considerably easier to proceed through this area slowly, taking out aliens as you go. After this is a segment in which you must follow a moving platform as it passes between rocks, forcing you to jump over them. While there are projectile-launching enemies here, if you stay on top of the rocks you should be able to avoid them.
If you jump at the wall to the left from the top of the blue moving platforms after the checkpoint, you'll find a secret area containing Nerkmids, a Force Field, and a Speed Wing. Using these power-ups, you can charge through the final portion of the level to quickly earn points.
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Our fourth scientist seems to have crash landed on the rocky planet of Gorignak V. The first act is markedly easier than Wuba Secundus was, with open areas, easily defeated enemies, and plentiful power-ups. At one point you will see a vertically-moving platform that you can't quite reach; if you collect the Gravity Boots, which are just a short platforming section away, you can ride it to find Nerkmids and a Speed Wing. You can also reach this area if you wall-jump just past where the Gravity Boots are found. When you reach the red checkpoint beacon, you can wall-jump against the wall to the left for an easy gross food.
Act 2 is another very easy area, with several moving platforms that take you to caches of Nerkmids and gross food. If you're going for a high score (or the avatar), this is a good place to quickly collect points.
Well, this is a familiar sight! The fifth and final scientist is on Kreludor, Neopia's moon. The first act is relatively easy, with wide open areas and plenty of Nerkmids, gross food, and power-ups. Use this opportunity to stock up on points, as well as lives... You'll be needing them.
At the start of the second act is a large pit filled with tough-to-kill enemies; to avoid them, stick to the upper route. Here you will find a small bonus area accesible with Gravity Boots, several of which are sitting on nearby platforms. After the checkpoint the level becomes a bit harder, with a tight corridor and robotic turrets that can only be destroyed by putting yourself in another turret's line of fire.
If you want to heal up before taking on this section, you can bounce to the left after landing on the second turret in the tunnel, which leads to a secret area full of Nerkmids and gross food.
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For an extra challenge, one more secret area can be found by jumping at the wall to the left of the first moving platform after the tunnel. The challenge aspect comes from the fact that to actually get to where the items are, you must have a pair of Gravity Boots in order to perform a wall-jump. This means going through the tunnel area with Gravity Boots on, and not taking a single hit. If you lose the boots, you will have to lose a life and start over from the checkpoint, as you're unable to leave through the tunnel's entrance. It may sound a daunting task, but as the forty Nerkmids and eight gross food items hidden here add up to 1,200 points, it may well be worth it.
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Kreludor - Final Act
At long last, you've found the final scientist. Unfortunately, it seems that his ship was shot down, and is being guarded by a large security robot. The robot's pattern of attack is fairly simple: it will jump three times, stop to launch one of two different types of projectiles, pause for a moment, then start jumping again. The first projectile it shoots is a series of nine green laser bursts (three up, three to the left, and three to the right) which travel in straight lines, and will harmlessly pass above your head if you're standing at ground level.
The second type of projectile is a searingly hot lump of molten metal, which will arch and fall in a way that should be familiar to you by now. It releases fifteen of these in three series of five, which can be hard to avoid. Unfortunately, there's no way to tell which attack the robot will use, so don't get too close to it until its attack is done. If you stand in the corners of the area, the robot will be unable to jump on you, but it will still be able to reach you with its arcing shots.
To fight back, wait until the robot is cooling down after an attack, then jump on the green dome on its top to cause damage. You can bounce on the dome three times before the robot starts moving again, after which touching any part of it will hurt you. If you can hit the dome ten times, the robot will become damaged beyond repair and explode. Congratulations, you've rescued the five Alien Aisha scientists, and completed Assignment 53!
C'mon, let's eat some delicious Gross Food and celebrate!
This game guide was written by: Chesu
A53 - LIKE A BOSS
Send a score of 20,000+ points in Assignment 53.