GENERATIONS – Journal of the American Society on Aging – Caring for an Aging American in the Twenty-First Century

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By Robyn I. Stone and Linda Barbarotta

Editor’s Note: This article is taken from the Winter 2010–2011 issue of ASA’s quarterly journal, Generations, and is an overview of both the contents of the issue and the topic that it addresses, “Building an Eldercare Workforce.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store.

In January 2011, the first baby boomers turned age 65. Over the next twenty years, the number of adults who are ages 65 and older will double. The population of those ages 85 and older—the group most likely to need acute, primary, and long-term care—is expected to increase five-fold. One in five Americans will be of age 65 or older, compared with 12 percent today (Institute of Medicine, 2008).

While this demographic phenomenon is to be celebrated, it is also expected to place increasing demands on those who care for our elderly population—a group that uses considerably more services than younger people and whose health and long-term-care needs are often more complex. Elders are more likely to suffer from multiple chronic physical and mental illnesses, have higher levels of functional disability, use multiple medications, and have higher rates of dementia and other cognitive impairments (Medicare Payment Advisory Commission, 2007).

These demands require an educated, highly trained, competent workforce across all settings where people receive care—the hospital, a physician’s office or clinic, a nursing home, assisted living (or other residential care setting), and private homes and apartments. The workforce ranges from the direct-care workers who provide hands-on care to a financially, racially, and ethnically diverse population, to the variety of clinicians who address the complex health and long-term-care needs of this population, to the managers and administrators who oversee the systems that deliver care.

This special issue of Generations recognizes the demographic reality that will be driving much of the health and long-term-care demand over the next twenty years and the need to develop a quality workforce to care for an aging America in the short and long term. The purpose of this special issue is to review the state of the art in the development of this workforce; to highlight the various policy and practice issues across professions and settings that are impeding or enhancing the development of this workforce; and to heighten awareness about the critical nature of these issues among the various stakeholders (policy makers, regulators, providers, professional organizations, educators, consumers, and families) who stand to benefit from the development of a quality eldercare workforce.

Why Workforce Matters

The development of a competent, committed workforce to care for our aging society is important and timely for two primary reasons. First, the supply of health and long-term-care workers does not currently meet demand and will certainly fall short of the increased demands expected in the future (Mather, 2007). Second, even if the numbers of workers were there, that is not sufficient: it is not possible to develop a quality and cost-effective delivery system without a well-trained, competent workforce that understands how to deliver care to older adults.

Concerns about supply

It has been estimated that the United States will need an additional 3.5 million healthcare workers by 2030 just to maintain the current ratio of healthcare workers to the population (Mather, 2007). And while the general need for professionals who care for older adults is high, the particular need for geriatric specialists is even greater. This trend is consistent across all professions including physicians (Association of Directors of Geriatric Academic Programs, 2007), nurses (Kovner, Mezey, and Harrington, 2002), social workers (Center for Health Workforce Studies, 2006), and other occupational categories. The current and projected lack of professionals and direct-care workers is particularly dramatic in the long-term-care sector (Harahan and Stone, 2009).

The needed distribution of the health and long-term-care workforce for older Americans varies by state and the individual profession (Institute of Medicine, 2008). The recruitment and retention of healthcare professionals in rural areas are particularly challenging (Institute of Medicine, 2005). This is important to consider when assessing the healthcare needs of the geriatric population, since older adults are disproportionately overrepresented in rural communities (Hawes et al., 2005).

While the lack of supply is a challenge, it also provides an economic opportunity for many communities. Over the next twenty years, much of the job growth will be in the health and long-term-care sectors. Investments in a quality eldercare workforce, therefore, will be an important economic driver in the coming years.

The workforce and quality

Although it is intuitively obvious that a quality health and long-term-care system cannot exist without a quality workforce to provide the care and manage the system, this relationship has, for the most part, been taken for granted. Several of the articles in this special issue of Generations underscore the fact that a knowledgeable, competent workforce—well-trained in geriatrics and gerontological principles and practice—is essential to achieving better quality of care and quality of life outcomes for elderly consumers of health and long-term care (see Bragg and Chin Hansen, page 11; Harahan, page 20; Seavey, page 27).

The interdisciplinary team approach to service delivery—the core of geriatric practice—has been linked to better quality across a range of settings (Coleman and Berenson, 2004). The literature emphasizes the critical role that well-prepared licensed nurses play—particularly in nursing home settings—in improving the quality of care (Harrington et al., 2002; Rantz, 2003; Bostick et al., 2006). Several studies have shown that geriatric nurse practitioners can have a positive effect on nursing home residents’ care outcomes (Garrard et al., 1990; Rosenfeld et al., 2004). Another study found a positive relationship between having a certified medical director trained specifically in the medical director’s role (based on geriatric principles and best practices) and nursing home quality outcomes (Rowland et al., 2009). Analyzing nursing home deficiency data from the Centers for Medicare and Medicaid Online Survey Certification and Reporting database, the research team found that the standardized quality score of facilities with certified medical directors were higher than the scores of facilities lacking a medical director with a special certification.

Challenges to Developing a Quality Health and Long-Term-Care Workforce

A number of factors challenge the successful development of this workforce. These include the lack of value ascribed to the aging services field and the occupations within the field; the lack of recognition of the importance of geriatric and gerontological education and training; and the consequent lack of appropriate investments in education and training that are knowledge- and competency-based across the full spectrum of professions.

Lack of value

Aging services occupations are undervalued in the United States. Ageism in the broader culture, the sensationalizing of nursing home and assisted living problems in the media, and negative attitudes of educators and leaders in professional schools and associations conspire to reinforce the image of “caring for the elderly” as a poor career choice (Kaiser Family Foundation, 2007). Among high school students considering a nursing career, for example, almost half have no interest in specializing in geriatrics, whereas 87 percent report having an interest in pediatric nursing (Evercare, 2007).

This undervalued status translates into noncompetitive compensation and benefits for all staff categories in the clinical and managerial arenas. Within the field there exists a hierarchy in which individuals working in hospitals receive higher compensation and better benefits than those working in nursing home care or homecare. Compared with registered nurses who work in hospital settings, registered nurses working in nursing homes or other extended-care facilities receive lower annual earnings on average, even though they work more hours per week, incur more hours of overtime, and have a larger percentage of overtime hours that are mandatory (Bureau of Health Professions, 2006). In 2007, Forbes Magazine profiled personal and home care aide jobs as one of the top twenty-five worst-paying occupations in America (Maidment, 2007). Stakeholders in some states have observed that acute-care hospitals are able to draw staff away from long-term-care employers by offering higher salaries and better benefits (Center for Health Workforce Studies, 2006). As well, aging services providers have a diminished capacity to increase wages because more than 70 percent of their financing comes from Medicaid and Medicare, which seek to limit costs regardless of labor market conditions.

The convergence of these issues creates significant recruitment challenges for educational institutions that are attempting to develop geriatric and gerontological programs, and for providers who are looking to hire individuals with the appropriate knowledge and competencies. These barriers also negatively affect the pipeline for a future workforce that will be needed to meet increasing demand.

Unrecognized lack of geriatric education and training

A number of the articles in this issue of Generations highlight the fact that the importance of geriatric and gerontological education and training is not widely recognized by most individuals and groups that have a stake in the current and future status of our health and long-term-care system. These include the majority of policy makers, regulators, providers, educators, and consumers. Even those who believe in the new models of care that are described by Katz and Frank (page 82) and Reinhard (page 75) in this issue, assume that if financial and regulatory incentives are aligned, the development and implementation of person-centered, integrated, coordinated care programs will magically occur. Unfortunately, the lack of attention to and wide-scale adoption of geriatric and gerontological principles and best practices could translate into program failure and the squandering of precious resources.

Inadequate investment in education and training

The undervalued nature of the field and the lack of recognition of the importance of geriatrics and gerontology undermine the development and sustainability of a quality health and long-term-care workforce for our aging society. The preparation of potential candidates for administrative and clinical positions is out of sync with the realities of current and future demand. As noted in several articles within this issue, medical, nursing, and social work students have little exposure to geriatrics and gerontology in their curricula or clinical placements. Administrators, nurses, and medical directors are poorly prepared for the management and supervisory roles with which they are charged, and there are few in-service training programs to help those who are already employed in these positions (Bowers, Esmond, and Jacobson, 2003; Institute of Medicine, 2008; Resnick et al., 2009).

The strategies employed by regulators and educators to prepare and license or certify the workforce, and to assure that personnel are able to keep pace with changes in the clinical knowledge base and new technologies, are not effective. There are developing competency-based standards that would help guide the workforce across occupations and settings, but these standards have not been widely disseminated or adopted at the policy and practice levels. Additionally, there is a huge shortfall of personnel who are competent and committed to educating and preparing both professional and direct-care workers for careers in delivering services to older adults. This translates into a dearth of people—of those who are currently working and of those who are in the pipeline—that are adequately trained and educated to assume increasingly complex jobs across the continuum of services.

Opportunities for Policy and Practice Change

While the aging of America’s population has been foreseen for decades, little has been done to prepare the health and long-term-care workforce for its arrival (Institute of Medicine, 2008). A number of efforts over the past few years, however, have helped to raise this issue to a priority level in both the policy and practice arenas. In 2008, the Institute of Medicine (IOM) created a Committee on the Future Health Care Workforce for Older Americans to assess the projected future healthcare status and health-care services utilization of older Americans; explore the best use of the healthcare workforce to meet the needs of the elderly population, including the most promising models to ensure high-quality, cost-effective service delivery, as well as the roles and types of providers required to successfully implement these models; determine the types of education and training needed to deliver services to elders, and the financial and other incentives that will best facilitate recruitment and retention; and recommend policy solutions to these challenges (Institute of Medicine, 2008: 3)

The report prepared by this committee, Retooling for an Aging America, was a seminal work that identified the key challenges, laid out a blueprint for action, and stimulated energy, excitement, and interest in policy and practice circles. With support from a number of foundations committed to developing a quality health and long-term-care workforce for older adults, a national coalition of professional, provider, and consumer organizations created the Eldercare Workforce Alliance (EWA) to spearhead implementation of the IOM’s recommendations. The Alliance was instrumental in getting a number of workforce provisions into healthcare reform—the Patient Protection and Affordable Care Act (ACA)—that support geriatric education and financial incentives to encourage people to enter professional fields related to caring for the elderly population. The EWA is currently focused on ensuring that these provisions are adequately funded and successfully implemented as well as continuing to raise awareness about the need for this workforce among policy makers at the federal and state levels.

The ACA provisions related to the development of new payment incentives and delivery models to better serve Medicare beneficiaries and “dual eligible” (individuals covered by both Medicare and Medicaid) have also spotlighted the need for a knowledgeable, skilled eldercare workforce to actually achieve the ACA goals “on the ground.” But successful development and implementation of the various integrated and coordinated care models, transitional care programs, and bundled payment methodologies that hold organizations accountable for quality care and costs will not occur magically—even if the financial incentives are perfectly aligned. They will depend, in large part, on the existence of professional staff across the full range of occupations and settings that understands how to coordinate person-centered services and integrate care through geriatric-based, holistic approaches that use interdisciplinary teams and that consider the most efficient ways of achieving quality outcomes.


The development of a quality eldercare workforce is no longer a backwater issue. The IOM report and the ACA provisions have established an important foundation upon which to build a workforce development agenda and to achieve actionable results. The development of a quality workforce to care for an aging America will require solutions at the policy, education, and practice levels. This issue of Generations underscores both the challenges and the opportunities that our nation faces over the next thirty years, and presents expert analysis, research findings, and unique insights that will, hopefully, form a roadmap to success.
Robyn I. Stone, Dr.P.H., is the executive director of LeadingAge Center for Applied Research at LeadingAge (formerly American Association of Homes and Services for the Aging) in Washington, D.C. Linda Barbarotta, B.A., is a consultant based in Washington, D.C.

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