An underlying health policy concept which psychology (and especially our practitioners) must appreciate is how long it takes to foster meaningful change through the public policy (i.e., political) process. The Institute of Medicine (IOM) recently released Retooling For An Aging America: Building The Health Care Workforce - interestingly, 30 years after its initial landmark report on the health professions requirements for our nation’s growing geriatric population. By 2030, the number of adults in the United States who are 65 years or older is expected to almost double from 2005, and we simply are not prepared to meet their social and health care needs. The next generation of older adults will be like no other before it, being the most educated and diverse group in the nation’s history. By 2030, the youngest members of the “baby boom” generation will be at least 65, and the number of older adults (65 and older) will exceed 70 million. The vast majority of this population (80%) will suffer from at least one chronic condition and chronic diseases will be their leading cause of death. The IOM proposes a three-pronged approach: * Enhancing the competency of all individuals in the delivery of geriatric care. * Increasing the recruitment and retention of geriatric specialists and care givers. And, * Redesigning models of care and broadening provider and patient roles to achieve greater flexibility. Has psychology been systematically involved in these important policy discussions?
The IOM notes that chronic disease brings an increased risk of major depression, which is associated with substantial disability along with non-adherence to treatment of co-existing medical illness and increased utilization of health care resources. Vulnerability to mental health conditions increases as older adults age and become more likely to encounter stressful events, including declines in health and loss of loved ones. Approximately 20% of adults ages 55 and older have a mental health condition; the most common being anxiety disorders, severe cognitive impairment, and mood disorders. Suicide rates for men 65 and older are higher than for any other age group, being more than twice the national average (especially elderly veterans). For many specialists older adults constitute a large percentage of visits (e.g., 35% for internal medicine, 30% for neurology, with 30% to 88% utilizing complementary and alternative medicine (CAM)). Yet, older adults account for only 9% of visits to psychiatrists – a pattern most likely due to the societal stigma attached to receiving mental health care, as well as its limited coverage under Medicare. Health economists agree that individuals with chronic conditions have fueled much of the increase in Medicare spending over the past two decades.
Services provided to older adults today are not as effective as they should be, with the quality of care often falling short of acceptable levels for a variety of conditions. Dartmouth researchers estimate that nearly 20% of total Medicare expenditures provide no benefit in terms of patient survival or quality of life. The elderly are not a homogeneous group. Their needs are complex and varying. Over two-thirds of older adults will need some form of long-term care at some point in their lives. Many will experience one or more geriatric syndromes – clinical conditions that do not fit into discrete disease categories (e.g., falls and malnutrition) and will need assistance with one or more activities of daily living. While the overall health professions work force is growing at a rate far short of the projected need, the shortage of geriatric specialists in all disciplines is markedly worse. All providers need additional training in working with the elderly. However, even those professions that have made a special effort to encourage the development of geriatric specialists have been mostly unable to produce a larger number of geriatric leaders (i.e., the teachers and visionaries for tomorrow). The IOM concludes: “The future health care workforce will be woefully inadequate in its capacity to meet the large demand for health services for older adults if current patterns of care and of the training of providers continues.” And, “(S)imply increasing the numbers of geriatric-trained workers will not be sufficient, as it will do nothing to fix the deficiencies in the way care is delivered to older adults or to address the inefficiencies in the current system.”
In the IOM’s judgment, there are three key principles necessary to form the basis of an improved system of care delivery for older Americans: * The health needs of the older population need to be addressed comprehensively. * Services need to be provided efficiently. And, * Older persons need to be active partners in their own care. A number of models might eventually prove to be cost-effective. Common elements would seem to include interdisciplinary teams, care coordination, disease management, and a clear evaluation process. To date, those models of care with the strongest evidence base often provide for an expanded range of services; for example, the addition of social services, care giver education and support, and preventive home visits. Those familiar with the British National Health Service will appreciate the importance of its historical broader definition of “medical care.” In the United States, Medicare typically does not cover these additional services, even when evaluations indicate that they reduce costly hospitalizations and nursing-home use. New models of care need to be tested for their appropriateness and effectiveness for special populations; including low-income groups, racial and ethnic minorities, rural populations; and sexual orientation. Older adults are increasingly diverse, with differences in language proficiencies, risks for diseases, education, acculturation, income, and family systems. Nevertheless, a general information gap and especially a lack of long range planning currently exists.
As we enter the 21st century, we should expect an increased use of health information technology, including electronic and personal health records, remote-monitoring technologies, etc., resulting in the eventual establishment of databases from which “gold standard” (i.e., data-driven) protocols, across patient populations, can be developed – hopefully, resulting in more independent patients for longer periods of time. The Chairman of the Senate Budget Committee estimates that adopting Information Technology (IT) would save $80 billion annually over the next five years. Quality health promotion and disease prevention initiatives, as well as patient-oriented palliative care will become increasingly important. One survey recently reported that seven out of eight “baby boomers” say their providers should have geriatric training, but a majority also report they cannot find such a doctor. And, almost 71% say they want more easy access to information related to their own health care, with one in every three indicating they need more help with their health care decisions.
Interestingly, the IOM also found that those health care providers who care for older patients find their work quite meaningful with geriatric medicine having the highest percentage of “very satisfied” specialists among physicians surveyed. An important agenda for the future is that cadre of direct-care workers (i.e., paraprofessionals) who are the primary providers of paid hand-on-care, supervision, and emotional support for citizens in the twilight of their lives. They receive low wages and few benefits, and have high physical and emotional demands placed upon them. Not surprisingly, their turnover rate is unacceptably high; the annual rate for certified nursing assistants is 71%, with 91% of nursing homes having insufficient staff to provide basic care. A major challenge in transitioning to a 21st century health system will be preparing the workforce to acquire new skills and adopt new ways of relating to patients and to each other (i.e., the breaking down of traditional professional isolated “silos”). There is a clear need for fundamental reform of our nation’s health care system in the near future.
Making A Difference – An Eye-Opening Career Path: Individual involvement in the public policy process is the key to long-term substantive change. Developing a quality therapeutic relationship with our own health care provider is critical to every one of us – regardless of our age or psychosocial-economic-cultural attributes. Colonel Robin Squellati: “As an Air Force Nurse for 22 years, I have experienced assignments in various places, worked with thousands of people, and enjoyed many types of jobs. However, being the 18th nurse detailee in Senator Inouye’s office is by far the most eye-opening, unique job I could ever imagine. Senator Inouye is extremely supportive of health concerns and quite knowledgeable about the meaningful contributions that our nation’s non-physician health care providers can bring to the table. Each year he invites a military nurse to serve in his office as a Congressional Fellow. Nurses cared for him after his WWII injury, and the relationship is reciprocal. Through his senior Senate position, he has given to nursing much more than most of us realize.
“The nurse detailee is selected from their military service, through an application and interview process. Nurses must be senior and have had a successful military career. The Air Force, Army, and Navy send a nurse for one year, on a rotating basis. Currently there is also a colleague from the Indian Health Service (IHS) and in the past the American Nurses Association (ANA) has placed ethnic minority mental health Fellows. The incumbent nurse orients and advises the newly selected nurse for a couple of weeks, and then by telephone or e-mail. All of the former nurses offer support throughout the year. One of my first of many, wonderful experiences was a lunch in the Senators’ dining room, attended by five former Fellows. Since then, I have had the opportunity to see each of them several times at Congressional events.
“Recently, I had the opportunity to attend the Nurse-Family Partnership (NFP) Congressional briefing. The essence of their programmatic efforts is facilitating a close, collegial relationship between nursing and high-risk parents. NFP is a nonpartisan organization whose mission is to improve prenatal health, child development, school readiness, and maternal employment. The results of NFP are evidence-based and have consistently delivered positive outcomes. Former APA President Martin Seligman is on the Board of Advisors for the Coalition for Evidence-Based Policy. His non-profit organization promotes government policymaking based on evidence of advances in health. They report that in most areas of social policy, governmental programs are failing to address critical needs of our society. In sharp contrast, at the 15-year NFP followup there was a 40% to 70% decrease in child abuse/neglect and arrests/convictions of children and mothers compared to controls.
During this inspiring briefing, CDC (Centers for Disease Control and Prevention) psychologist Ileana Arias described how focused, data-guided efforts such as those of NFP can make a significant difference in the lives of our nation’s citizens. Overall, the NFP observed through randomized, controlled trials that there is a 31% reduction in closely spaced pregnancies, and a 79% reduction in preterm delivery among women who smoked. There were 39% fewer injuries among children, 56% reduction in emergency department visits, 48% reduction in child abuse and neglect, and 67% less behavioral and intellectual problems in six year olds. The long term results are very impressive. There were 72% fewer convictions of mothers at child age 15, 20% reduction of welfare use, and 46% increase in father presence in the household. Although the cost of the program is $4,500 per family per year, the Brookings Institution, RAND Corporation, Coalition for Evidence-Based Policy, and CDC have reported significant cost-benefits for NFP. Financial support for this extraordinary program is provided by Children’s Services Council of Palm Beach County, Doris Duke Charitable Foundation, Picower Foundation, Ronald McDonald House Charities, Edna McConnell Clark Foundation, Robert Wood Foundation, Bill and Melinda Gates Foundation, and several other organizations.
“As an Air Force Nurse, I have experienced the benefits of this type of program for almost 20 years, and was very pleased to learn that our efforts were, in fact, established at Senator Inouye’s suggestion. Many of our first-time moms are separated from family and often have husbands who are deployed. The nurse and mom make a commitment to each other. Then the nurse visits the mom in her home during the prenatal period and follows the family during infancy and toddler-hood.” Lucy In The Sky With Diamonds....
Aloha
Pat DeLeon is a former APA President.
