Improving the Health Care of Americas Older Adults Through
Social Work Corinne H. Rieder Executive Director and Treasurer The
John A. Hartford Foundation The Leadership Academy in Aging
NYAM/NADD Partnership Saturday, June 18, 2011 1
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Overview I.What are Key Challenges to Overcome in Meeting the
Health Care Needs of Older Adults? II.What Steps can Social Work
Educators & Practitioners Take to Improve the Health Care of
Older People? III.The Hartford Foundation: What is it? Why Aging?
IV.The Foundations Social Work Initiatives: What are they? What has
been Accomplished?
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I. 7 Key Challenges to Overcome in Meeting the Health Care
Needs of Older Adults Demographic changes Chronic diseases Use
& cost of health & support services Inadequate & poorly
prepared health care workforce Failure to deliver care
cost-effectively Discrimination & ageism Important financial,
ideological & ethical issues 3
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4 First, the Demographics The growth of older Americans is
dramatic. - Today there are 40 M people 65 & older. By 2050
there will be 85 M. The increase in the number of people 85 &
older is especially large. - They will increase from 1.5% in 2000
to 5% of the population by 2050. - Those 100 & older are
projected to grow from 50,000 to 800,000. 4
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5 US Population Pyramids 5
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6 Increases in the Oldest Old U.S. Population Aged 85+ (in
millions) Sources of data: U.S. Census Bureau, 65+ in the United
States: 2005, December 2005; U.S. Census Bureau, U.S. Interim
Projections by Age, Sex, Race, and Hispanic Origin, 2004. 6
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8 Second, the Prevalence of Chronic Diseases Increases with Age
4% 13% 27% 37% 7% 31% 49% 55% 2% 8% 19% 24% 0% 10% 20% 30% 40% 50%
60% 18-4445-6465-7475+ Age in Years Heart Disease Hypertension
Cancers 8
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10 Third, the Use & Cost of Health & Social Services
Increases with Age 1. Older adults represent 13% of the population,
yet account for: 26% of physician office visits 50% of specialty
ambulatory care visits 46% of patients in critical care 50% of
hospital days 32% of prescriptions 70% of home health services 90%
of residents in nursing facilities 10
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Third, the Use & Cost of Health & Social Services
Increases with Age (Continued) 2. Medicare beneficiaries with 5 or
more conditions: See more than 3X as many physicians (14 different
physicians per year) Visit physicians more than 4X as often Receive
almost 5X the number of prescriptions (on average, 49 per year,
including refills) 11
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Third, the Use & Cost of Health & Social Services
Increases with Age (Continued) 3.Health Care Spending About 95% of
all health care spending is for the chronically ill. 64% of all
Medicare spending goes to the 10% of beneficiaries with 5 or more
chronic conditions. More attention to the 10%. Estimates are that
about of Medicares budget goes to patients in their final year of
life. 40% of that is in the last 30 days. It is interesting to note
that the cost of people age 85 & over is 1/3 lower than for
people 65 to 75 in their final year. 12
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Third, the Use & Cost of Health Care Services Increase with
Technology (Continued) 4. The development & use of technology
in health care increases health care costs, i.e., medical
technology Medical technology refers to procedures, equipment, and
processes by which medical care is delivered. New medical &
surgical procedures & Units (angioplasty, joint replacements,
ACE units) New medical devices (defibrillators) New support systems
(electronic medical records & transmission of information,
telemedicine) New therapies & drugs (statins, beta-blockers)
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Fourth, an Inadequate & Poorly Prepared Health Care
Workforce NIA estimates a need for 60,000--70,000 geriatric social
workers by 2020. In 2000, there were only 13,500 geriatric social
workers with a median age of 50 years. Of the 240,000 advanced
practice nurses only 3,500 are geriatric nurse practitioners.
Overall, the projected shortages in nursing range from 340,000 to 1
M nurses by 2030. 15
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Fourth, an Inadequate & Poorly Prepared Health Care
Workforce (Continued) By 2030 there will be fewer than 8000
geriatricians against a projected need for 30,000 geriatricians.
Half of all geriatric fellowship positions go unfilled & half
of those filled go to physicians from other countries who may not
be committed to geriatrics. By 2030 there will be only 1,700
geriatric psychiatrists (1 per 5,700 older Americans with a mental
illness). 16
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Fourth, an Inadequate & Poorly Prepared Health Care
Workforce (Continued) There are 43.5 M unpaid caregivers who
provide care to a person 50 or older. Many of them are unprepared
to deal with chronic diseases & the geriatric syndromes of old
age. This unpaid care totaled approximately $375 billion in 2007. 1
M more direct-care workers will be needed by 2018, according to the
latest employment projections. They are required to receive very
little education, often less than dog groomers & people that
shampoo your hair in salons. 17
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Fifth, the Failure to Deliver Care Cost- Effectively Increasing
the numbers & skills of geriatrics- trained workers will not be
sufficient, as it will not fix the deficiencies in the way care is
delivered or address inefficiencies. The health care system remains
focused on acute care rather than on chronic diseases. Specialist
care is favored over primary care & prevention The fragmented
system challenges communication between & among providers &
care coordination is infrequent. 18
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Fifth, the Failure to Deliver Care Cost-Effectively (Continued)
Payment policies (fee-for-service) encourage service volume rather
than quality. Capitated & bundled care is essential to better
integrate health delivery & social services. Patients &
their caregivers need to be active partners in their care. Health
care & social supports need to take account of patients
cultural & geographic diversity. 19
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Fifth, the Failure to Deliver Care Cost- Effective (Continued)
Errors (for the general population between 44,000 & 98,000
deaths per year) Hospital infections (for the general population
100,000 deaths per year) Unsafe prescribing (1.3 million for the
general population) High rates of hospital readmission (20% within
30 days at a cost of $17 B/Y) 45% of people in nursing homes have
no advanced directives & 75% of older people will not be able
to make some or all of their end-of-life decisions. 20
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Fifth, the Failure to Deliver Care Cost- Effectively
(Continued) There is poor adherence to guidelines (33% for
geriatric conditions) Too many health care expenditures that are of
little value (estimates range from 25 to 30% of all expenditures) A
2005 report by the NAE & the IOM found that 30 to 40% of every
$ spent on health care was associated with overuse, misuses,
duplication, system failures, unnecessary repetition, poor
communication & inefficiency. 21
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Sixth, the Prevalence of Discrimination & Ageism
Discrimination & ageism negatively impact: The quality of care
that older people receive. Recruitment of students into geriatric
health professions. The educational & training environment,
i.e., poor care becomes standard care. There are large numbers of
older adults that are abused (physically, psychologically,
financially) &/or suffer from self-neglect. 22
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Finally, there are Important Financial, Ideological &
Ethical Issues Medicare expenditures were $524B in fiscal year
2010, representing 15% of federal outlays, 17.6% of GDP &
$14,000/year per Medicare beneficiary). + $100B in out of pocket,
retiree & supplemental A growing concern about the mismatch
between projected costs of health & the ability of the economy
& younger generations to pay for them. Ethical issues abound.
Competing ideological viewpoints, particularly on the role of
government versus that of the private sector. 23
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II. Next Steps to Improve the Health Care of Older People What
is Hartfords vision? What is the Foundation doing to achieve that
vision? What steps can the social work profession take to improve
& integrate health & supportive services for older people?
I will offer 4 recommendations & what I will call 4
inconvenient truths. 24
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Hartfords Vision Older adults receive quality health care from
sufficient numbers of well-trained health professionals. Care for
older adults is integrated, patient-centered & coordinated.
Health professionals are trained to & work in
interdisciplinary/inter-professional teams & our countrys
financing & delivery systems support them. Our health care
system takes account of the increasing social, demographic &
geographic diversity of older adults. Health care is seamless
across various delivery sites & all clinicians have immediate
access to patients health information & communicate with one
another. 25
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Hartfords Vision (Continued) Older people & their families
are active partners in their care & greater attention is paid
to & financing of disease prevention, the adoption of healthy
life styles & the preservation of function. Movement away from
fee-for-service payment of physicians toward innovative provider
payment & delivery system reforms, e.g., accountable care
organizations, bundled acute & post-acute care payment, &
patient centered medical homes. 26
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Hartfords Work to Achieve this Vision Maintain the Foundations
national scope even with reduced assets. Maintain a narrow &
consistent focus in one area. Maintain our commitment to be
strategic in our grantmaking with clear goals, objectives,
strategies & self-evaluation. Increase partnerships &
advocacy efforts with grantees, other foundations & government
entities with the same goals. 27
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Recommendation #1 The Work Site Every practicing social worker
is prepared to provide quality care to older adults through
innovative partnerships with academic institutions &/or
on-the-job education & training. Work sites provide high
quality clinical training & education for students. Social
workers advocate for patients & clients & teach patients
& families to advocate for themselves. 28
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Recommendation #2 Education & Training More faculty members
are expert in geriatrics. Geriatrics is infused into & across
the curriculum. Students have more, better & a greater variety
of clinical experiences with older people & the institutions
that serve them. Field experience is elevated within academic
programs. Schools of Social Work move closer to becoming more like
such professional schools as medicine & nursing, rather than
arts & sciences adjuncts. SW Schools & their faculty bring
together social works unique expertise at the individual &
community level with a greater knowledge base in health care
systems & service delivery. 29
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Recommendation #2 Education & Training (Continued) Barriers
to interprofessional training, such as scheduling, accreditation
requirements & financial impediments need to be removed.
Training together will enable students to see the value of &
work better together in interdisciplinary teams after graduation.
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Recommendation #3 Team Care Team care for older adults with
chronic & complex health & social needs are instituted:
teams have a common purpose, specialization of function, defined
roles & processes for coordinating their efforts. Clinicians
work at the top of their training & the edge of their license.
Team members are empowered to perform tasks according to scope of
practice, experience & education. Teams find ways to
incorporate & coordinate the supports already existing.
Patients, families & communities are also part of the team.* *
Who Will Provide Primary Care & How Will They be Trained?
Josiah Macy, Jr. Foundation, 2010 31
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Recommendation #4 Partnerships Improving the health care of
older people needs both interdisciplinary/inter-professional &
community partnerships. Are there silos or turf battles that need
to be addressed in your organization &/or community? Have you
utilized the resources of other professions & your community to
advance social work? 32
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The Inconvenient Truths: Truth #1 ARE YOU AT THE TABLE OR ON
THE MENU?* Social workers have to be advocates & leaders for
change even without the money to do it. You cannot wait for
otherspoliticians, bureaucrats or academic colleagues in other
professionsto allow or invite you to join the debate &
revitalize & reshape the health care system & the
profession, e.g., join your local or state Alzheimers Association,
meet & work with your local & state elected officials. One
heartening development is the collaborative work nationally of 6
healthcare regulatory organizations (Med, SW, Nursing, Pharmacy, PT
& OT) to guide regulatory decision making with regard to scopes
of practice. *Diane Meier Be at the Table or Be on the Menu 33
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The Inconvenient Truths: Truth #1 (Continued) What are the
dangers & opportunities for social workers & other health
professions with implementation of the Patient Protection &
Affordable Care Act (PPACA or ACA)? The tools of policymakers are
very bluntchanges in payment & regulatory incentives give great
scope to professionals & institutions to decide how to
implement. Take advantage of these funding opportunities and new
delivery & funding structures. - Hospital Readmission - ACA
programs, e.g., ACOs, Innovation monies - Reducing health care
costs - Coordination & integration of service delivery -
Disease prevention - Caring for patients with multiple chronic
diseases - Patient-centered medical homes how will they be
implemented? Roles for social workers? 34
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The Inconvenient Truths: Truth #2 You dont need to re-invent
the wheel. In education & service delivery there is an
abundance of ideas & materials, & numerous models waiting
to be adopted in your institution or community.* * For example, see
the IOM Report, Retooling for an Aging America: Building the Health
Care Workforce (2008) which identifies many evidence- based service
models. 35
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The Inconvenient Truths: Truth #3 Social workers need to better
define who they are, what they do, & they need to make a
business case with evidence of their cost-effectiveness. The
general public & other health professionals are not fully aware
of social works real & potential contributions to improving the
health care of older people. 36
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The Inconvenient Truths: Truth #4 The social work profession is
sometimes hurt by its fragmentation. Who speaks for social work
nationally? The field is fragmented by its multiple national
associations. This situation reduces its impact & dilutes the
potentially pivotal role played by its leaders. 37
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III. The Hartford Foundation 82 year old, $500 million
mission-driven foundation; 30 year history of improving the health
of older people National in scope; premium on projects that can be
sustained & have a multiplier effect; avoid duplicating the
focus of others; place importance on partnering with grantees &
other funders Strategic in grantmaking; grants are made
competitively; rarely fund unsolicited proposals Our narrow &
consistent focus is unique for a foundation our size; peers have
multiple foci & shorter term commitments to a funding area
Committed $430 million to 200 organizations over the past 30 years
Hartford is one of the largest funders of social work & nursing
outside of state & federal governments
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The bequest from John A. Hartford, which established the
Foundation, directed future Hartford trustees to do the greatest
good for the greatest number. Andto carve from the whole vast
spectrum of human needs one small band that the heart and mind
together tell you is the area in which you can make your best
contribution.
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43 The Foundations Choice & Its Importance to Social Work
Given Mr. Hartfords wishes, what led the Foundation to choose
improving the health care of older adults as its goal? 1. Respect
for Mr. Hartfords desire to target a limited area to achieve
maximum impact. 2. The demographics. 3. No other foundation had
that area as a major focus. 43
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IV. Hartfords Social Work Initiative Goal All social workers
are prepared to care for older adults 44
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45 Hartfords Objectives 1. Prepare a geriatrically competent
workforce. 2. Infuse geriatrics in the education programs of all
schools of social work in the country. 3. Ensure that there are
sufficient geriatrics faculty members. 4.Develop, test &
disseminate innovative, cost- effective models of care that improve
services to older adults. 5.Draw national attention to the
importance of social work in improving the health care of older
people. 6. Communicate the idea that older adults are a core
business of health care & its professions. 45
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46 Hartfords Strategies The Foundation pursues two major
strategies in its social work initiative: Faculty & Leadership
Development Curricular Change
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Hartfords Intermediate Indicators of Impact Social Work 1.50%
of MSW programs require coursework in aging (currently about 25%)
2.75% of MSW programs adopt the Hartford Partnership Program for
Aging Education (HPPAE) model (currently about 50%) 3.60% of
programs have more than 2 faculty members specialized in geriatrics
(currently about 45%). 47
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48 Hartfords Financial Commitments to Social Work to Achieve
these Objectives 1999-2010 Social Work $70 Million authorized 36
Major grants approved 48
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49 The Foundations Specific Accomplishments in Social Work in
the Past Decade 1.Faculty development Faculty Scholars Program
--106 scholars in 11 cohorts Doctoral Fellows Program--88 doctoral
fellows Pre-dissertation Awards--80 awardees The Leadership Academy
in Aging--24 deans 2.Curriculum Grants resulted in new aging
curricula being disseminated & adapted by over 180 schools
Gero-Ed is a model for the development of additional competencies
(CSWE EPAS) Aging-content increased in social work text books.
3.Providing real-world training for social work students. Hartford
Partnership Program for Aging Education (HPPAE, formerly PPP)
adopted in 72 schools in 32 states. 4.Three important books by
Barbara Berkman & Nancy Hooyman. 49
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50 Hartfords Leveraging: 2001-2009
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52 Partnerships The Archstone Foundation The Atlantic
Philanthropies The Hearst Foundations The Jacob and Valeria
Langeloth Foundation The Helen Bader Foundation Veterans
Administration National Institutes of Health National Association
of Social Workers AARP Andrus Foundation The Louis and Samuel
Silberman Fund The Administration on Aging Plus more than 50 local
funders 52
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Conclusion There has never been a time in history for social
workers to make a more important difference to the care of older
people than now. What do I want you to do when you leave this
meeting? -- A commitment next Monday to begin implementing at least
one of these recommendations & to start a discussion in your
institution or organization on these inconvenient truths or others
of your choice. Hartford has many available resources & tools
that can help you implement these recommendations. -- If this is
not done, all of us in this room & older people everywhere,
will not have the health care they need & deserve. Thank you
very much. 54