The growing demand for quality geriatric care and the equally increasing shortage of geriatrics healthcare providers are major concerns for Jennie Chin Hansen, RN, MSN, FAAN, Chief Executive Officer of the American Geriatrics Society, one of the country’s largest organizations of healthcare professionals focused on the health and well-being of older adults. Ms. Hansen discussed these issues with Picker Institute recently.
Picker Institute: What factors are driving the future demand for geriatric care?
Jennie Chin Hansen: There are a number of reasons that the demand is increasing and will continue to increase.
First, Americans are living longer, and they are prone to more diseases, chronic conditions and disabilities as they age.
Second, one in five Americans will be eligible for Medicare in 2030, compared to one in nearly seven in 2010.
Those 65 years of age and older will account for almost 20 percent of the U.S. population by 2030, compared to 13 percent now, 12.4 percent in 2000 and 4.1 percent in 1900.
The fastest growing segment of our population are people 85 and older, and nearly half of them will likely be affected by Alzheimer’s disease.
Finally, older adults account for a disproportionate share of healthcare services. Here are some examples: 26 percent of all physician office visits; 35 percent of all hospital stays; 34 percent of all prescriptions; 38 percent of all emergency medical responses; and 90 percent of all nursing home use.
And 80 percent of older adults require care for such chronic conditions as hypertension, arthritis and heart disease.
Picker Institute: How serious is the shortage of healthcare professionals certified or specializing in geriatrics?
Jennie Chin Hansen: Very serious indeed. As of March 2011, there were 7,162 allopathic- and osteopathic-certified geriatricians in the United States, or one geriatrician for every 2,620 Americans 75 or older. Taking into account the projected increase in the number of older Americans, this will drop to one geriatrician for every 3,798 older adults by 2030.
This disparity holds true in most medical disciplines. There are at present 1,751 geriatric psychiatrists, or one for every 10,865 older Americans. By 2030 that ratio will have shrunk to one geropsychiatrist for every 12,557 older Americans.
Less than one percent of RNs, pharmacists and physician assistants, and about 2.6 percent of advanced practice registered nurses, are certified in geriatrics. Outside the field, 3 percent of psychologists and some 4 percent of social workers devote the majority of their practice to older adults.
Picker InstituteIs there any chance that medical schools will start to turn out more geriatricians?
Jennie Chin Hansen: At this point, the numbers are not promising. Fewer and fewer graduates of medical schools in the United States are pursuing advanced training in geriatrics. For example, in 2002-2003 there were 394 post-residency geriatrics fellowship training slots available, and 292 of these were filled (74.1 percent). By comparison, in 2010-2011, there were 488 slots available, but only 279 were filled (57.2 percent).
Picker Institute: What are the reasons for this decrease?
Jennie Chin Hansen: Sadly, the reasons are very cogent. Young physicians are carrying more and more medical school loan debt, and they won’t find a career spent focusing on older adults—based on current funding methods—very financially attractive. Physicians in internal medicine, family medicine and geriatrics earn significantly less than those in other medical and surgical specialties, in spite of the fact that caring for older adults is often more time-consuming and complicated. The bottom line is that there will not be enough geriatricians to give older adults the care they need.
Picker Institute: Do you see a solution to the problem?
Jennie Chin Hansen: Not a single solution. But at AGS we are working very hard on multiple approaches to the problem.
For one thing, we are trying to create a broader base by working with physicians in different fields—surgeons, orthopedists, ophthalmologists, urologists—to help them better understand the specific wants and needs of the geriatric population and to develop, we hope, a greater interest in and knowledge of geriatric care.
We’ll continue to advocate for loan forgiveness programs for professionals who choose to study geriatrics and work in the field for a period of time.
Another creative solution could include a commitment to advancing geriatrics competency as part of the current push for care quality and safety. This movement has performance incentives built into health systems, which helps providers recognize that there are interventions that can improve care for medically complex older adults, who are the primary user of services.
And there are opportunities to influence and prepare other health professionals who provide care to many older persons but may not have this specialized knowledge or may not be accustomed to working in teams, which is such a signature aspect of geriatrics.
Picker Institute: Where are you on that journey?
Jennie Chin Hansen: The cost and quality of healthcare are probably two of the most significant issues we face in this country—and around the world—and people are beginning to see how important it is to look more carefully at people who have multiple chronic conditions. In addition to a focus on managing multiple chronic conditions and multiple medications, there are three other elements that we think are vital to meeting the healthcare needs of older patients.
1. Health goals. What can an older person, given the parameters of age and condition, realistically expect and wish for? Two 85-year-olds can be quite different. One may be an active tennis player, in which case a new knee may be in order if the person is having pain and decreased mobility. On the other hand, a frail 85-year-old who has significant cognitive loss and multiple chronic conditions and doesn’t walk at all may need to be evaluated regarding the benefits of a knee replacement.
2. Functional ability. How much self-care is an older person capable of? How will an elderly person manage if they have care only some of the time? And how do you know who has the capacity to look after herself, and who doesn’t, without a thorough examination of lifestyle and current medical conditions, such as arthritis or decision-making capacity?
By the way, this is where caregiving professionals other than physicians are going to be very important. Nurses, physician assistants, pharmacists, direct care workers—the people in these roles function as primary caregivers, both because they give the kind of care a physician can’t for reasons of time and best use of skills and training, and because they are often more familiar with an older person’s totality of needs than a physician might be.
So it’s important to increase the number of all care providers who are trained in geriatrics approaches to care, including family/informal caregivers.
3. Cognitive and emotional status. A person’s mental status can be difficult to measure and address as part of a total healthcare plan, but it is just as important as the above two elements when making decisions about how to care for an older person. For example, depression is one of the most common conditions older people experience, and yet it is often unrecognized and untreated.
Picker Institute: The other day a member of the Picker Institute board of directors called this crisis “the elephant in the room.” What is the American Geriatrics Society doing to educate the public about the shortage of healthcare professionals in geriatrics, and the need to find a solution—fast?
Jennie Chin Hansen: We’re working through the public facing arm of AGS, our Foundation for Health and Aging, and its new Web site, Healthinaging.org, to develop highly visible programs and information aimed at achieving some of these goals. We want older people and their families to have knowledge and solutions that will help them maintain their well- being and manage their health, especially when they have complex conditions. We want to help them understand the unique aspects of geriatric care so they are empowered to ask questions and be active partners in their healthcare decisions with their care providers.
We are collaborating with other organizations that are also direct sources of information to the public. These partnerships will enable an even greater dissemination of the valuable information and research that AGS members have dedicated their careers to advancing. I’m confident we’ll succeed in raising awareness of the challenges of aging, as well as of solutions that will help people live their later years with confidence and capacity.
But the one sure thing is that this need must be addressed, and soon. If it’s not, we have a looming crisis that could become debilitating for individuals, families, our communities and our nation. The growth of our older population is a wonderfully challenging and stimulating issue; we must make our case to the public so that they understand how vital geriatrics knowledge is to an effective healthcare system and a stronger society. Time is of the essence!