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Nurse-Researchers Instrumental in Planning for the “Silver Tsunami”

January 16, 2019

Source: UCSF Nursing's Science of Caring

As the so-called “silver tsunami” of aging baby boomers rolls across the country, addressing their long-term care needs is critically important. Yet a shortage of long-term care workers in the United States, from geriatric-specialist physicians and nurses to home care aides, is affecting seniors’ access to skilled care. At the UCSF Health Workforce Research Center on Long-Term Care (UCSF HWRC), faculty from Healthforce Center are leading several research projects that examine these important and often neglected workforce issues that are highlighted below.

“Care isn’t delivered by robots; it’s delivered by people,” says Joanne Spetz, associate director of research at Healthforce, and the director of UCSF HWRC.

The Workforce and Emerging Technologies in Long-Term Care

In November, Spetz and Healthforce faculty member Susan Chapman, who serves as deputy director of UCSF HWRC, attended the Aging 2.0 Optimize conference in San Francisco, which provided entrepreneurs an opportunity to showcase potential technology-based solutions to the problems of aging.

“Technology for aging populations is a booming field, with enormous implications for the health care workforce,” says Spetz. She names several examples, including information technology (IT) troubleshooting — “Who in grandma’s house knows how to reset a router?” — and clinician staffing needs at service centers. She says, “When you have a congestive heart failure patient whose weight is up on the home high-precision scale, there can’t just be a call-center person receiving the data. It has to be a clinician — usually a nurse — who can make an assessment as to whether the client needs a second diuretic or if he needs a home care visit with a nurse practitioner or physician.”

A key question, then, for companies and entrepreneurs promoting these technologies is how — or if — they are considering these issues.

At the Aging 2.0 Optimize conference, Chapman and Spetz identified more than 100 new technologies with potential uses in home- and facility-based long-term care settings, which Chapman and research assistant Jackie Miller have categorized into several areas, identifying organizations within each category to interview to identify health care workforce implications and find out how the organizations envision planning for them.

The research team will analyze data from the interviews to determine how the various technologies might affect future workforce demand and training needs to inform policy and curriculum development.

The Impact of Home Care and Nursing Scope-of-Practice Policy on Older Adults

State laws that govern what types of home care different workers can provide vary widely and have the potential to affect the feasibility of a senior remaining at home rather than moving to skilled nursing or assisted living.

For example, in some states, a nonlicensed home care aide can be authorized to put pills into the mouth of a client who can’t do it herself due to mobility limitations. In other states, medication administration is limited to licensed vocational nurses (LVNs), registered nurses (RNs) and medical doctors (MDs and DOs), making it much more difficult for some seniors without friends or family members — who aren’t governed by scope-of-practice regulations — to adhere to a daily medication regimen while living at home.

In partnership with the Disability Rights Education and Defense Fund, Spetz and Chapman are examining these laws to clarify what tasks nonlicensed workers are permitted to do in each state, how long-term care agencies comply with them and how they affect the ability of seniors to remain in their communities. Spetz and Chapman hope to identify the strengths and weaknesses of the current system in order to provide policy guidance to the federal Centers for Medicare & Medicaid Services, the agency tasked with establishing regulations regarding long-term care programs.

Alzheimer’s Disease Staffing, Services and Outcomes in Adult Day Health Centers

Spetz and Healthforce faculty member Jason Flatt are conducting a national study designed to examine differences between staffing models in adult day health centers (ADHCs) that provide specialized care for people with Alzheimer’s disease (AD) and Alzheimer’s disease-related dementia (ADRD) and those that don’t, and how those variations affect outcomes.

The study will use data from the National Study of Long-Term Care Providers, a series of surveys collected by the National Center for Health Statistics, to measure differences in several areas, including staff-to-patient ratios, client attendance and enrollment size, center ownership type, payer mix, chain affiliation and region.

Flatt, Spetz and their research team will then look at whether any of these variations affect rates of adverse events, such as falls, emergency department visits and hospitalizations, among ADHC clients. They hope that information gleaned from their research will help ADHCs and other long-term care providers adapt their staffing models to better care for the growing number of people with ADRD.

Rural Long-Term Care Worker Shortages and Local Economic Conditions

Rural areas are facing severe shortages in long-term care workers. Spetz, Flatt and Assistant Professor of Social and Behavioral Sciences Ulrike Muench, another Healthforce faculty member, are examining how local social and economic conditions are affecting the availability of both family and professional caregivers.

Spetz, Flatt and Muench’s hypothesis is that a confluence of factors is creating a crisis for older people needing long-term care in rural parts of the country.

They suspect that as young people flee economically depressed rural areas for greater opportunities in more prosperous cities and suburbs, aging parents and grandparents are often left without caregivers. The demographic changes may also mean that home care agencies can’t find workers to take generally low-paying caregiving jobs. Moreover, the opioid epidemic is affecting both young people and those in middle age, who have traditionally cared for aging relatives, leaving a potential gap in caregiving.

The team is analyzing county-level demographic and employment data to quantify and make predictions about caregiver shortages, examining changes in the ratio of working-age adults to older adults across counties, the association of job losses with those ratios, and the effect of opioid misuse rates on employment rates in rural areas.

Having solid data about potential long-term care workforce shortages and their causes could help federal, state and local governments create better policies affecting rural areas’ ability to care for vulnerable elders.

Who Prescribes Behavioral Health Medication to Seniors with Behavioral Health Needs?

Research suggests that increasing numbers of older adults are using behavioral health medications (such as antidepressants, antianxiety medications and antipsychotics), raising concerns about the expertise of the clinicians prescribing them to an aging population with multiple chronic health conditions, who may be at higher risk for medication interactions and side effects.

Muench is analyzing Medicare data to determine how many prescribers are geropsychiatrists versus other specialists (such as cardiologists) and primary care providers, and how their prescribing patterns vary. She is also looking at how the composition of behavioral health medication prescribers for older adults has changed over the last five years, and how the length of the patient-provider relationship affects prescribing patterns.

Once the prescribing patterns have been described and analyzed, Spetz says, researchers can begin to examine how different prescribing patterns affect outcomes among older adults with behavioral health needs.

Collaborating to Advance Research and Inform Policy

UCSF HWRC is one of seven research hubs across the U.S. funded through the Health Resources and Services Administration’s (HRSA) Health Workforce program. Each has a different focus, and the other centers’ areas of research often overlap with long-term care, such as oral health (at the State University of New York at Albany School of Public Health), behavioral health (at the University of Michigan) and building the allied health workforce (at the University of Washington).

Their work is highly collaborative, and there is a lot of cross-pollination among researchers, both within UCSF HWRC and with the other HRSA-funded research centers across the country, Spetz notes.

She says, “We all hope our research provides information, guidance and some food for thought for policymakers and for organizational directors and nursing home administrators — the whole panoply of people involved in managing the workforce. Because until those tech robots get really, really good, we’re still going to need people to provide this care.”