A new survey of state laws around dementia training reveals a patchwork of requirements and standards across settings, professional licensure and personnel. It found that existing laws and training are not keeping up with the growing needs of people who are cognitively impaired.
The survey and accompanying analyses looked at existing laws and gaps in training, as well as required curriculums in all 50 states, plus the District of Columbia and Puerto Rico. It compared facilities like nursing homes, assisted living and adult day centers; examined mandatory training requirements for nurses, LPNs CNAs and home health aides, as well as first responders such as police and EMTs, ombudsman and protective services staff.
According to report co-author Georgia Burke, directing attorney at Justice in Aging, (formerly the National Senior Citizens Law Center) this is the first survey of its kind to hone in on the gaps and variations in mandated training. “We were surprised at the number of holes in training and how many gaps there were for educating personnel around the country,” she said in a phone interview.
According to the survey:
- 64 percent of people in nursing homes have dementia but fewer than half of the states have dementia training requirements for nursing home staff.
- Training requirements are more intense in special dementia care units of assisted living facilities, but much less attention paid to providers serving people in their homes or other community based settings.
- Half of the states require dementia training for Certified Nursing Assistants, but only two states require training for registered nurses, licensed practical nurses, or licensed vocational nurses.
- Only 13 states require dementia training for home health aides and licensed personal care assistants.
- Ten states have dementia training requirements for law enforcement personnel, but training typically focuses exclusively on wandering behavior.
“This is concerning,” said Burke. “There’s a real lack of training and support for those in community-based settings, where much of the day-to-day care takes place. It’s critical to expand this effort as the health system tries to move away from institutional care to more long term care in communities.”
According to the Alzheimer’s Association – who funded the project – more than 5 million people in the U.S. live with Alzheimer’s disease. That number is expected to increase dramatically as people live longer and aging baby boomers swell the ranks of older adults. Professionals in many care settings are encountering people with dementia with increasing frequency, yet many have poor or limited training in meeting the special needs of these individuals.
States basically have two avenues to impose training requirements. One is their role in licensing health care facilities. The other is their role in licensing individuals to practice in their fields in that state. States use both of these approaches but most of the regulation is on the facilities side, Burke said.
Assisted living is by far the category where there is the most regulation, though it is by no means universal. “We think in part it is because it came later, many nursing home regulations are older and there had been more of an advocacy push – especially because assisted-living memory care units are widely promoted and advertised and more in the eye of regulators and advocates,” Burke said.
According to the Alzheimer’s Association, 42 percent of people living in assisted living residences have dementia. The survey found that 44 states had some training requirements, but 14 of the 44 only cover Alzheimer’s special care units and don’t have dementia training requirements for the rest of the staff or administrators.
In nursing facilities, nearly two-thirds (64 percent) of residents have dementia, yet only 23 states require dementia training. “And here too those requirements often are minimal if the facility isn’t specifically licensed as a specialized dementia care unit,” Burke said. Additionally, “there is wide variation in actual content, who is required to take it, and how often it is delivered.”
Burke noted that 17 states require that dementia training be included as part of a single package of required training hours but don’t specify how much of that time goes to dementia versus all the other topics to be covered. She highlighted California and North Carolina as examples of states with more stringent and specific requirements. They mandate that administrators and direct care staff receive some 20 hours of dementia-specific training as well as ongoing education throughout the year.
One state, Washington, was held up as a model of good dementia care. Burke said that the state employs a comprehensive training approach across settings and caregiver roles. There is also direct involvement in designing outcome-based training modules and testing core competencies, which include very detailed objectives.
“While we have to allow states flexibility in development and implementation, there is also room for some uniformity of training guidelines,” Burke said. “There is a lot at stake here and we need some good models to address these serious gaps in how institutions and care providers deal with people with Alzheimer’s disease.” She said the survey shows that while many states may give lip service to training, they clearly don’t follow through.
The analyses are broken out across five papers, and include state-by-state breakdowns of training criteria.
- What is your state doing well, and where is there room for improvement?
- How does your state compare with neighboring states?
- What plans, if any, are regulators making to address gaps and discrepancies in dementia training for providers, first responders, or across care settings?
- Are private or non-profit groups stepping in to fill the gaps?
- Do nurses, home care aides, or other direct care workers have stories to share?
- What about training for family caregivers?