Geriatric workforce training supports rural elderly

Photo: Otto Phokus via Flickr

Photo: Otto Phokus via Flickr

A shortage of qualified geriatric health providers to address the often complex health needs of rural seniors around the United States requires some innovative approaches. One effort is the Geriatric Workforce Enhancement Program (GWEP), which helps train and support primary care practices in rural areas to offer better care management.

GWEP is funded through the Health Resources Services Administration (HRSA). It concentrates on improving services such as the Medicare annual wellness visit, chronic care management, advance care planning and dementia care. Integrating geriatrics with primary care ideally will develop a larger and better-trained health care workforce to enable stronger patient and family engagement and better health outcomes, HRSA said.

The American Geriatrics Society is managing a Geriatrics Workforce Enhancement Program Coordinating Center, which provides resources for the awardees.

The Dartmouth Centers for Health and Aging in New Hampshire is one of 44 funded organizations in 29 states participating in GWEP. The hope is that this could become a national model for meeting older adults’ health care needs. “We’re actually going into the practices, and we’re redesigning how the care is delivered and providing toolkits and assistance,” said Stephen Bartels, M.D., the center’s director, in a phone interview.

The approach includes creating teams of care professionals — nurses, physician assistants and coaches — who are embedded in a primary care practice and can work at the highest level of their licenses. Paid and unpaid caregivers also would be incorporated into individual care teams. The team would coordinate with the aging social service provider in the region to ensure patients receive other services they may require. “So you go from a dyadic situation to the patient in the middle, with everyone else as a virtual team helping maintain this person independently in their home as long as possible,” he said.

As this story explains, a recent Oregon State University study found that poor access to care among rural elderly leads to increased risk of death. Other barriers, such as transportation, health literacy and communication, significantly affect regular, quality care for rural older adults. Medicare covers many basic services, but high out-of-pocket costs and prescription drug prices can be enormous burdens. The Economic Research Service reported that in 2014, the poverty rate for senior adults (65 years and older) was 10.5 percent in non-metro areas compared with 9.3 percent in metro areas.

While Medicaid helps narrow the insurance gap for low-income seniors and many people under age 65, that could change in the coming years, said Bartels, community and family medicine professor at the Geisel School of Medicine at Dartmouth, and a professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice. Before Medicaid expansion under the Affordable Care Act, more non-elderly rural residents (22.3 percent) were uninsured than non-elderly urban residents (21.4 percent) according to the RUPRI Center for Rural Health Policy Analysis.

Rural health is a huge challenge, and we still haven’t figured out how to do it effectively and efficiently for older adults, Bartels said. “There’s no question in my mind that the solution will have to be some sort of combination of technology, smart homes, or monitoring or telehealth, combined with high-touch, hands-on care.”

That care does not necessarily have to be nurses or home health aides, which can be expensive and may provide more than is needed. Instead, “we have to develop a new type of health outreach worker who knows about older adults and who’s specialized in older adult concerns; direct care service workers who actually can do many of the things required without the nurse or physician intervention,” he said.

This strategy could be supported through good professional supervision and employing appropriate technology, something spouses and daughters already do every day. This can include assisting an older person to perform fall prevention exercises, get adequate nutrition and help alleviate their social isolation.

“An entry level provider in a rural northern setting could be visiting people in their homes and providing great value,” he said. “We need to think about different models that include lay trained outreach workers that get adequate training and can do the sort of outreach supported by tech.”

Lack of a trained geriatric workforce is of particular concern in New Hampshire, which (after Maine) has the second oldest median population in the United States. “You don’t have that younger workforce coming in,” Bartels said. Instead of an inverted age pyramid, with the oldest at the top, the baby boomer demographic has created more of a squaring effect, with not enough people at the bottom to support those at the top.

Bartels believes this is not a sustainable picture, describing a looming crisis, especially the lack of geriatric mental health services in this New England Journal of Medicine article. He stressed that it is time to consider different models, such as lay trained outreach workers who would be trained to do outreach supported by technology. Training a new kind of geriatric workforce is no longer a “should do,” but a “must do.”

Here are some ideas for reporting on rural health and aging:

  • Explore the special needs of rural elderly, who often have some different issues than urban elderly.
  • How can mental health services be incorporated into service delivery for older adults? Do providers recognize mental health needs apart from depression or dementia?
  • How will states and counties provide/pay for long-term care for rural elderly, who may not have access to nearby assisted living or naturally occurring retirement communities (NORCs)? Most seniors want to live independently at home, but the dearth of home and community-based programs is a significant barrier.
  • Isolation and loneliness are significant challenges, particularly their effect on the aging brain. What are communities doing to address this issue?

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