[Senate Hearing 111-820]
[From the U.S. Government Publishing Office]
S. Hrg. 111-820
TAKING CARE OF MOM AND DAD:
WHY WE NEED A QUALITY WORKFORCE TO SERVE OUR OLDER AMERICANS
=======================================================================
FIELD HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED ELEVENTH CONGRESS
SECOND SESSION
__________
WILKES-BARRE, PA
__________
AUGUST 2, 2010
__________
Serial No. 111-22
Printed for the use of the Special Committee on Aging
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
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SPECIAL COMMITTEE ON AGING
HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon BOB CORKER, Tennessee
BLANCHE L. LINCOLN, Arkansas RICHARD SHELBY, Alabama
EVAN BAYH, Indiana SUSAN COLLINS, Maine
BILL NELSON, Florida GEORGE LeMIEUX, FLORIDA
ROBERT P. CASEY, Jr., Pennsylvania ORRIN HATCH, Utah
CLAIRE McCASKILL, Missouri SAM BROWNBACK, Kansas
SHELDON WHITEHOUSE, Rhode Island LINDSEY GRAHAM, South Carolina
MARK UDALL, Colorado SAXBY CHAMBLISS, Georgia
KIRSTEN GILLIBRAND, New York
MICHAEL BENNET, Colorado
ARLEN SPECTER, Pennsylvania
AL FRANKEN, Minnesota
Debra Whitman, Majority Staff Director
Michael Bassett, Ranking Member Staff Director
(ii)
?
C O N T E N T S
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Page
Opening Statement of Bernard Graham, Ph.D., Dean, Nesbitt College
of Pharmacy and Nursing, Wilkes University..................... 1
Opening Statement of Senator Robert Casey........................ 2
Panel I
Statement of Janet Heinrich, DrPH, Associate Administrator,
Bureau of Health Professionals, Health Resources and Services
Administration, Rockville, MD.................................. 6
Panel II
Statement of Robert D'Alessandri, M.D., Executive Officer and
Chief Academic Officer, The Commonwealth Medical College,
Scranton, PA................................................... 22
Statement of Vera Salter, Ph.D., Professional Development
Director, the Direct Care Alliance, New York, NY............... 35
Panel III
Statement of Melissa Lear, President, Beck N'Call and President,
Allen Lear Home Care Associates, East Stroudsburg, PA.......... 45
Statement of Connie Kreider, Direct Care Worker, Columbia, PA.... 55
APPENDIX
Dr. Heinrich's Responses to Senator Casey's Questions............ 65
(iii)
TAKING CARE OF MOM AND DAD:
WHY WE NEED A QUALITY WORKFORCE TO SERVE OUR OLDER AMERICANS
---------- --
MONDAY, AUGUST 2, 2010
U.S. Senate,
Special Committee on Aging,
Wilkes-Barre, PA.
The Committee met, pursuant to notice, at 10 a.m., at
Wilkes University (Hon. Robert P. Casey Jr.) presiding.
Present: Senator Casey [presiding].
STATEMENT OF BERNARD GRAHAM, PH.D., DEAN, NESBITT COLLEGE OF
PHARMACY AND NURSING, WILKES UNIVERSITY
Dr. Graham. Good morning. My name is Bernie Graham, and I
am the Dean of the Nesbitt College of Pharmacy and Nursing here
at Wilkes University.
The college is the home to the School of Pharmacy, which
has graduated approximately 700 Doctors of Pharmacy since the
first graduating class in the year 2000. These graduates have
mainly settled in northeastern Pennsylvania and are having a
positive impact on the healthcare of our population, especially
in the area of immunization and medication therapy management,
areas in which pharmacists have gained the knowledge and
experience and now have the privileges in the Commonwealth.
We are also the home of the School of Nursing. Nursing
education, in one form or another, has been a hallmark of
Wilkes University since 1952. Since inception, Wilkes
University has awarded over 1,500 degrees in nursing. Wilkes
currently awards a B.S. in nursing, has an accelerated entry-
level Master's degree for career-change adult learners with a
Bachelor's degree in other fields, has a traditional Nursing
Master's of Science programs and, most recently, the Doctor of
Nursing Practice.
At the master's level and now the doctoral level, Wilkes
has concentration areas to prepare clinical nurses, nurse
specialists in geriatrics, which is the care of the aged
population, and psychiatric mental health. We also prepare
graduates for the areas of nursing management and nursing
education.
We in education also see this train of aging citizens fast
approaching. The need for a larger workforce of well-trained
healthcare individuals is obvious, but also perplexing. We have
responded to the well-publicized need, but something, probably
the economy or lack of money, has led to an interesting
problem. Some--not many, but an increasing number--of our
graduates are having a hard time finding employment. This is
both in nursing and pharmacy.
We see the workload of the existing workforce increasing
almost beyond capacity, but yet employment market is very slow.
This has also led to a very interesting problem with the
training of the bachelor-level nurses in Wilkes-Barre. This
problem is with all B.S. programs here in the region.
The local hospitals are so overworked that they cannot
precept any senior-level nursing students. These students, in
their last year, need individual mentoring and leadership
experiences, which can only be accomplished at bedside. This is
a problem that we, as educators, are trying to address.
As you can see that this hearing today will be informative
and extremely timely, and we thank the Senator for his concern.
Senator Bob Casey, who will soon be the senior Senator from
Pennsylvania, will chair this U.S. Senate Special Committee on
Aging field hearing, entitled ``Taking Care of Mom and Dad: Why
We Need A Quality Workforce to Serve Our Older Americans.'' The
hearing will focus on legislative action in the Senate and
taking measures to ensure that Pennsylvanians have access to a
quality workforce to care for an aging population, with a focus
on medical education in the frontline healthcare workforce.
Senator Casey.
OPENING STATEMENT OF SENATOR ROBERT CASEY
Senator Casey. [Off-mike.] I call this hearing of the
Senate Special Committee on Aging to order.
I do want to, first of all, thank Wilkes University and
President Gilmour and Dr. Bernie Graham for having us here, for
welcoming us and giving us this opportunity----
OK. We want to thank Dean Graham and President Gilmore and
others for welcoming us here to Wilkes University today to
focus on a series of challenges that the people of northeastern
Pennsylvania, the people of our Commonwealth, and, indeed, our
country face as it relates to caring for older citizens
throughout our Commonwealth and our country.
There are many, many challenges, but there are also, as we
will find out today, a lot of solutions to those difficult
challenges. We have in Pennsylvania one of the fastest-growing
populations in the country over the age of not only 65, but
also the age of 85. We know that, for example, when you compare
that to the United States of America, we know that the baby
boom generation will start turning 65 next year.
By the year 2030, all 78 million--that is hard to believe--
but 78 million will have reached that age, the age of 65 by the
year 2030. Between 2005 and 2030, the number of adults age 65
and older will almost double--almost double, just imagine
that--from 37 million to over 70 million, accounting for an
increase of 12 percent of the population to 20 percent.
So what that means is that the country will look like
Lackawanna County or Luzerne County because, as you know, now
about 12.5 percent roughly of our U.S. population is over 65.
Pennsylvania is above 15 percent, just about 15.5 percent. But
here in Luzerne County and next door in Lackawanna County,
consistently over the last 20 or 30 years, but it is certainly
in the last 10 to 20 years, both counties have been right about
19 or 20 percent over 65.
So that increase nationally will mean that the country will
have a percent over 65 that we have had here for many, many
years.
What we have to do, though, is not just recite those
numbers and list the many challenges we have. We have to
recommit ourselves to make sure that those who are, as Hubert
Humphrey said a long time ago, in the twilight of life, that
those who are in that age bracket get all the help that they
need.
Who are we talking about here? We are talking about people
who fought our wars, worked in our factories, taught our
children, and gave us life and love. All of those
Pennsylvanians and all of those Americans, we have an
obligation to make sure that they are taken care of in the best
way possible.
We have the blessing in this country of the best education
systems in the world, the best schools in the world. When it is
working as it should and when we are focused on the best parts
of it, our healthcare is the best in the world. We have to
bring all of that learning, all of that knowledge, all of that
expertise and ability to strategies to care for, to take care
of those in the twilight of their lives.
In Pennsylvania, we have a particularly significant
challenge over the age of 65. We are fourth in that category
for the country. This puts us in a unique position to be able
to be, in a sense, a laboratory for all kinds of great
strategies, all kinds of new ideas, all kinds of new pathways
of learning to make sure that we are taking care of people who
have contributed so much to Pennsylvania and to our country.
I remember reading a story, a series of stories in the
Philadelphia Inquirer about a decade ago, about I want to say
it was 1998, or 1999. I will get the date, but it was in that
time period. The writer of the story was Michael Vitez, and he
was talking about long-term care in Pennsylvania and across the
country. I will never forget something he wrote in that story,
that series.
I think I am quoting him accurately. He said, ``Advocates
for the frail elderly say that life can have quality and
meaning even until the very last breath.'' Life can have
quality and meaning even to the very last breath. Sometimes we
forget that. Sometimes we think of long-term care, nursing home
care, care for older citizens as somehow--oh, I don't know, I
guess somehow just kind of managing old age and figuring out a
way to make it as comfortable as possible.
Well, we don't really believe that if we think about it for
a little while. We don't believe that. We believe that life
does have quality and meaning, even to the very last breath.
That means that people can have full lives, lives of great
contribution and lives of great promise even when someone is
very old. That there is not just a dignity and a worth, but
also a lot of opportunity and a lot of promise in the life of
someone much older. They can contribute so much if we have the
strategies in place to take care of them.
So, first of all, it is a necessity that we get this right.
The people of our country who are in that age bracket know that
we have not just an obligation to them, but this is critically
important that we get this right for our workforce and for our
quality of life.
In Pennsylvania, we know that the trend, just like it is
across the country, those who are over the age of 85 are going
to increase even faster than the population over 65.
Pennsylvania is expected to grow by 50.6 percent between the
years--we are 10 years into this now--2000 and 2030. So in that
30-year time period, the population over 85 is supposed to grow
by more than 50 percent.
We also believe that when we are focused on these sets of
challenges, this is an opportunity for our State of
Pennsylvania. We were talking just earlier this morning about
our healthcare infrastructure. We have a lot of it in
Pennsylvania. A big workforce, you can make an argument, pretty
good argument, that healthcare is our biggest employer if you
set aside the jobs that are in agriculture or the economic
impact of agriculture or tourism, Government employment.
But you can make a very good argument that healthcare is
either the biggest employer or a very close second. The bill
that we passed in Congress and the President signed into law
this year, the healthcare reform bill, presents an opportunity
to create new models of care for people across this country.
We know that in Scranton, for example, we have a medical
school. A lot of people didn't think that would happen. But
because of the leadership of a number of people, including Dean
D'Alessandri, who is here with us today, will provide
testimony, this school allows us to test some of those new
models of care in primary care, comparative effectiveness
research, all kinds of new discoveries and new ways of
approaching the care for older Americans, to benefit them.
We know that collaboration will be critically important
with other healthcare providers and other experts in the field
to make northeastern Pennsylvania a leader, literally a leader
in this field in the world. Not just in the State or the
country, but indeed across the world.
So this isn't just some problem we have got to manage. This
is an opportunity. It is an opportunity for Pennsylvania, and
it is an opportunity especially for northeastern Pennsylvania.
For that reason, we should embrace it, not just hope we can
deal with it. We should embrace it as an opportunity.
Third, I think we are also at the same time, as much as we
think of this as both a necessity in terms of demographics and
opportunity because of our values, it is also something that
calls us to be summoned by our conscience and our commitment to
get it right. We will not be the kind of community that we have
been in northeastern Pennsylvania and across the State unless
we get this right.
The good news is we know exactly how to get it right, and
we can do this. Our parents and our grandparents who raised us
and cared for us and built this region, built this
Commonwealth, and really built the country, when you think of
the generations two or three that just preceded ours, how they
got us through World War II. We weren't prepared for World War
II. But they fought that battle, and they built our economy.
They built the middle class.
They made us the envy of the world--our economy, our way of
life, our ability to defend freedom. All of that came from one
or two generations of Americans. So we have a great opportunity
not only to improve and grow strategies to care for older
citizens, but also to build a very strong economy.
We are told that the American Association of Medical
Colleges predicts that the United States is expected to face a
shortage by the year 2025 of between 124,000 and 159,000
physicians across the country. The American Association of
Colleges of Nursing reports that the number of registered
nurses needed will grow, will grow by 260,000 nurses by that
same year, 2025.
So we are going to need more doctors. We are going to need
more nurses, and we are also going to need more direct care
workers in roughly that same time period. Direct care workers
are often not given the respect they deserve for the work that
they do. It is the direct care workforce that provides most of
the care to our loved ones. They help every day of the week a
quarter of a million Pennsylvanians and their families, every
single day.
It is one of the fastest-growing populations. According to
the Bureau of Labor Statistics, employment of home health aides
and personal and home healthcare aides is expected to grow
between 46 and 50 percent between the years of 2008 and 2018.
Just imagine, in one decade in one part of our healthcare
workforce, direct care workers is going to grow by roughly 50
percent in Pennsylvania.
So it is our responsibility to make sure these jobs are
both personally rewarding, but also that they provide an
opportunity for advancement and economic stability. So, for
that reason, tomorrow I will introduce in the U.S. Senate the
Direct Care Workforce Empowerment Act. This legislation will do
three things.
First of all, ensure that home care workers receive the
Federal minimum wage and overtime protections of the Fair Labor
Standards Act. That is a good idea. I can't believe we haven't
done it already. It doesn't make any sense that we haven't done
it. No. 2, improve Federal and State data collection and
oversight with respect to the direct care workforce. Three,
establish a grant program to help States improve direct care
worker recruitment, retention, and training--three or four
words that we hear over and over again when it comes this part
of our healthcare workforce.
So we are here to talk about how we care for Pennsylvanians
and Americans in the twilight of their lives, just as we hear a
lot of talk about folks that we worry about in the dawn of
their lives, our children. Both ends of our age spectrum, young
children and older citizens, both need our help, both need our
attention, and both need much more of our focus.
So we will have three panels today. Our first panel will be
one person, but someone who I think will be able to give us a
great overview of some of the opportunities we have, especially
in relationship to the new healthcare bill. Dr. Janet Heinrich,
the Associate Administrator of the Bureau of Health
Professionals of the Health Resources Services Administration.
Dr. Heinrich is a former executive director of the American
Academy of Nursing. She is here today to discuss many of the
important changes that the Affordable Care Act, the health
reform bill I referred to earlier, has made to improve and
support the healthcare workforce.
As I will tell her and I will remind our other witnesses,
if we can keep your testimony to about 5 minutes, you should
know, each of the witnesses should know that your entire
testimony will be made part of the record. So if there is a
part of it that you want to make sure is part of the record,
don't worry, it will be part of the record.
If you can keep it to around 5 minutes, Doctor, we would
appreciate it. So, Doctor, why don't you start us off? Thank
you very much for being here.
[The prepared statement of Senator Senator Casey follows:]
STATEMENT OF JANET HEINRICH, DRPH, ASSOCIATE ADMINISTRATOR,
BUREAU OF HEALTH PROFESSIONALS, HEALTH RESOURCES AND SERVICES
ADMINISTRATION, ROCKVILLE, MD
Dr. Heinrich. Senator Casey, Mr. Chairman, thank you for
the opportunity to testify today on behalf of the Secretary of
Health and Human Services and the Administrator of Health
Resources and Services Administration, which I will refer to as
HRSA.
The Affordable Care Act provides us many opportunities,
especially as we think about expanding the essential healthcare
workforce and the importance of the direct care worker, as you
so eloquently described.
HRSA is the primary Federal agency for improving access to
healthcare services for people who are uninsured, isolated,
medically vulnerable, including the elderly. Our programs help
Americans receive quality care without regard to ability to
pay. HRSA programs also help train the future nurses, doctors,
and other clinicians so essential to providing our healthcare
services.
My testimony today will focus on new activities related to
the Prevention and Public Health Fund, our programs to improve
access, the new programs we have for the frontline direct care
workers, and specific programs for training people to care for
older people. I want to give examples of organizations in this
area especially that are taking advantage of these new
opportunities that are made possible through the Affordable
Care Act.
Let us start with the Prevention and Public Health Fund. We
know that communities across the country have suffered from a
shortage of primary care workers. Without action, experts
continue to say that we will have a shortfall in our needs to
care for the aging population, with a decline in the number of
students selecting primary care.
To address this, Secretary Sebelius announced a series of
new investments worth $250 million, made possible by the
Affordable Care Act, to increase the number of providers in
primary care. Specifically, we will be funding additional
primary care residency slots to train new primary care
physicians. We will be supporting physician assistants training
for primary care, as well as nurse practitioner training
programs--nurses who will be going into primary care, and one
of those specialties, of course, is geriatrics.
There will be $5 million to fund States to plan and
implement innovative strategies to expand their primary care
workforce. This is a terribly important program, again made
available under the Affordable Care Act, to encourage our
States to address barriers to expanding the healthcare
workforce, especially for primary care. So that, in fact,
States can address issues of scope of practice which limit what
providers other than physicians can provide, especially to
older populations. Certainly, we know that Pennsylvania is a
leader in this area of addressing scope of practice issues.
Let us focus now on the programs we have to increase access
to care. HRSA's mission to improve health and achieve health
equity through access to health services includes the
administration of the Community Health Center Program, and the
National Health Service Corps.
With the community health centers, their mission is to
provide primary care to vulnerable populations, including older
citizens, no matter their ability to pay. Across the country,
we have a network of over 1,100 healthcare centers. In fact,
there are more than 20 HRSA-funded community health center
service sites within 50 miles of where we are today.
Community health centers are a vital source of healthcare
for aging populations. In 2009, health centers served over 1
million patients age 65 years and older.
The Affordable Care Act provides $11 billion in funding
over the next 5 years to increase support for community health
centers. About $9.5 billion of that will increase services at
existing sites, provide funds for new community health center
sites, and fund plans to create more community health centers
in underserved areas.
With the National Health Service Corps, HRSA seeks to
strengthen primary care by placing healthcare providers in
communities where they are needed most. For example, the
National Health Service Corps, through scholarship and loan
repayment programs, help address specific shortage areas for
medicine, dentistry, and mental health providers.
In fact, there are currently 12 National Health Service
Corps providers serving across northeastern Pennsylvania.
Moreover, in recognition of the aging of the U.S. population,
geriatricians were included recently as a physician category in
the National Health Service Corps to help provide more of these
essential services in underserved areas.
The Affordable Care Act increases and extends funding for
this corps. Through the loan repayment program, we now offer
$145,000 over 5 years to repay student loans that treat
uninsured and underinsured citizens. This is a substantial
increase from what was available to students before.
With the scholarship program, there is payment for tuition,
fees, a living stipend to students enrolled in accredited
programs for dentistry, nurse practitioners, nurse midwives,
and physician assistants, as well as physicians.
Let us now talk about the frontline worker and the needs
that you just spoke about. Across the United States, there is
growing concern about current and projected shortages of
frontline workers, direct care workers such as nursing and home
health assistants who provide the services for the elderly,
chronically ill, and disabled. The number of older and disabled
patients with very complex healthcare needs is outpacing the
supply of workers trained to meet these needs.
As a result, the need to train personal and home health
aides is ever increasing. The Affordable Care Act addresses
some of these challenges in training for frontline workers. Let
me describe three new programs that we are administering.
We have now, as a result of the Affordable Care Act, the
Personal and Home Healthcare Aide State Training Program. This
program is designed to address the challenges that you have
just described. The Personal and Home Care Aide State Training
Program aims to ensure the supply of competent personal and
home health aides with acquired skills that would be
transportable to any job market in the Nation, thus
strengthening the direct care workforce.
This program will support the development, evaluation, and
demonstration of competency-based uniform curriculums to train
qualified personal and home health aides. That program is now
in the review process, and we will be making awards by the end
of September.
Another new program is the Nursing Assistant and Home
Health Aide Program. This program establishes a new initiative
to train nursing home aides and home health aides. It will
support the development, demonstration, and evaluation of,
again, competency-based uniform curriculum to train qualified
assistants, strengthen the direct care workforce, making sure
that they have the necessary skills that can be transportable
and building blocks for moving up to other higher paying
professions in healthcare.
Awards and grants will be made to colleges and community-
based training programs for development, testing, and training
of these programs and emphasize telehealth and new
communication methodologies for training.
Another program is the Patient Navigator Outreach and
Chronic Disease Prevention Program. This program is
reauthorized under the Affordable Care Act and expanded. This
program supports individuals serving within communities to
assist patients in overcoming barriers to receiving healthcare
services.
Patient navigators help patients coordinate healthcare
services, determine whether clinical trials are right for them,
conduct outreach to populations to make sure that they have
access to the care they need.
We have several geriatric programs, and I will be brief
here in consideration of time available. In addition to
supporting the frontline workers, the Affordable Care Act
reauthorizes HRSA programs specifically focused on training the
healthcare workers we need with the special skills in
geriatrics.
Moreover, it is important that we appreciate the fact that
these training programs, as a result of the Affordable Care
Act, are more focused than ever before on interdisciplinary
training. We need to be able to work in teams. No one
profession can do it alone. We are not only relying on
physicians or nurses, but an array of health professionals that
we will be needing.
So one of our programs, the Comprehensive Geriatric
Education Program, really targets nurses and nurses who will
receive degrees in geriatric nursing, long-term care,
geropsychiatric nursing, and other nursing areas that
specialize in elderly populations. In 2009 in Pennsylvania,
HRSA awarded these grants to the Community College of Allegheny
County and the University of Pennsylvania.
We also have a Geriatric Education Center Program. These
programs provide interdisciplinary training for health
professionals in assessment, chronic disease syndromes, care
planning, emergency preparedness for elderly, and cultural
competencies unique to caring for older Americans.
The Affordable Care Act authorizes supplemental grants to
these programs in geriatrics, chronic care management, long-
term care for faculty in a broad array of health professions
schools, as well as training for frontline, direct care workers
and family caregivers. The Affordable Care Act authorizes these
short-term intensive courses to assist in these areas.
Currently, in 2010, we have awarded grants to the
University of Pennsylvania, University of Pittsburgh, and
Thomas Jefferson University. Interestingly enough, Thomas
Jefferson University provides these geriatric education
programs through a consortium that includes Marywood University
and The Commonwealth Medical College in Scranton, and The
Commonwealth Medical College then expands these through three
regional campuses in Scranton, here in Wilkes-Barre, and
Williamsport. So a broad reach that I think is very innovative.
We also have the geriatric training program for physicians,
dentists, and behavioral and mental health professionals. This
program supports geriatric training to train these
professionals who will go into the geriatric specialties in
their professions. We also have a Geriatric Career Award that
provides career development for faculty who will be training in
these programs.
Another program that you have in this area is the Area
Health Education Center Program. We fund the Area Health
Education Center programs to really encourage the establishment
and maintenance of community-based primary care training in
off-campus rural and underserved areas. One goal is to educate
and train students to become culturally competent primary care
providers.
The Pennsylvania Area Health Education Center has seven
AHEC centers, including northeastern Pennsylvania center, which
is located on the campus of Keystone College and serves a nine-
county regional area that includes Wilkes-Barre and Scranton.
The northeast Pennsylvania center also offers programs to spark
interest in science and preparing for health careers among
students in the high school and lower grades and encourages
students to enter the health professions careers.
In this area, there are consortium that include East
Stroudsburg University, Wilkes University, and the University
of Scranton to provide these experiences for students still in
their high school years. I can't stress enough that we really
do need to encourage the pipeline to go into the health
professions careers.
Whether we like it or not, in medicine and nursing for
sure, we have a huge cadre that are just at the cusp of
retirement. So, as fast as we are bringing in the health
professions on the front end, we are losing them to retirement
on the other end.
So, in conclusion, we are extremely proud of our programs,
look forward to continuing to work with you, Mr. Chairman, to
ensure the provision of quality care to all Americans and by
ensuring the availability of highly competent, adequately
prepared healthcare workers, especially workers who can care
for our older citizens.
Thank you very much. I am happy to answer any questions.
[The prepared statement of Dr. Heinrich follows:]
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Senator Casey. Doctor, thank you very much.
I wanted to ask you a few questions that relate to
northeastern Pennsylvania in particular. We have, fortunately,
passed the Affordable Care Act. It took a lot of work to get
that bill passed. I spent a substantial amount of time working
on a lot of different parts of the bill.
We are happy it passed. In fact, we are very happy it
passed. But we know that if this were a five-chapter book, as
hard as passage and enactment was, there are probably four
chapters after that that are all going to be difficult. A lot
of those chapters, a lot of the challenges are on
implementation.
We have an opportunity I think in northeastern Pennsylvania
and throughout the Commonwealth to take advantage of parts of
the bill that, frankly, not enough people have heard a great
deal about, which is true of a lot of parts of the bill. I
think there is a chance, as we begin to implement different
parts of the Affordable Care Act, that people will have a
better sense of what those provisions are all about.
As it relates to the whole series of programs that you
outlined, we have a lot of program names, a lot of acronyms,
and fortunately, a lot of funding to be able to help move those
programs forward, either new programs, new strategies, or
existing programs that will be expanded or reauthorized.
I guess one question a lot of people might have is if
someone bumped into you walking out of here today and said I
heard you passed this big healthcare bill, and I know here in
northeastern Pennsylvania, we have got a number of healthcare
challenges. One of them is this challenge of taking care of and
providing quality care for older citizens. How would you rank
or prioritize the programs within the legislation that would be
most helpful in the near term?
In addition to the programs, what Health and Human Services
resources do you think could be made available for the people
of northeastern Pennsylvania?
Dr. Heinrich. It almost sounds like you are asking me to
choose among my children. [Laughter.]
The fact is that there are themes, I think, in the
Affordable Care Act that are very important to this area, as
well as the rest of the country. But it seems as though you may
have a head start on some of these areas.
So I think there is definitely the theme of expanding the
primary care workforce. With the primary care workforce, we
have to emphasize the fact that it is physicians, yes, but it
is also nurses. It is also pharmacists. It is also physician
assistants. They all play a critical role in providing primary
care access, especially for older and a growing older
population.
Senator Casey. Can I just stop you there?
Dr. Heinrich. Yes.
Senator Casey. Just so we kind of go program by program.
You stated in your testimony with the Prevention and Public
Health Fund, and you spoke there about primary care workforce.
The bullet points you have, it is $168 million for residency
slots, $32 million for physician assistants training, money for
nurse practitioners, innovative strategies, nurse-managed
health clinics.
What is the best way for individuals--well, let me say what
is the best way for institutions in northeastern Pennsylvania
to take advantage of the Prevention and Public Health Fund? Let
me just start with that.
Dr. Heinrich. OK. The Prevention and Public Health Fund
was, in fact, a one-time--the $250 million was a one-time
initiative that may be, in fact, repeated in the future, but we
are not sure. It depends on the availability of funding. But I
think that the message for the institutions in this area is
that you have a new and developing medical school. You have
nursing programs. I haven't heard about physician assistant
programs.
But there are, in fact, opportunities for different levels
of training for healthcare providers. It sounds like the School
of Nursing here at Wilkes is already taking advantage of a lot
of the increasing, expanding programs in nursing. I would hope
that they would continue to do so in the future. I learned, as
I came in this morning, that, in fact, the new expanding
medical school is also taking advantage of some of the ongoing
programs.
So the message is that primary care is interdisciplinary
and that there are monies that are available for expanding the
numbers, and we would hope to continue that in the future.
Senator Casey. So for all those areas that I just talked
about, this fund is a 5-year program, right?
Dr. Heinrich. Right.
Senator Casey. It will support 16,000 new primary care
providers. So there are obviously opportunities.
What is the best way to access these programs? In other
words, how do you apply? What is the process?
Dr. Heinrich. There is a Web site called www.grants.gov,
and on that Web site, you will see all of the initiatives, all
the competition for all of our grants. You can also go to HRSA,
hrsa.gov, and look for grant opportunities, and they will be
listed there as well.
Senator Casey. Obviously, you mentioned before the impact
that the community health centers will have. I don't think many
people understand that we have had a very successful community
health center program, strategy--I don't know how you want to
define that. But it has been in place for years. In your
testimony, you pointed to some of that history and the network
of sites all around the country.
But this community health center part of the healthcare
bill is $11 billion more that will be provided over 5 years to
support that. It is almost impossible to calculate, in my
judgment, the positive healthcare benefits that will provide to
the country. That community health center part of the
healthcare bill could be its own bill, and it would be
considered a substantial piece of healthcare legislation.
So it is a part of the bill that I don't think people know
much about yet, but it will be of tremendous help. As you said,
you said there are more than 20 HRSA-funded community health
center service delivery sites within 50 miles of Wilkes-Barre,
as we sit here today. That is substantial.
I wanted to also go to the part of your testimony on page 4
and 5. You talked there about increasing the number of
frontline direct care workers as a major priority.
Dr. Heinrich. Right.
Senator Casey. You talked about in particular I highlighted
``older and disabled patients with very complex healthcare
needs.'' Sometimes I think we forget that it is not just
demographics, but the complexity of the healthcare needs is
significant.
Obviously, the rates of vacancy and staff turnover. We talk
about that over and over again. I have always found that in a
long-term care facility, when you walk in the door--and I know
I am simplifying this a bit, but it tells you a lot. You walk
in the door, one of the first questions you should ask is what
is your turnover rate?
Interestingly, in my experience, and I am not a
professional, but in my experience you can have a very
successful long-term care facility even though the turnover
rates are pretty high--40, 50 percent. A lot of them have 90
percent, right?
Dr. Heinrich. I was going to say that would be good.
Senator Casey. Much higher. I mean 40, 50 percent would
be--it is hard to believe that that would be actually a good
number compared to a lot of other sites.
But in this category, I wanted to clarify something on page
4. You have two sections here, two programs. Personal and Home
Healthcare Aide State Training Program. That is No. 1 on that
page. It is a $5 million program. No. 2, you have the Nursing
Assistant and Home Health Aide Program. That is $2.5 million.
What I wanted to know was, and get a better description of,
the difference between home care aide, that part of the first
program, and home health aide? I think people can get confused
by the overlap in the terminology. What is the difference
between those two?
Dr. Heinrich. In fact, you have a number of terms that are
used for people who are direct frontline workers, and it is one
of the issues that we hope to address in our programs, as a
matter of fact. So you have your personal assistant. You have
home health aides. You have nursing assistants who work in
nursing homes. Then you also have assistants who work in
hospitals.
Each of those areas have been looked at separately, and it
seems to me very few people, very few organizations have looked
across all of these siloed areas and said what are the basic
competencies? Can you build those competencies as you move
from, say, personal assistant, personal care assistant on
through to maybe the more complex activities you would be
expected to perform in a nursing home or even a hospital?
What we would hope is that through our model curriculums,
we could actually look at competency-based skills where an
individual could build their skill base and progress forward,
even to thinking about entry into new types of jobs, new jobs
in the healthcare provider disciplines.
Senator Casey. Both these programs are 2 years, 2010 to
2012?
Dr. Heinrich. Yes. Well, one is 3, I think.
Senator Casey. OK. I also--I wanted to ask you as well. We
have obviously the great opportunity, which is to say that it
might be one of the few, if the only place in the country to be
able to say this is accurate, and that is because we have a new
medical school that is just getting off the ground.
The medical school has their second class coming in. Is
that right, Doctor? I don't mean to jump ahead to panel No. 2.
I want to make sure we are right.
As that school develops--and it is a tremendous
opportunity, and that is an understatement--it just happens to
be developing and growing as we are beginning to implement the
healthcare bill. So it is a tremendous opportunity for lots of
reasons.
But what role can medical schools play in developing this
workforce that we have spoken about this morning already?
Especially when we have both a significant challenge, but also
a tremendous opportunity here at the medical school but even
nationwide the new strategies, the new programs that the
healthcare bill provides?
Dr. Heinrich. Right. Well, again, with the new focus on
primary care and the new focus on interdisciplinary education,
it seems to me that there are many opportunities, as a new
school is developing curriculum and thinking about how they are
going to meet the needs of the population in different ways,
and it sounds like you are very fortunate that the leadership
of the medical school is really moving in that direction.
So for many of our medical schools, it is very difficult to
fight tradition. So, here you are with the opportunity to think
about how you train together medicine, pharmacy, nursing, and
the area of mental health. I was just so excited to hear about
the program in pharmacy and nursing that you have here where
you already have training programs, basic science programs
where people are leveraging your existing resources so that you
are much more efficient in the training programs.
Sad to say, though, that you still have issues with the
preceptorship and the placement because you have to have the
clinical training, and it sounds like that is still a challenge
for many of these programs. So we have to find ways of
addressing the barriers that we have there with our expanding
student populations but still needing the excellent preceptors
and the clinical sites for the training.
Even when we expand physician clinical traning beyond the
hospital walls, which is wonderful to hear is happening in this
community, into home care, into skilled nursing care, you still
need to have hospital clinical sites to have an excellent
program. It sounds like that is the direction that people are
going.
Senator Casey. Well, we are fortunate to have these
opportunities.
Doctor, I know we are over time by a little bit, and I have
a lot more questions. But what we will do is I and, I think,
others will submit questions for the record. If you could
answer those in writing, we are grateful. I wish we had more
time to spend, but we have got two more panels.
Dr. Heinrich. Thank you very much. Appreciate it.
Senator Casey. Doctor, thank you for your testimony. We are
grateful for your service. Especially at this time in our
Nation's history, we are confronting a lot of difficult
healthcare challenges. So thanks for your service.
Dr. Heinrich. But it is fun doing all that implementation.
Thank you very much.
Senator Casey. Thank you.
We will move to our second panel. What I will do by way of
introduction, as our witnesses are moving to the witness table,
I would, first of all, like to welcome, as I mentioned him
before, Dr. Bob D'Alessandri, the Executive Officer and Chief
Academic Officer of The Commonwealth Medical College, who is
responsible for setting priorities, institutional direction,
and management, and functioning of The Commonwealth Medical
College, as well as the curriculum development and execution,
the student experience, faculty recruitment, and the execution
of the research agenda at the medical college.
Dr. D'Alessandri is an educator with over 18 years of
experience in senior leadership positions at West Virginia
University, including almost 15 years as dean of the West
Virginia University School of Medicine.
Our other witness today on our second panel, Dr. Vera
Salter, Professional Development Director of the Direct Care
Alliance. Dr. Salter was the founding director of the National
Clearinghouse on the Direct Care Workforce at PHI, where she
worked from 2001 to 2007. Before that, she co-owned a national
planning and marketing firm with clients across the continuum
of health and long-term care services.
She has served as vice president of a multi-institutional
healthcare system and has held a number of health planning and
research positions. Dr. Salter, thank you.
Dr. D'Alessandri, thank you. I think we will start with Dr.
D'Alessandri.
STATEMENT OF ROBERT D'ALESSANDRI, M.D., EXECUTIVE OFFICER AND
CHIEF ACADEMIC OFFICER, THE COMMONWEALTH MEDICAL COLLEGE,
SCRANTON, PA
Dr. D'Alessandri. Thank you very much.
Good morning, Senator Casey, Dr. Heinrich, staff, and
honored guests. I am delighted to be here this morning to speak
to you about our aging population and the need for more medical
personnel to care for them.
While we have all seen the statistics--the percentage of
the population aging, the increased demand because of chronic
diseases, the aging of the provider population--those
challenges are different in rural and small-town America. We,
as a Nation, need to come up with solutions that are not one-
size-fits-all because our needs and challenges are unique.
I would like to take just a minute and introduce myself and
my school to you because why we were created is specifically
relevant to these interests. Wilkes-Barre, Scranton,
Pennsylvania, northeast Pennsylvania has many small
communities. Like many small communities in the United States,
we suffer from a number of concerns.
We have an aging population with many chronic diseases. In
fact, Pennsylvania has the third-oldest population in America.
Our physician population is also aging. In fact, almost half of
the current physicians in this region will retire in the next
decade. It is estimated that by 2025 this region will lack
almost 1,500 needed physicians to care for our population.
We have a very fragile healthcare system. Hospitals
incapable of investing capital in infrastructure improvement.
We have had a poor track record of recruiting physicians,
both primary care and specialists, to the region. Almost half
of Pennsylvania physicians practice either around Philadelphia
or Pittsburgh despite the fact that only one-quarter of the
population resides there. Not surprisingly, that is where
Pennsylvania's medical schools have traditionally been located.
Northeastern Pennsylvania suffers from a shortage of almost
every type of physician and has fewer physicians per capita
than national averages.
We have over $1 billion in care. Yes, that is $1 billion
leaving the region because people cannot get appointments with
physicians or cannot get access to physicians for the type of
care they need. This involves increased expense, hardship, and
inconvenience for families and patients.
We also have a region that has experienced tough economic
times. The heyday of coal has been and gone. The economy here
is not made up of major corporations. It is small companies,
businesses trying to hang on. We don't have a lot of wealthy
people to support healthcare, the arts, and community civic
programs.
As I said at the beginning, we have a scenario that is
typical of most of America's small cities and towns--nothing
remarkable, significant, or special, just people who work hard,
who are trying to carve out good lives for their families and
get their loved ones good, high-quality healthcare. What is
unique about this community is how it decided to address the
problem of physician aging, lack of access to care, and their
relative lack of success in recruiting replacements for these
aging physicians.
This community came to the conclusion it needed to grow its
own physicians and thus start its own medical school. The
community had several goals for the school that included
improving healthcare in northeast Pennsylvania by increasing
the number of area specialists and primary care physicians;
improving the quality of care in the region; improving access
to care, especially in underserved and rural areas; generating
economic impact by creating high-paying, sustainable jobs and
attracting fresh dollars into the economy; increasing the
education of the area residents; and providing the region with
``intellectual capital.''
I was hired in 2007 from West Virginia University to take
these ideas and help create the school. In 3 years, we have
obtained degree-granting authority from the State, received
provisional accreditation from the LCME, the Liaison Committee
on Medical Education, and the Middle States Higher Education
Commission. We offer two degrees, a Master's in Biomedical
Sciences and a Doctor of Medicine Degree.
We have hired 160 full-time faculty and staff. We have over
700 community-based physicians participating on a volunteer
basis to train our M.D. students and have graduated our first
class of Master's students. Next week, our second class of M.D.
students--65 of them like the first class--begins.
Our 40 Master's students began in July. Our second-year
medical students begin in late August. It has been a very busy
3 years.
Now we are not a model that is easily replicable in
America. Starting a freestanding medical school is not a model
that is really economically feasible. We exist because Blue
Cross of Northeastern Pennsylvania invested $25 million in
funding our startup and another $45 million in our new
building. Our State invested $35 million in our building,
funded our feasibility study, and gives us an important, but
modest grant every year.
Thanks to Senators Casey and Specter and our congressional
representatives, the Federal Government has supported TCMC,
helping us with grants to fund our Clinical Skills and
Simulation Center and other small projects. Ongoing funding is
a challenge not only for us, but for the other dozen or so new
startup schools across the country. But solving the problems of
communities such as ours, the small towns and cities in
America, and having enough doctors and other health providers
to take care of our aging population is a complex issue.
The solution starts, like many problems, with changing our
educational process because we don't just need more doctors, we
need doctors with different skills. We need to address the
problem of fragmentation in the healthcare system by training
physicians, nurses, pharmacists, physical therapists, and
others to work as a team.
As Dr. Heinrich mentioned, this is the interdisciplinary
model. We need each of these individuals to understand not only
their role, but others as well. We need to train physicians not
just to lead, but how to work effectively as a team member.
At TCMC, we have created the first Consortium of Health
Professions Education Program with all the regional schools
that have health education programs to develop opportunities
for our students to learn to work as a member of an
interdisciplinary team.
We need physicians who can communicate effectively.
Effective communication is essential for safe and effective
care. This is one of the major complaints we hear from seniors.
``My doctor doesn't listen to me.'' We need to develop these
skills as rigorously as we teach molecular biology.
We need physicians who know how to find information on
state-of-the-art care and then incorporate it into their
practice. One of our faculty told our students recently that he
is not doing one procedure the same way he learned in medical
school or his residency. What we teach today has a very short
shelf life. We need to develop their interest in being lifelong
learners and their skills at finding the information on care
that they need, when they need it.
We need physicians who understand the process of care
improvement, how systems of care work and how to improve
quality and safety as members of the healthcare team. Concepts
like 6 Sigma and other quality improvement strategies and
processes need to be learned by students, and they need to see
they play a role in care and process improvement so care is
both effective and cost efficient. Students need to understand
critical thinking and systems thinking.
We need physicians who understand when care should be
standardized and when patients need proven therapies modified
for their particular issues. Standardization of care flies in
the face of how many schools select and train physicians. They
are selected because they are independent thinkers, not because
they can follow a formula. But data shows that, in many cases,
standardization improves care and improves costs. We need
physicians to know when each is important.
Physicians need to be trained in cultures that are
collaborative, transparent, outcomes focused, accountable, team
based, patient focused, and service oriented. They need to see
this culture modeled not only at their medical school, but in
their community sites where they train.
To do that will take a culture change in many of our
healthcare organizations. They need to see models of care that
work, first and foremost, for the patient, but also for the
care team. They need to see innovative, cost-effective models,
and we need a system that supports the development of these
models, another place the Federal Government could provide
support perhaps.
Physicians must understand the critical issues facing our
seniors--polypharmacy, end-of-life issues, depression,
dementia, and the need to feel that you can still contribute in
some way. Each of our students is assigned to a multi-
generational family. The student follows this family for 4
years, makes house visits, hears from family members about how
they have to make choices between medicine and food.
I have to tell you that I have learned a great deal from my
mother, who is 92. She keeps teaching me all the time. In
recent years, she continues to get her Medicaid bills when she
sees a physician, and frequently, she hands me the bill and
tells me, ``Pay this.'' I look at it and say, ``Mom, this is
not a bill. I don't have to pay this.''
She said, ``No, no, pay it.'' I say, ``No. I'm not paying.
It's not a bill.'' A month later, she receives another bill,
and she says, ``Pay it.'' I say, ``It says, Mom, this is not a
bill.''
The next month, of course, she gets a letter from the
collection agency saying that she is late. So I pay the bill.
Then 6 months later, she gets a check from the provider saying
you have overpaid. She says to me, ``Don't you know what you
are doing?'' I said, ``No, I really don't.''
This is a complicated system, and seniors face this all the
time. We would like our students to hear that from the families
that they follow. We would like them to actually see what
healthcare is all about in the home, not just in the clinic.
So the very first part of this program is that the student
visits the family in the home, and one of the first things we
ask them to do is look in the medicine cabinet because that is
where you will find an entire history of healthcare. It is a
very important part of the educational experience, and to my
knowledge, this may be unique in the education of medical
students.
We also want our students to follow healthcare providers,
not just physicians, but many of the direct providers that we
are talking about. Experiences in nursing homes and in other
facilities where care is provided, that is part of our new
curriculum.
Our country needs a cadre of physicians specialized in the
problems of our seniors. To that end, we are also planning a
special training program in geriatrics. These specialists
become resources for primary care physicians as well as
seniors. Part of that program is not merely learning about the
diseases and the illnesses that relate to seniors, but it is
also learning about the social problems and also the health
policy issues.
We want these geriatricians of the future to relate not
only to the diseases and illnesses that affect our seniors, but
also the economic and social problems as well. We want them to
become leaders in policy changes as well. This is an important
new aspect of geriatric training.
We need to view medical education as a continuum of
competency. We need an educational program that is cost
effective and allows students to move through it not in
lockstep, but as they develop competencies that build through
the educational process. We are in some danger of pricing the
cost of medical education out of the marketplace.
Finally, we need to connect the education of physicians to
their community and to service. We need to select bright
students who want to serve, who want to make healthcare better,
stronger, more effective--who want to care not only for the
individual but improve the care in their community. We need to
prepare physicians in their educational program to do that.
I would recommend to the Committee three excellent
resources--the new Carnegie Foundation Report, entitled
``Educating Physicians: A Call for Reform of Medical School and
Residency,'' the Josiah Macy Foundation's reports on medical
education and the new medical schools, and a wonderful book by
Boston physician Atul Gawande, entitled ``The Checklist
Manifesto,'' that addresses how healthcare can be safer and the
importance of team communication. All these resources discuss
what physicians need to know to care more effectively for
patients.
At TCMC, we are addressing many of these issues and
recommendations. Our curriculum was easy to adjust to current
needs since we could start from a clean slate and attracted
faculty who want to teach state-of-the-art curriculum.
Our model also has a community benefit. Since most of our
faculty are community practitioners, they learn state-of-the-
art care and thinking in their faculty development courses.
Changing the way they deliver care will change over time the
quality of care in our communities. Our educational model is
deeply rooted in our goals and our reason for being. Our
students are assigned a multi-generational family that they
follow for 4 years. I mentioned that.
They are exposed to an integrated curriculum from the very
beginning where science and patient care are constantly tied
together to create relevance. They are deeply embedded in our
region's communities. In the first 2 years, they have a
clinical mentor, they do community research projects, and they
learn about quality and safety processes all in a community-
based setting.
In their third and fourth years, they actually live in
those communities and learn directly from over 700 volunteer
clinical faculty who have been specially trained to teach
students community-based medicine. Our students learn how to
work in teams in our Clinical Skills and Simulation Center and
develop their professionalism and community service skills as
part of the educational process.
It is good public policy for the Federal Government to
support new schools--to support new models of education,
innovative models that seek to educate the students
differently. The answer to our problems is not just to have
more resources to train more doctors. We need to provide new
models of medical education that lead and support new,
effective models of care.
We need to support educational innovation and the programs
that are trying to do that and educational programs that are
trying to change community-based care. We need to give our
students the tools that they are going to use to take care of
us and our children and grandchildren.
Then we need to invest in our hospitals and clinics who are
barely hanging on. We need to make it possible for them to
innovate and support quality improvement. If we are going to
keep these newly trained physicians in this community, the
places they practice must support the way they have been taught
to practice.
Our hospitals and clinics need infrastructure, information
technology, training in systems thinking, quality improvement,
improved communication. They must be examples of innovation,
not just places that are themselves on life support.
Then our small cities and towns will be able to care for
our aging population. Our students who train in these
communities will want to stay and raise their families in these
communities. The answer is not just more money. It is money we
spend differently to creatively meet the needs of an aging
America in an effective and sensitive manner.
The medical schools in this country committed to innovation
and reengineering the educational and care delivery models
deserve your consideration and support. The new medical schools
can be a community-based catalyst for change, creating a
national model that will enhance the efficiency and
effectiveness of healthcare that is available to all Americans
of every age.
Our aging population must have access to the latest, most
effective treatments, to providers who are sensitive and
knowledgeable about their special needs, and we will be able to
provide the kind of healthcare that works for everyone.
Thank you very much.
[The prepared statement of Dr. D'Alessandri follows:]
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Senator Casey. Thank you, Dean. Thank you, Dean, for that
testimony.
Dr. Salter, thank you.
STATEMENT OF VERA SALTER, PH.D., PROFESSIONAL DEVELOPMENT
DIRECTOR, THE DIRECT CARE ALLIANCE, NEW YORK, NY
Dr. Salter. Thank you, Senator Casey.
I want to start by thanking you for your announcement that
you are going to introduce the Direct Care Worker Empowerment
Act tomorrow. That is very exciting news for us, and I think
the very title is critical because what is so important is to
recognize that there will soon be 4 million direct care workers
working daily, one on one, with elders and people with
disabilities.
It is only if direct care workers have the resources and
are empowered to take the actions that are needed to improve
the quality of life for those they are working with, that is
the way we are going to get quality care. I work with Direct
Care Alliance, and I am proud to work for an organization that
is the advocacy voice for direct care workers throughout the
country.
I won't go through the statistics again of the greatly
increasing aging population, but I think one theme I have heard
from many of the panelists is that as the population ages, the
cohorts of people that are available to do the work to care for
them is shrinking.
Senator Casey. You might want to move that mike a little
closer.
Dr. Salter. Saying that there is a gap between the care
needs and the number of people who will be available to do that
work, whether they are family caregivers or paid caregivers
because you were talking of the physicians aging out of the
profession and this is aging out of the profession. So the
crisis becomes amplified by that care gap.
I want to add that in 2008, there were 3.2 million nursing
assistants, home health aides, and personal assistants in the
United States. That number is projected to increase to 4.3
million by as early as 2018. I would like to also comment on
the question you asked about the difference between home care
aides and personal assistants and home health aides.
In some ways, if you think of an elder or a person with
disabilities that needs care in their home for a long period of
time, the complexity of the work that a personal assistant has
to provide may be greater than a home health aide, who is
defined as someone who is working for a home care agency under
the Medicare program.
So, in some ways, the definitions of workers are created by
the funding stream and not by the competencies that are
required to do the work. That is why I think it is so important
that the training and the compensation be based on
competencies, as many of you have already said.
So who are direct care workers? There are 165,000 direct
care workers employed in Pennsylvania, and these are among the
largest and fastest-growing occupations in the Commonwealth,
projected to increase by 50 percent in the next 10 years. Most
direct care workers receive low wages--on average, $10 an
hour--little or no benefits, and insufficient training and
professional development.
As a result, as we have said already, this profession is
plagued by high turnover rates that compromise the quality of
care of the people they serve. If we are to retain direct care
workers in this profession and make it an occupation that
people want to enter, we will need to provide basic labor
protections as are provided in the bill that you are
introducing, livable wages and benefits, training and
opportunities for advancement.
I was asked to address the issues of what is needed in
terms of training, certification, and advancement to make
direct care a desirable profession. First, I want to stress
that all direct care workers should be required to receive
adequate training.
Currently, Federal regulations require only 75 hours of
training for nursing assistants and home health aides, and
there are no Federal requirements for personal care assistants
who provide services under the Medicaid program or to private
individuals. We recommend, in line with a recent Institute of
Medicine report, that all direct care workers receive at least
120 hours of training, either before they start work or while
they are working on the job.
We also think it is very important that direct care workers
have competency-based credentialing and recognition of their
professional competency. The Direct Care Alliance has just
established a National Professional Credential for personal
assistance workers, the group that is not currently federally
regulated. We also recommend that specialty credentials in such
areas as dementia, peer mentoring, wound care, diabetes
management, and many other areas be available to direct care
workers.
I would love to see more recognition of the role of direct
care workers in the care team because while they are the people
who are spending all day with an elder in their home, they are
often not included as part of the medical team.
One of the things that struck me as we look at the
competencies of this workforce, this is difficult work. The
same issues of communication, knowledge of a variety of medical
background are critical for people to do their work well. Yet,
as you know, under the Fair Labor Standards Act, they have
been--home care workers have been categorized as ``companions''
and not as professionals that are a necessary part of the team.
One of the most critical things is respect and
opportunities for advancement. There have been numerous
evaluative studies of what it takes to retain direct care
workers, and it is really in some ways blazingly obvious. But I
just want to tell you about some of those studies.
There was a program funded through the Robert Wood Johnson
Foundation called the Better Jobs, Better Care program, and
there was a special edition of the Geriatric Journal that gave
the results of some of those studies, and the message gets
repeated. For example, a study in Massachusetts found that
nursing assistants were more committed to their jobs when they
perceive their jobs as having more autonomy, use of knowledge,
and teamwork.
In another study at Cornell, a retention specialist program
demonstrated that assigning a manager with expertise in all of
the techniques of retaining people improved retention when
compared to facilities without such a program. The WIN A STEP
UP program in North Carolina provides continuing education and
compensation for education modules, also had great success.
There are numerous career ladder programs throughout the
country, and at Genesis Healthcare, headquartered in Kennett
Square, PA, they have had a geriatric nursing assistant
specialist program for 21 years that trains and compensates
nursing assistants for their advanced knowledge.
There have been many studies of what direct care workers
are looking for, and in one study conducted by Dr. Peter
Kemper, a professor at Penn State, he summarized what is
important to direct care workers. What they want is more pay,
better work relationships, being appreciated, listened to, and
treated with respect, which is basically what we all want in
our work.
Unfortunately, recognition of these issues and efforts to
create the right work environment is limited and sporadic. What
is needed is a broad public policy that changes the way direct
care work is managed and compensated so this becomes a
respected profession that people want to enter.
[The prepared statement of Dr. Salter follows:]
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Senator Casey. Well, Doctor, thank you very much.
I want to thank both of our witnesses for your testimony. I
just had a couple of questions, and in light of our time,
probably just maybe about 5 minutes of questions.
First of all, Dr. D'Alessandri, I wanted to ask a basic
question about--kind of a ``where we are'' question. I know the
medical school is up and running. You have got your second
class coming in. But can you give us a little update on the
construction, kind of where that is.
Dr. D'Alessandri. Construction is proceeding very nicely.
We will be occupying the building by April 11, 2011, in plenty
of time to accept our third class. At that time, the class will
increase in size to 100 and eventually 120 students per year.
So we are right on target for that and feel very, very good
about that.
Senator Casey. This incoming class is?
Dr. D'Alessandri. Sixty-five.
Senator Casey. Last year's was 65?
Dr. D'Alessandri. That is correct. We are currently at
Lackawanna College, utilizing their temporary space there, and
that is really the limit that we could manage at the present
time.
Senator Casey. You mentioned the students working with a
multi-generational family. We don't hear enough about those
kinds of approaches, and I wanted to have you expand on that
and why you think that is so critically important to expose a
young medical student to that kind of experience?
Dr. D'Alessandri. Right. It really is a very important
concept. Our students are relatively young. Not relatively,
they are young. Most of them, if not all of them, have very
little experience with the healthcare system. Their parents are
young.
By the time they become familiar with the healthcare system
from a patient perspective, they are physicians and treated
differently. Physicians don't really understand healthcare from
the patient perspective, and we see the patient in the clinic,
in the office, and patients just won't tell you things.
So the young mom who takes her two children, waits in the
waiting room for 2 hours, then sees the doctor in a skimpy
gown, waits there for 20 minutes, and her doctor walks in and
looks at her and wonders why her kids are running around and
she can't take care of them. That young lady will never say a
word to the doctor about all of that.
But she will go home, complain about that. Our students, we
hope, will hear that and will learn about the problems about
the healthcare system from the patient's perspective. It isn't
learning about medical knowledge. It is really learning about
the social-economic impact that this has on a family and on
their health, and that is really why we think this is so
critical.
It will also bond those students to those families, and we
hope those families will also play a role in recruiting those
students and keeping them in our community.
Senator Casey. I also want to note for the record that in
Dr. D'Alessandri's testimony, starting on page 3 and going
through most of page 5, when he walked through those various
points about working effectively as a team member, helping
physicians to communicate better, finding information on state-
of-the-art care, how a system of care works, standardization of
care, collaborative and transparent outcomes-focused,
accountable team-based focused strategies, critical issues
facing seniors--when he went through that whole list, he starts
with the word on page 3, ``solutions,'' which we want to hear
about.
We know that sometimes, especially in Washington, we can be
very good at diagnosing problems and challenges and not often
enough outlining solutions and then pushing forth ways to
implement those solutions. So we are grateful for that kind of
roadmap or list of solutions that we can all work on together.
Dr. Salter, I wanted to ask you about--and a lot of your
testimony is very consistent with my own unprofessional
observations, but I think significant experience as a public
official. I am not sure there is any public official in the
State over the last decade or so who has spent as much time on
some of these issues as they relate to direct care workers and
older citizens as I have. I still don't consider myself an
expert, but I learned a lot along the way.
Your testimony was very consistent with experiences I have
had, as both a public official and as a member of the family.
As Dr. D'Alessandri and others have noted, we learn a lot more
about healthcare and the work and the policy as members of the
family than we do sometimes in our professional lives.
But one observation, one insight that you and others have
had is that the direct care worker wants to be seen as a
professional, wants to be valued more, and sometimes one of the
ways to get there is to develop what people in the industry
have said not a career ladder necessarily--it could be that, I
guess--but a career kind of lattice. In other words, they can
move almost laterally or--can you explain that, what your sense
of that is?
Dr. Salter. Well, we have found that when somebody enters
an occupation, at the beginning they are learning the basics of
doing it. But when you have spent 10, 20 years in the
occupation, you have learned a lot of skill. There can be lots
of ways to recognize people's advanced knowledge so that people
can have specialty training in geriatrics, in dementia, in
diabetes management, and be compensated for it so that people
are moving up a ladder, as it were, within the direct care
profession.
There are also some people that do want to take that
learning and move on to LPN or RN programs, but we have found
that that is a minority. Many people who do this work do it
because they love the work but find it impossible to stay in
the occupation because it is so poorly compensated and
regarded. So I think there are a lot of different pathways for
different people, which is why the word ``lattice'' has been
introduced.
There has also been a lot of success with peer mentoring
programs because one of the biggest turnover times is in the
first 6 months of the work. People enter the work in the
nursing home, for example, and leave within 6 months. Whereas
if there is a senior aide who has already done this work who is
assigned to support them, they are much more likely to stay.
Again, that peer mentoring role can be trained and supported
with compensation.
So I think there are opportunities for people to move ahead
in the profession and also to work in more supervisory ways
because there is a shortage of RNs and a shortage of people to
take on some of the management functions because a lot of self-
scheduling where people are allowed to schedule their own work
that can be organized. So, there are many ways that people can
be empowered more and compensated for their knowledge and their
advanced work.
Senator Casey. Well, I can't tell you how many times over
the last it is now 15 years since I have been a public official
that people have told me that are experts in long-term care
that run nursing homes about a whole myriad of problems. It
would be complicated enough if this were just a worker, direct
worker, direct care worker problem, but this is a big employer
problem.
Dr. Salter. Right.
Senator Casey. We haven't gotten our public policy right to
the extent that you have a nursing home might train over the
course of a year or more, or maybe more than a year, they might
train 10 people and retain 1.
Dr. Salter. Yes.
Senator Casey. So they spend all that time, all those
dollars training someone who leaves within months. So it is
obviously bad for the worker, bad for the employer in a
significant way, and bad for the person in that bed who is
dealing with Mary or John for a couple of months, maybe longer,
and then they have a turnover and then another turnover,
another turnover.
So the family is confused. The person who is the recipient
of that care is not getting the quality of care they should
get. The employer is out money, and the worker is bouncing
around to different jobs. So we need to get it right, and there
is a lot more to do to get it right.
I did want to ask Dr. D'Alessandri one more question. Just
about the--you did mention the training program in geriatrics.
Can you talk about that for a moment just a little more?
Dr. D'Alessandri. Sure. Also, I wanted to mention just a
couple of things that relate to that, if I might?
Senator Casey. Yes.
Dr. D'Alessandri. One is that we think pipeline programs
are really critical, and I know that Dr. Heinrich mentioned
that. We are actually involved in and have applied for an HCOP
program and have been working with Wilkes and LCCC, Luzerne
County Community College, in developing those pipeline
programs.
So we think that has a real important aspect in terms of
training workforce in healthcare for this region and really
focusing on rural, first-generation, underserved minorities. So
that is a really strong program for us.
The second is that in residency programs--and I really
applaud the effort that HRSA is making in increasing residency
slots primary care. But very often, primary care residency
slots go unfilled. Where the dollars would be better spent or
at least equally well spent, let me put it that way, would be
really encouraging medical schools to increase primary care
training among their students and giving incentives for medical
schools to really educate primary care physicians.
The geriatric program is a very important one. Ninety-five
percent of the care, primary care for seniors is really going
to be with primary care providers, not with geriatricians. We
see geriatricians as being a resource for the primary care
provider, as well as the patient and for other agencies that
work with seniors. We see the geriatrician as the advocate in
terms of public policy for the senior from the healthcare
perspective.
So, with that in mind, the training program involves not
only the usual aspects of medical education, disease, and that
sort of thing for the geriatrician, but it also involves an
intense knowledge of the social agencies and other agencies
that relate to seniors----
Senator Casey. To be an advocate.
Dr. D'Alessandri. To be an advocate. An understanding from
the senior's perspective of how they may utilize and work with
those. I was intrigued by the navigator concept that Dr.
Heinrich talked about. In some ways, the geriatrician is also a
navigator, helping the senior through the system, and maybe
even helping the primary care provider through the system.
So we think that the traditional model teaching knowledge-
based content, skills, all of that is very important, but also
the other aspect of this, health policy and also understanding
dynamics within the community, are really important.
For example, transportation is a huge problem in our area
for not only seniors, but for everyone. Getting to an
appointment, relying on family, those kind of things. Helping
work through those problems with seniors, we see the
geriatrician as being a very important part of that.
Senator Casey. Well, Doctor, thank you so much. Dr.
D'Alessandri, Dr. Salter, I know we have more questions, but
not enough time. But we will send questions for the record that
will be additional to amplify your testimony. We are grateful
for your time here today. Thank you very much.
Dr. D'Alessandri. Thank you, Senator. Thank you.
Senator Casey. We will move to our third panel. As our
panelists are getting to their seats and we are transitioning
to our third and final panel, we will be pleased to welcome
Melissa Lear and Connie Kreider.
Melissa is President of Beck N'Call Home Health and
President of Allen Lear Home Health. In these positions, she
has focused on providing in-home assistance to older citizens
in the indigent, serving people whose activities of daily
living are not covered under Medicare, Medicaid, or other
insurance programs.
Ms. Kreider is a Certified Nurse's Assistant and since 1998
has worked at Luthercare, an assisted living facility in our
Commonwealth. She is also the co-chair of the Pennsylvania
Direct Care Workers Association.
So, Ms. Lear, we will start with you.
STATEMENT OF MELISSA LEAR, PRESIDENT, BECK N'CALL AND
PRESIDENT, ALLEN LEAR HOME CARE ASSOCIATES, EAST STROUDSBURG,
PA
Mr. Lear. OK. Good morning and--I guess almost afternoon
now. I can't thank you enough for letting me come here and do
this.
Senator Casey. Let me interrupt for one second. I know your
printed testimony is longer than 5 minutes.
Mr. Lear. I am going to make this amazing for you.
Senator Casey. Summarize as best you can.
Mr. Lear. The fact of the matter is that I am one of the
faces of home care. I am not only the CEO, I am a registered
nurse. As the CEO of two companies, I still see patients on a
regular basis.
I could talk about home care from now until years after I
am dead and gone. I think that the reason that it is important
for me to be here today is to let you know that recruitment has
always been a problem in home health for both aide--direct care
workers, home health aides and nurses. But my agencies have
been successful over the years by making the rewards and
benefits of working in home care a primary focus.
I don't believe that the financial rewards of doing this
kind of work are ever going to match the personal satisfaction
that the people who do it get. So a few of the real important
factors of working in home care is our one-to-one patient
relationships. I graduated with a bunch of nurses who work in
hospitals. They see 10, 12, 14 patients a shift. I see one at a
time. They have my undivided attention for the amount of time
that I am there, and I am there however long I need to stay to
get done what I am there to do.
If you would imagine for a moment sitting in the kitchen
with Miss Vivian in her late 90's, and she cries and speaks
softly to you about how cruel it is for her to continue living.
She has lost most of her sight. She has outlived all of her
friends, and her family lives too far away to help. She knows
and you know that without home care she would be placed in a
nursing facility, being forced to leave her home.
Imagine working with Miss Margaret, performing wound care
on a dressing and listening as she tells the story of how her
husband built the home she still lives in with her son. She
reminds you that your agency took care of her husband also, and
it has been a few years since he passed away.
She lets you know that what she wants most for her 100th
birthday, which is right around the corner, is a record number
of birthday cards. So you head back to the office. You spread
the word. All the employees that can get a card in the mail to
her do so. Miss Margaret got an unbelievable number of cards, a
spot on the local news, huge bouquets of flowers, and one more
birthday before she passed away at 101 years of age.
In total, your agency provided almost 9 years of care to
Mr. and Mrs., but they rarely required more than 3 or 4 hours
per day because their son, in his 80's, bridged the gap between
our services.
The only difference between you and I is that I don't have
to imagine these stories. These are not the stories of my
employees or employees of other agencies. For me, they are real
events, and they belong to me.
Benefits to working in home care include flexible schedules
that work for patients as well as staff. It is a process of
care that I have kind of coined the phrase ``wholistic,''
meaning W-H-O-L-E, because we solve care management problems
that stem across the entire family dynamics. We find many
problems in home care that we can fix that we have talked about
earlier today that physicians don't know about, hospital
discharge planners don't know about, clinics don't know about
because families are either too embarrassed to share it or
don't believe that anyone has the solution.
I can offer to you that the first single-biggest impact you
can make in the future recruitment of individuals is to
encourage and support a growing influx of available nurses,
home health aides, and caregivers, and that would be to show
firsthand potential pool of individuals the impact that they
can make on another person's life.
What makes a young man or woman at the age of 18 enlist in
the military is not a paycheck. It is a deep-seated love for
their country and the freedom that being part of this country
brings them. It is the need to be part of something bigger than
is just themselves. It is a lifestyle that is presented to them
when they are very young.
This is what we need to do for the home care agency. I was
not a nurse since a long, long time ago when I was 18. I quit
college three times before I finally finished. I didn't finish
in nursing. I have a Bachelor's degree in computer information
systems. I have a Master's in business. I didn't graduate from
nursing school until I was in my late 30's, when I went back
and decided this is what I wanted to do.
I spent 2\1/2\ years working full time while I attended
classes and did clinical rotations. During my 2 years of
clinical care work, I spent weeks in nursing homes learning to
apply what I had learned. I moved to a hospital clinical
rotation. I spent three semesters, did clinical rotations in
four or five different hospital settings. I spent one day in
home care and hospice. That was not enough to change my life.
I already knew home care. I already loved home care. That
is what keeps me in home care today. Most people that I meet
still have no idea what a home care nurse is, what a home care
aide is. They don't understand what we do or the impact that we
make. My very small agencies employ 75 people, and we see
approximately 200 patients a day. We make a huge difference in
the community that we serve.
Picking through to see what I really want to add. I think
that home care also has a very serious place in chronic care
management, and I would hope that as different issues of the
healthcare reform come through that home care is not left off
the table. We are a very important resource to kind of spread
that physician avenue for patients out geographically.
I know that there are a lot of initiatives under the
healthcare reform legislation that focus on chronic care
management, and I would like to let everybody know that home
care would certainly love to partner in many of these endeavors
in reaching out to people from telehealth right on up through
any other demonstration projects that are going on. We
certainly would be appreciative to be present at the table when
those are put forth.
The only other thing I can share is that we serve a large
number of populations who are squeezed between Medicaid and
Medicare. When you cross over, just over the Medicaid border of
financial eligibility is a population of individuals who are
making hardcore choices between taking their meds every other
day, between doing their lab work as regularly as they should
because they can't afford to have someone come into their home
and do it. Medicare doesn't cover it in many, many cases for
them, and they don't have the ability to get out to a physician
or a lab to do this kind of testing.
The example would be like a Coumadin patient, someone who
takes blood thinners, requires frequent blood monitoring. Right
now, you can have a Medicaid patient who gets that service
covered for them. They could be monitored every 2 weeks like a
physician would order.
Somebody who just misses those financial eligibility
guidelines is negotiating with their physicians, trying to
stretch that time period out because they don't have the
resources available or the means to get that kind of medical
care as regularly as they should.
The one final note I will toss in is if there is an
opportunity at some point in the near future to allow
Pennsylvania physician assistants and nurse practitioners to
order and write home care services, that would be a huge help
for us. We work with a lot of nurse practitioners who right now
are not permitted to sign our home care orders, and it slows
down a patient's availability of services.
[The prepared statement of Ms. Lear follows:]
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Senator Casey. Thanks very much. You did a good job staying
within the time, and I know, as I said before, your whole
testimony will be part of the record.
Connie? Thank you very much.
STATEMENT OF CONNIE KREIDER, DIRECT CARE WORKER, COLUMBIA, PA
Ms. Kreider. Hi. Good morning. What an honor it is to be
here today, and I would like to thank everybody for the
opportunity.
I am a direct care worker. I have been in the field for
roughly 13 years, and my background started in retail, which I
intended to stay in. But with the overwhelming amount of stress
and long hours and managing a family, a husband, and family's
multiple schedules, it got to be harder and harder to stay in
that field.
So I decided to look for a career change. Someone I had run
into had said I should try to get into the nursing field
because, of course, that is the cutting edge of the future, of
a growing future. So I went down to the area nursing home,
which I had never actually entered a nursing home before. So
this was my first time ever.
This turned out to be a very rewarding and blessing area
for me. I believe that people want to provide a positive way of
life for the elderly. I believe that people want to actually
give back. It is almost like a sense of giving to others.
I really am a firm believer of doing unto others as you
would have them do unto you--the Golden Rule. Treat someone
with love and respect, and they will treat you back with love
and respect. If you work in this mindset, everything else
really falls into place.
It is really sad that the Federal Government--Federal law
only requires 75 hours of training in this field when, really,
that is not near enough. You really need to have additional
communication skills, compassion training, and good customer
service, also with multitasking with several things going on at
the same time.
On a daily basis, you may have anywhere between 8 to 12 to
sometimes more residents. The high turnover for nurses aides in
the first year is roughly 60 percent and in the second year is
roughly 80 percent. They are not nearly prepared for the
physical work, the emotional demands, and the stress that comes
with this line of work.
So when there is this high turnover rate, who really
suffers? Well, we all suffer. The residents are very upset that
someone new has just come in to take care of them. The quality
of care that is provided to the elderly and to people with
disabilities is so important that change is very difficult on
them and also difficult for the family members who have also
formed a close relationship with the caregivers.
They form a close relationship with their caregivers and
become emotionally attached with them. We become a part of
their lives, and so many caregivers are often thought of as an
extended member of the family. We are the eyes and the ears of
the many different places we choose to work from. It takes a
qualified, adequate, positive caregiver to stay focused on the
issues. It requires a large amount of teamwork and
communication and also a great sense of humor to pull this work
off.
Direct care workers are roughly 90 percent female, and many
work more than one job in order to support their families. Many
do not have adequate healthcare, or if they do, it is so high
in the cost of things that they really can't afford it. Many
are great providers of others, but they lack the ability to
provide for themselves. I can't stress that enough.
Stress takes a toll of your mind, body, and spirit. It can
consume you and leave you feeling burned out. This is also seen
across the board as ``compassion fatigue.'' So who takes care
of the caregiver? We need to be kind to each other, have a
peaceful work environment, work as a team.
I am a member of the Pennsylvania Direct Care Workers
Association, and we promote compassion and quality care for
people living with disabilities and the elderly, the
chronically ill, and the terminally ill. The association
strengthens the quality of professional personal care for all
Pennsylvanians by providing education, advocacy, and support
for the direct care worker profession.
I am also very proud to be a supportive member of the
Direct Care Workers Alliance. Vera had talked earlier. The DCA
provides direct care workers with advocacy and leadership
training. They support all direct care workers in assisting in
the development of associations and coalitions with technical
support and leadership training. They also work toward
improving the direct care workforce and support initiatives
like the Direct Care Workforce Empowerment Act.
So what does this mean for all direct care worker? It means
a better workplace and a better way of life. We are not alone.
There are many of you who want to stay connected. We want to
learn to give of ourselves. We learn to give to ourselves and
celebrate our successes, love where we work, and work where we
love.
So what is a good direct care worker worth these days?
Anybody have a clue? Just ask your one and only best friend in
the world, one of your residents, and they will say that you
are absolutely priceless.
[The prepared statement of Ms. Kreider follows:]
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Senator Casey. Connie, thanks so much.
I was struck by your testimony in a number of ways. One is
just the language that you used to describe your work and the
work of so many direct care workers across our Commonwealth and
across the country. Words like you said at one point earlier in
your testimony--I am not sure this is part of your prepared
testimony. You said ``the sense of giving to others. People
want to provide a positive way of life for others, a way of
giving back.''
A little later in your testimony, ``Love and respect,
compassion.'' You used that word several times ``compassion.''
You used that word on page 2 as well.
We don't often see that language associated with the
profession and with healthcare. God, we need more of it. We
need a lot more of that kind of passion for the work that you
are doing and passion for the care that you and others have
provided.
I wanted to ask you about some of the mechanics of how you
prepare. This has always mystified me, and I know that you
mentioned it about the 75 hours of training not being enough.
Now 75 hours of training is not insignificant. That is
basically two solid weeks of doing nothing but training. So I
don't want to downgrade it, but it is clearly not enough for
the work that you have to do and others have had to do to care
for people where, let us face it, in that long-term care
setting with that resident, you are providing most of the care.
Most of the kind of hands-on care, I will say.
But talk for a moment about that training question because
I know, for example, in Pennsylvania, in other professions that
often don't involve as much direct care giving, per se, the
requirements are much, much higher. Also in professions that
don't provide any care giving.
For example, my recollection is to be a barber or a
beautician in Pennsylvania, you need my recollection is 1,000
hours, but I could be wrong about that. But it is a lot more
than 75. It is multiple times higher than 75. My recollection
was more than 1,000.
So talk to me about the hours of care--or the hours of
training. Not just that, but the preparation itself in a
broader way. Or lack of preparation, as I would characterize
it.
Ms. Kreider. Right. You know, the 75 hours gives you the
basic. Really, your hands-on care and your hours of working
with a seasoned caregiver is really where your training comes
from and from having an open line of communication with your
family members and your residents, also with the required in-
service hours that you put forth in your year of training.
There is also several programs out there that have
continuing education that is really essential to tap into also.
Senator Casey. Connie, I think what causes so many of us to
be in awe of the work that direct care workers do every day,
although our policy doesn't always reflect that awe and respect
that we have, and we need to change that. That is why I and
others have legislation to move in that direction.
But we do have a tremendous respect for what you do. We do
have a sense of awe. It is work that I would like to be able to
think I could do, but I am not sure I could. I hope I could,
but I am not sure I could. I think that is true of a lot of
people.
What drives someone to enter this field of providing direct
care and staying with it, despite all of the obstacles, all of
the ways that our country has not put in place policy to be
reflective of the care that you give. What motivates people to
do it and to stay with it?
Ms. Kreider. Well, that is a very good question. I
originally went into this field because of the convenience of
it. But I quickly fell in love with this field. Early on, I
wanted to think that perhaps it would lead into LPN or an RN
position, but I quickly changed my mind after a couple of
weeks.
I think it has a lot to do with the relationships you have
with your residents, just to work with them and to get to know
them and to know their histories. Some of them are vets, and
some of them have a long history of incredible stories to
share, and just that relationship that you have with them is
just priceless. They teach you lessons far beyond any textbook
or history book you will ever be exposed to.
So it is really fun, a learning experience. It humbles me
many, many times because they have so much to offer and so much
to give because they have seen so much.
Senator Casey. I remember years ago--I will tell a very
quick story--my father was in a long-term care setting, and we
would go to visit him. All four of his sons, when one or more
of us were in the room, we are all pretty big, all over 6 feet
tall and should have some degree of strength.
He would be in the bed, and he would be on one side and, of
course, would need to be turned. He was at a point where he
didn't have the strength to turn himself in a way that was
appropriate, and he was someone who really valued expertise in
a certain area or certain skill level.
Once in a while, we thought we could be helpful, and we
would pull--what seemed like an easy task, pulling the sheets
or the pads underneath him to try to turn him. Invariably, we
would do it, and we would do it wrong. So wrong that he would
look at us like you made the situation worse, but he wouldn't
complain.
Then a direct care worker came in the room, and invariably
almost every one that I remember was a woman. She was a foot
shorter and hundreds of pounds lighter, and she would pull that
pad with a skill and expertise to make him feel comfortable. I
couldn't do it. My three brothers couldn't do. My sisters
couldn't do it. It looked like we could, but we couldn't.
So that gave me an insight into just one, tiny--one small
part of the work that gets done every day. Just to make someone
feel comfortable in that bed was a big task, and he stopped
asking us for help in that part of his care. He wanted a
professional to do it, a direct care worker.
Melissa, I wanted to ask you a question as well. You
referred as well to what drove you to get into the business of
caring for people and providing that kind of help in their
homes. If you had an opportunity to write a piece of
legislation or to draft a policy, what do you think is most
needed as it relates not just to this field more broadly, but
in particular to the work that you do, what you see every day?
What do you think is our most pressing need or pressing
challenge?
Mr. Lear. Our pressing need is still staff. It is very hard
to find nurses who want to come to the home care because I
don't think that they know enough about it. The other huge
barrier that we have is what I mentioned with the physicians
being the only ones right now in Pennsylvania who can sign home
care orders.
There are lots of wound care clinics that serve
predominantly geriatric patients who are run by nurse
practitioners, and their patients can't get access to home care
without a physician to sign off on it. The nurse practitioner
is the one who sees the patient. The nurse practitioner is the
one who should be ordering the home care and signing off on it
so that we can get out there and do the dressing changes. So it
is really slowing down that delivery system.
I think those would be the most important things from a
nursing standpoint. I am certainly onboard with the training
for the home health aides and that component. Home health aides
are near and dear to my heart. I mean, my 75 employees, 90
percent of them are home health aides.
To the credit that some facilities have high overturn and
things like that, we retired our first home health aide last
year after 10 years of service, recognized two others, and we
have two more this year who are serving 10 years.
Senator Casey. I guess, over time, that profession, that
part of our workforce will be growing substantially, right? As
more and more people prefer to want to be cared for in the
home, as more and more public policies incentivize that so you
are getting in some ways less and less nursing home or
institutional care, that workforce will become ever more
important. Isn't that correct?
Mr. Lear. It is ever more important. But I think it is not
something that is--you don't see the face of us a lot. We are
standing next to you in the supermarket, and you don't know who
we are or what we do because we don't look like other
healthcare professionals. So I don't think we are drawing
enough young people into this.
I frequently get calls for nurses who want to work in home
care because they are burned out from their hospital setting,
and they think that--I don't know what they think, that we
don't see patients. But they want--they are looking for that
desk job or case management job now that I can't give them.
People just don't have--I can't think of anyone in my
graduating class who is working in home care besides me. That
is kind of sad.
Senator Casey. You said very little of your training was
directed at that, huh?
Mr. Lear. Very little of my?
Senator Casey. Very little of your own training.
Mr. Lear. Oh. No, one day. I spent one day in home care and
hospice, and they shared it. I saw one home care patient, one
hospice patient.
Senator Casey. I was noting in your testimony, you didn't
have a chance to go through all of it, but you had three major
categories. The first one, in terms of the focus of your
testimony, meeting the increased need for senior care and
support was one. The second was preparing a workforce to
support a growing elderly population. Third was retooling our
healthcare system, including long-term care.
Is there anything that you wanted to, any point you wanted
to make that you didn't have a chance to before in either or
one of those three areas?
Mr. Lear. I think maybe two points. I just think that
somewhere in the Medicare system, it would be nice to fund
chronic care conditions. Maybe not the traditional 60-day
payment, well, that I am familiar with. We get one lump sum to
care for somebody after hospital stay.
If we could get in there before the hospital stays and
provide some support, we have had a lot of success in home care
with HIV patients who are frequent fliers in the hospital, of
medication management patients who are frequent fliers in the
hospital because they can't get it right.
But under the Medicare system, there is no vehicle to pay
for that. So if we didn't look at maybe traditional Medicare,
but some kind of a new--and I say that cautiously, some kind of
a new payment system to manage those chronic care conditions,
that would be hugely important to keeping people at home.
Senator Casey. OK. Well, thanks very much. I know we are
out of time. It is about 5 after 12 p.m. That is a record that
we are pretty much on time. That is pretty good.
We will have more questions for both of you. We will submit
them for the record and ask that you answer them in writing,
but we are grateful for your testimony and grateful for the
testimony of all of our panelists.
For those who were here for the basically 2 hours of
testimony and discussion, we are grateful. I was saying as I
was coming in here today, we don't get a chance to do this very
often. People think this is very common to have hearings like
this in states like Pennsylvania or across the country. Its
not, unfortunately it should be more common and even in
Washington we have lots of hearings but sometimes not enough
that are as focused as this one is, and has been and we are
grateful for that. So thanks for your testimony and we are
adjourned.
[Whereupon, at 12:08 p.m., the hearing was adjourned.]
A P P E N D I X
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Dr. Heinrich's Responses to Senator Casey's Questions
Question 1. Pennsylvania has the fourth highest percentage
of residents over age 65. This gives us a tremendous
opportunity to play an important role as the nation decides how
to care for our older citizens. How can we work together to
allow Pennsylvania to be a model for other states with younger
populations?
Answer. We recognize that one of the major health care
challenges facing the United States is providing appropriate
care to the increasing number of older Americans with complex
health needs. The Census Bureau estimates that the number of
adults age 65 and older will almost double from 2005-2030.\1\
HRSA recognizes the need for additional health care providers
with knowledge and training in the unique health needs of older
Americans, and has several funding opportunities that support
geriatric workforce development. Pennsylvania residents and
institutions (including educational institutions) are eligible
to apply for the varied funding opportunities that the Federal
government has relating to elder care. HRSA offers consultation
and technical assistance to anyone interested in these funding
opportunities.
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\1\ 65+ in the United States: 2005, released by the U.S. Census
Bureau.
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Question 2. What HHS resources could be made available to
the Scranton-Wilkes-Barre region to help guide our health
professions training schools and healthcare providers in taking
full advantage of the federal grant programs you cite in your
testimony? How do we ensure that a comprehensive system of
services and qualified healthcare professionals are available
to this population, and that all of the programs you mentioned
are leveraged, and not a few hit or miss?
Answer. HRSA has an array of resources available to help
identify grant opportunities to support health professions
schools and healthcare providers in the Scranton-Wilkes-Barre
region, as well as all other parts of the nation. The best
starting place is HRSA's website, http://www.HRSA.gov, which
has information about HRSA's programs and links to additional
sources of information. It is also a good place to identify
additional sources of assistance--toll-free numbers, written
products, and contact information for federal program staff.
Question 3. You mentioned in your testimony several federal
grant programs that are assisting this region or that could
soon assist this region in improving the healthcare of our
older adults and their families. In issuing grant guidelines
for applicants of HHS, HRSA, NIH or AHRQ programs, is there any
preference afforded to new medical schools? What about a set-
aside of a percentage of funds for new grantees, so repeat
grant recipients are not the only ones being able to take
advantage of scarce federal resources?
Answer. None of HRSA's programs have a statutory preference
for new medical schools or set-asides for new grantees. We
cannot address this question as it pertains to NIH or AHRQ.
Question 4. You referenced several provisions to address
the challenges we face in training frontline health care
workers and especially direct care workers. What steps do you
think a state like Pennsylvania with a high percentage of older
citizens should do to best respond to these initiatives and
become a model for other states around the nation?
Answer. Pennsylvania is clearly a leader among States in
caring for older Americans and poised to build upon this
experience. HRSA encourages all qualified applicants to submit
applications for funding opportunities like the State Health
Care Workforce Development grant program. This program, created
by the Affordable Care Act, will enable State partnerships to
plan and implement innovative strategies to expand their
primary care workforce by 10 to 25 percent over ten years to
meet increased demand for primary care services.
Question 5. Is our nation's current approach to medical
education sufficient to meet the growing demand for health care
services? And related to that, what do you think is the best
way to expand the number of residency slots to meet the
forthcoming physician shortage?
Answer. Current projections suggest that there will be a
shortage of providers, particularly primary care physicians, in
the years ahead. The Administration has responded to the
shortage by announcing $250 million for its workforce
initiative, which is designed to increase the number of health
care providers and strengthen the primary care workforce.
Resources, made available by the Affordable Care Act and the
American Recovery and Reinvestment Act, will support the
training and development of more than 16,000 new primary care
providers over the next five years. HRSA plays a key role in
managing this initiative , and is currently implementing a
multi-pronged approach to strengthen the numbers of primary
care providers, including physicians, nurse practitioners and
physician assistants.
In addition, the Affordable Care Act funded several new
grant opportunities for primary care providers, including the
teaching health center program which will provide GME payments
to support community-based training. Teaching Health Center GME
payments will cover the costs of new residency programs in
community-based ambulatory primary care settings such as health
centers. This will have a strong positive effect on the number,
and quality, of primary care physicians in this country.
Question 6. In many ways new medical schools present a
clean slate for many of the new models we will be testing and
utilizing under health care reform. How can we work together
and with these schools to harness those resources and work to
develop residency programs that complement what these students
learn in medical school?
Answer. HRSA recognizes that new medical schools are
uniquely poised to create and implement innovative curricula.
Residency programs and medical school curricula can be molded
to incorporate competency-based models of care, including
interprofessional team-based competencies and patient-centered
medical homes. HRSA training programs for physicians are
available to support these efforts and we look forward to
working creatively with you and the medical school community to
achieve these goals.