Connecting Education and Practice in Geriatrics and Gerontology
Background
In 2009-10, the John A. Hartford Foundation conducted a communications audit to explore opportunities to amplify and augment the work of our grantees and impact of the Foundation. One of the audit’s key findings was that respondents encouraged the Foundation to more deliberately link its investments in education and training programs with those made to support the new models of practice and service delivery. This echoes recommendations suggested in the 2008 Institute of Medicine report, “Retooling for an Aging America” and recognizes the critical relationship between the success of clinical and service models designed to improve the care of older patients and what happens in education and training efforts in academic and practice settings. We also know that information must flow in both directions between clinical care and the education sector in order to create the workforce we need for the 21st Century.
GSA Event: An Initial Conversation
Since the audit, the Foundation has launched a Strategic Planning process that is reviewing its grant making approaches generally. As part of this work, and in an effort to learn more about how we might better connect our education and service grants more effectively, the Foundation hosted a small, group discussion at the Gerontological Society of America (GSA) Annual Meeting at the Boston Sheraton Hotel on Saturday, November 19. In addition to Foundation program staff, 19 people attended including several Foundation grantees and a number of service delivery leaders in the Boston area (see Appendix A). A lively and informative conversation ensued (See Appendix B for the meeting’s agenda).
Christopher Langston, Program Director of the Hartford Foundation, opened the discussion by framing the issue and the gathering’s objective, which was to “start a conversation about the connections between the care needed for older adults and the education and training required to prepare a workforce to deliver that care.” Ultimately, he said, the Foundation was hoping for ideas that “will make the most difference now in improving the health of older adults.”
The meeting formally began with introductions, in which each participant noted his or her most “burning issue” related to this topic. Senior Program Officer Amy Berman facilitated the first half of the conversation focused on “Employer/Provider Perspectives on Workforce Readiness for Work Today and Tomorrow.” Senior Program Officer Rachael Watman then led the group through the other side of the equation, namely how academic leaders are addressing issues in workforce readiness. Perhaps not surprisingly, the conversation had much overlap between the two perspectives. Practice examples prompted comments about educational and training ideas, and educational and training efforts sometimes prompted additional thinking on practice or service delivery. Finally, Chris Langston concluded by seeking clarification on a few key issues that the discussion had raised. Thanking everyone for their time, he noted that this was an initial conversation that the Foundation looked forward to deepening and continuing over the next several months.
The following brief describes some of the major ideas and issues that emerged from this meeting. This distillation necessarily elides some of the particular detail and compelling anecdotes in the discussion, but we trust provides an accurate description of our conversation.
Key Themes and Ideas
In all of discussion’s vigorous give and take, several themes surfaced:
• While reform and change are challenging, there are opportunities in the service delivery environment that are building demand for greater geriatrics and gerontology skills.
o Sometimes a problem (like the environmental challenges that are noted below) can also be an opportunity. Some issues driving change in the operating environment are actually building demand for geriatrics or geriatrics-infused services. This is true particularly around issues related to reducing hospital readmissions, taking advantage of payment bundling, and the need for greater care coordination and collaboration being generated by the Affordable Care Act. Geriatrics-focused practice and training innovations can demonstrate the value of the field, while helping to solve pressing service delivery problems.
o Given the current resource limitations of geriatricians and gero-practitioners in so many settings, it will be important to choose initiatives that are highly leveraged, that have the opportunity to broadly demonstrate value to the system and other actors, and recruit new attention and resources to these kinds of efforts over time.
• Noting the pressing need for gero-competent clinicians today, the discussion highlighted several ideas for building the skills of practitioners.
o Given the clinical needs of an aging patient population, it is critical to incorporate training on basic geriatrics skills into practice settings. There is also the need to incorporate similar training in inter-professional collaboration and team skills, as well as risk tolerance.
o It is important to demonstrate a strong value proposition for these training opportunities and to create needed incentives for time and resource-strapped practitioners (e.g., clear career ladders, paid internships, stipends, “buy-out time” for agencies to allow employees to attend trainings, CEs, certificates, etc.). Conversely, there should be incentives for non-licensed practitioners to receive formal training in academic settings.
o For the relatively smaller number of practitioners with geriatrics preparation, there is a need to build their leadership and management skills to guide teams and participate in systems and institutional change efforts that require geriatrics perspectives and resources (perhaps through a kind of Executive MBA-geriatrics program?). This can help burnish the “geriatrics” brand and serve as an important way of distinguishing gero’s unique contribution to health care delivery and transformation.
o At the community level, several participants identified the need to develop more practitioners who were multi-lingual and culturally competent. This is clearly important in our nation’s growing diverse and immigrant communities and will be increasingly needed as the percentage of elders of color grows over the next few decades.
o All of these education and training efforts should seek to build the capacity of clinicians to “cross borders” between and among disciplines and particularly settings. They should create professionals comfortable working with many types of clinicians and in acute, clinical, long-term care and community settings.
o The need for greater communication between the academic and practice environments can better align “tooling,” (i.e., the initial preparation of health care professionals) and potentially reduce the need for retooling.
• The discussion also highlighted several curricular and education/practicum/residency issues.
o Adding gero into the curriculum is critically needed but remains a challenge, as new information and new constituencies continue to compete for limited space in the curriculum. Nursing may be further ahead in this area.
o There are already a variety of competencies, tools, and curricular materials available. One big challenge is, how do we best get these into broader usage? Another is determining whether graduating students have acquired these competencies once established.
o There continues to be the need for training in more varied practice settings (i.e., hospital, community, clinic, and long term care) that will expose students to the whole continuum of older patients’ needs. Post-graduate residencies and internships in these settings create additional resources in resource-strapped settings/communities and provide needed exposure for students at the same time.
o All students need greater contact with their counterparts in other disciplines so that they can come into practice with a clearer understanding of team work and team roles.
o Placing the patient at the center of the education experiences can facilitate a more helpful perspective on aging (and all clinical) issues, promoting the importance of multi-disciplinary team care, bringing to light older adults’ diverse life experiences and how they move in and through the health care system.
o Faculty members, particularly in nursing and social work, sometimes have limited or no clinical responsibilities. Promoting or supporting these roles could make faculty’s courses and research more practically relevant.
o Academic research is often disconnected from the most relevant and pressing issues faced in the practice setting. Clinical researchers needs to move from “give me subjects” to involving practitioners in identifying research questions and topics for study.
o Moving even further back on the developmental spectrum, the discussion noted the need to integrate human functioning and the aging process into the undergraduate curriculum, so that students are better prepared for a gero perspective when they get to their clinical or specialized training.
• Responding to these opportunities and ideas will be complicated by a variety of challenges in the service delivery environment that continue make improving care for older adults difficult.
o Geriatrics and gerontology practitioners in all disciplines are paid less well and experience lower levels of professional prestige than their colleagues. For these and other reasons (including a lack of appreciation for the extent of the older patient population), we are not always invited initially into service delivery change conversations generally and other discussions pertinent to training opportunities. This is further complicated by a lack of understanding a) of what gero-experts bring to the table and b) of what certain team members (e.g., social workers) do.
o Resource limitations appear increasingly acute as one gets further away from the hospital and into community settings. Resource scarcity for organizations responsible for these community clinicians creates a challenging environment for training or educational innovations to prosper.
o There is a tension between developing higher level skills (e.g., case management) and enabling new practitioners to get up to speed with the raft of compliance issues and paperwork that can take up huge amounts of time and energy.
o The workforce we have is often not deployed efficiently or not working to full scope of practice.
o Our society’s ageism is infused into choices both students and practitioners make. Students seek courses of study and jobs away from clinical settings focused on older people. Even though most clinicians in acute and other settings see large numbers of older patients, there is a lack of appreciation for the need for basic and specialized geriatrics skills.
o Due to cost pressures and policies mandated (or soon to be mandated) by the Affordable Care Act, health systems and settings are undergoing dislocating and ultimately transformative change. This is creating a very dynamic operating environment, challenging efforts to implement specific training and practice changes focused on older patients.
Next Steps
Based on the discussion at this gathering, the Foundation will draft a brief concept paper that outlines what we learned in our meeting and possible next steps and future directions. Our plan is to build, sharpen and even expand this thinking and ultimately shape our grantmaking in this area in the years ahead.
To this end, we would like to get your reactions to this summary. What have we missed? Where did we get it wrong? Can you help us create a more compelling vision of what should be?
Appendix A
Attendee List
Melissa Aselage, PhD, Duke University School of Nursing
Mercedes Bern-Klug, PhD, University of Iowa School of Social Work
Elizabeth Capezuti, PhD, New York University College of Nursing
William Dale, MD, PhD, University of Chicago Medical Center
Rosanne Distefano, Elder Services of Merrimack Valley
Sadhna Diwan, PhD, San Jose State University School of Social Work
Nancy Giunta, PhD, Hunter College School of Social Work
Judith G. Gonyea, PhD, Boston University School of Social Work
Janet Gottler, LICSW, Kit Clark Senior Services
Joan Hatem-Roy, Elder Services of Merrimack Valley
Nancy Hooyman, PhD, University of Washington School of Social Work
Rita Jablonski, PhD, Pennsylvania State University School of Nursing
Nancy Kropf, PhD, Director, Georgia State University School of Social Work
Rosanne Leipzig, MD, Mount Sinai School of Medicine
Kevin O’Neil, MD, Brookdale Senior Living
David Reuben, MD, University of California – Los Angeles School of Medicine
Steven Snyder, East Boston Neighborhood Health Center
Joan Stanley, PhD, American Association of Colleges of Nursing
Robert Schreiber, MD, Hebrew Senior Life
Foundation Staff
Christopher Langston, PhD, Program Director
Amy Berman, RN, Senior Program Officer
Nora OBrien-Suric, PhD, Senior Program Officer
Rachael Watman, MSW, Senior Program Officer
Marcus Escobedo, MPA, Program Officer
Wally Patawaran, MPH, Program Officer
John Beilenson, Strategic Communications & Planning (facilitator)
Appendix B
AGENDA
Connecting Education and Practice in Geriatrics and Gerontology
Breakfast meeting at the Gerontological Society of America
Boston, MA
November 19, 2011
Beacon B, 7:00-8:30 AM
1. Welcome and Introductions
2. Overview and Context — Christopher Langston, PhD, Program Director, The John A. Hartford Foundation
This will include a brief description of the Foundation’s interest in this topic and its strategic planning process.
3. Understanding Practice: Employer/Provider Perspectives on Workforce Readiness for Work Today and Tomorrow — Discussion facilitated by Amy Berman, RN, Senior Program Officer, The John A. Hartford Foundation
Given the needs of our healthcare system today, what are the strengths and challenges in how our workforce is currently prepared? What are the gaps in knowledge and skills? Looking ahead, what are the challenges in preparing the workforce to deliver new models, new ways of delivering acute, chronic, and long term care for older patients?
4. Understanding Education: Educator/Academic Leaders Respond to Workforce Readiness — Discussion facilitated by Rachael Watman, MSW, Senior Program Officer, The John A. Hartford Foundation
For professional schools and other education providers, what is driving and/or constraining efforts to prepare the workforce for current and future needs? What would help educators and educational institutions accelerate change (e.g., GME flexibility, better placements, more field instructors, clearer consensus on what health care employers want, etc.)?
5. Bringing It Together — Facilitated by John Beilenson, President, Strategic Communications and Planning
How can we better connect health professions education with the current and future realities of clinical practice to generate better care and outcomes for older patients?
6. Next Steps — Christopher Langston, PhD, Program Director, The John A. Hartford Foundation
