Luring Health Care Providers into Geriatrics

Supporters of loan forgiveness programs aimed at encouraging health care providers to specialize in geriatrics got a boost from a report issued last month by the Institute of Medicine (IOM). Retooling for an Aging America: Building the Health Care Workforce is based on the findings of an ad hoc committee that looked at the health care needs of the 78 million baby boomers who’ll soon be turning 65. The group estimates that there are currently only about 7,100 doctors certified in geriatrics in the US, one for every 2,500 older Americans, a shortage they attribute to a lack of training programs and low Medicare reimbursement rates for geriatricians compared to other specialists. The report comes just as the government prepares to cut Medicare physician payments this July. The group has called for increased reimbursement rates, loan forgiveness programs, and student scholarships.

I was pleased to see that the report also addressed the need for more direct-care workers, including nurse aides, home health aides, and personal care aides. Unlike geriatricians, who have high job satisfaction rates (the highest, in fact, of any specialty), these hands-on workers are generally dissatisfied and have high rates of turnover due to low pay and working conditions, high rates of on-the-job injury, and few opportunities for advancement. Turnover among nurse aides, for example, averages 71% annually, and 90% of home health aides leave their jobs within the first two years. In response, the committee is calling for more opportunities for career growth, higher pay, and access to fringe benefits. They also recommend that all health care workers be trained in basic geriatric care and treating older patients.

As I've said many times before, we can screen and regulate all we want to prevent worker abuse and neglect, but it’s not going to do much good until we make these jobs tenable and have an adequate pool of workers for seniors to choose from.

At the national level, Senator Boxer’s Caring for an Aging America Act of 2008 (S. 2708) would amend the Public Health Service Act to attract professionals and direct care workers by earmarking $130 million for a loan forgiveness program. Those covered include physicians, physician assistants, advance practice nurses, social workers, and psychologists. The legislation would also create the Health and Long-Term Care Workforce Advisory Panel for an Aging America to advise the Secretary of Health and Human Services, the Secretary of Labor, and Congress on workforce issues related to elder healthcare. The bill has bipartisan support and counts among its supporters the American Geriatrics Society, the National Council on Aging, the Alzheimer's Association, AARP, American Academy of Physician Assistants, American College of Nurse Practitioners, American Psychological Association, Coalition of Geriatric Nursing Organizations, and the National Association of Social Workers.

Here in California, our loan forgiveness program is also making headway. AB 2543, which was developed by the California Senior Legislature under the leadership of Shirley Krohn and introduced by Assembly member Patty Berg, is called the California Geriatric and Gerontology Workforce Expansion Act of 2008. To qualify, loan recipients would have to commit to a minimum of three years of service in geriatric care settings. Covered under the bill are physicians, dentists, psychologists, registered nurses, and social workers.

I thought I’d end with an excerpt from the terrific New Yorker article "The Way We Age Now," by surgeon Atul Gawande, which I cited in a posting last fall (see Geriatricians, Angry and Otherwise):

Several years ago, researchers in St. Paul, Minnesota, identified five hundred and sixty-eight men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric specialists. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, ten per cent of the patients in both groups had died. But the patients who had seen a geriatrics team were a third less likely to become disabled and half as likely to develop depression. They were forty per cent less likely to require home health services.

Little of what the geriatricians had done was high-tech medicine: they didn’t do lung biopsies or back surgery or PET scans. Instead, they simplified medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

How do we reward this kind of work? Chad Boult, who was the lead investigator of the St. Paul study and a geriatrician at the University of Minnesota, can tell you. A few months after he published his study, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

“The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he is now a professor at the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a twenty-five-thousand-dollar pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs.

Seems to me that the need for more geriatric training is pretty much a no-brainer.

Guardianship Under Assault

Indictments of guardianship and guardians are flying fast and furiously these days on Web sites and blogs:

A new site, operated by a group calling itself the National Association to Stop Guardian Abuse, explains guardianship this way:

"At present, it operates to ensnare the most vulnerable people in a larger and larger trawling net, now including those merely physically "incapacitated"! It has become a feeding trough for unethical lawyers and other "fiduciaries" appointed by the courts to protect, but many of whom become nothing more than predators."

Another, called “Abusive Guardianships of the Elderly,” exhorts readers to share their stories:

“Has someone you love been victimized by the guardianship racket? Please share your experience. We must look to each other for ideas and support if we are to stop the blatant exploitation our elderly and infirm suffer at the hands of the system and the law who is charged to protect them.”

And, in a recent response to my Feb 12, 2007 posting “Feel Good Laws or Real Reform?” about California’s conservatorship reform package, a respondent named “Sherry” had this to say:

"(The vulnerable) have become the prey for a predatory and lucrative guardianship/ conservatorship industry. In case after case, the ward's estate is pilfered by the guardian, while the ward is isolated in a nursing home against his will, not allowed contact by family members or friends, and eventually dies, bewildered and alone, all with the blessing of the court!"

Some of these critics have personal tales to tell. I don’t doubt their stories or their motives. We all know that abuses happen more often than they should. And I can think of nothing more disturbing than when “helping professionals” exploit those they’re charged to serve. Whether the offenders work for public agencies; private, non-profits; or they’re in private practice; their misdeeds leave colleagues feeling betrayed and demoralized. It casts a shadow on our field and undermines the public’s trust. But the wholesale vilification of the system and those involved, which seems to be accelerating, is deeply troubling.

The censure isn’t just coming from the public. Among professionals too there’s a tendency to impugn “the system” rather than those who corrupt it. And there’s been far too little meaningful discussion about how to fix problems, promote promising practices, offer safe alternatives, and provide the public with accurate and balanced information.

Guardianship was created to protect the vulnerable and prevent abuse and neglect. For the most part, that’s what it does. California’s Administrative Offices of the Court recently released a report, Effective Court Practice for Abused Elders, which includes the findings of a file review of conservatorships. In over 70% of the petitions filed in one county, there were allegations, suspicions by court investigators, or other indications of abuse or neglect by family members, neighbors, businesses, and others. (The report, which was funded by the Archstone Foundation, is available on line at Effective Court Practice.

The stories behind these cases—estates that have been saved and predators who’ve been thwarted--don’t get much attention or make headlines. They are, however, well known to those of us who have seen the system at its best. I admit that many of us in the San Francisco Bay Area are a bit biased as we have some of the best courts, attorneys, and professional guardians around. When I directed the San Francisco Consortium for Elder Abuse Prevention, members of our multidisciplinary team often breathed a collective sigh of relief when a particularly thorny abuse case was referred to the court, where we knew it would be rigorously reviewed.

So how do we go about restoring trust? An important first step, I believe, is to shed light on the system so that we fully understand and can explain both its strengths and shortcomings. To date, we lack such basic information as how many guardianships there are nationally, why they’re established, and how well they’re doing what they’re supposed to.

We also need to dispel damaging and persistent myths and misperceptions. As the quotes above suggest, there’s widespread belief that anyone who has a mental impairment can be placed under guardianship and that courts go “trawling’ for wards. We need to get the word out that while nearly 50% of people over 85 suffer from cognitive impairments, only a small proportion need guardianships. We also need to inform both professionals and the public about who initiates guardianships (not courts), and why—often, it’s because less restrictive legal devices like powers of attorney or trusts have been misused or when APS, police, or emergency personnel discover gravely disabled elders living in horrible conditions as a result of dementias. Once appointed, guardians can remove wards’ assets from wrongdoers’ control, initiate lawsuits to recover misappropriated assets or property, evict wrongdoers from elders’ residences, purchase needed services, authorize medical treatment, and arrange for elders to live in safe places.

Probably the most common complaint against guardianship is that it’s overly restrictive. For that reason, it’s considered the option of last resort. But as I pointed out in “Feel Good Laws or Real Reform?” the fact is, there are few alternatives. Those that are typically cited -- case management, daily money management, powers of attorney, and other advance directives--aren’t really alternatives. They might have circumvented the need for guardianship had they been implemented prior to the onset of incapacity; but once someone loses capacity, it’s too late to execute advance directives, and many social service providers can’t accept clients who are incapable of giving informed consent.

The few options available for those who have already lost capacity include representative payeeship, limited guardianships, and the appointment of surrogate decision makers on a one-shot or temporary basis. Rep payeeship, which can protect clients whose primary income is from public benefits, can be put in place for those who are unwilling or unable to consent. Under Georgia’s Health Care Placement Decision-Maker for An Adult Act, any person can petition the court to authorize placements in long-term care facilities. A few states have “protective custody,” which allows for vulnerable adults to be hospitalized for a few days when they lack capacity to consent to protective services and are in imminent danger or at risk of death. While in “custody,” their capacity and protective service needs are carefully assessed.

California has explored several options, which I discussed in my earlier posting. But for the most part, they’re untested, and many aren’t being used. Some, like Probate Code section 2952, which allows public guardians to freeze the assets of vulnerable elders when there’s cause to believe that they’ve been the victims of financial abuse, are coming into use gradually. Although the statute was enacted years ago, most counties continued to rely on temporary conservatorships (t-cons) in these circumstances. It appears that PGs have been using section 2952 more since the passage last year of a new law that requires courts to complete full investigations of t-cons. California also has a protective custody law, Welfare & Institutions Code Section 15703 - 15705.40, which has only been adopted in a few counties.

Clearly, these options need to be carefully scrutinized. For years, I’ve been calling for a statewide group to identify policy needs and perhaps more importantly, track what laws have been implemented, why some haven’t, how they’re working, and if they need tinkering.

As the population ages, more people are going to need guardianships and safe alternatives. It’s time to seriously address the problems in the system, explore alternatives, dispel myths, and earn the public’s trust and confidence. The longer we wait, the harder it’s going to be to turn things around.