Editor`s Opinion: Attention, Graduates: Think about the “Golden” Years

    By the time this issue of Ostomy Wound Management arrives in your mailbox, many readers will have participated in, or witnessed, the spring ritual of graduation.

Congratulations to all — and an especially big welcome to those poised to enter one of the many caring professions. We need you! Graduates hoping to find some good news about healthcare today should look at information regarding healthcare professionals’ job security. If, per chance, you decided to focus your education and professional future on the aging population, you are set for as long as your legs can carry you, regardless of your area of practice or the country in which you live. In the US in 2002, although people ages 65 and older comprise only 13% of the population, this group incurred 45% of hospital inpatient expenditures.1 If current hospitalization trends do not change, total acute care admissions could increase by almost 13 million in the next 25 years — of those, 51% are expected to be older adults who will occupy 59% of the acute care beds.¹

    Meanwhile, the average length of a hospital stay for Medicare enrollees age 65 and older decreased from 8.4 days in 1992 to 5.9 days in 2001, while the number of skilled nursing facility stays increased from 28 to 69 per 1,000 Medicare enrollees.² Yet according to the Centers for Disease Control and Prevention (as reported by the American Public Health Association), of the 650,000 practicing physicians in the US, fewer than 9,000 are geriatricians and that number is expected to drop to 6,000 in the coming years³ — this at a time when the number of people 85 and older, the group requiring more healthcare services than their younger fellow seniors, is expected to increase from 4.2 million in 2000 to 9.6 million in 2030.² For example, in 2002, 1% of 65- to 74-year-olds, 5% of 75- to 84-year-olds, and 19% of persons 85 years of age and older resided in a long-term care facility.² The projected increased need for long-term care services occurs at a time when many states are struggling to maintain (let alone increase) current levels of Medicaid funding. Plus, shortages among nursing home staff are a current and future problem.

    Finally (and fortunately), the vast majority of older adults live in their local communities. Increasingly, social service agencies and health policy analysts are looking to this group of older adults to help ease the demands of home-based and community services. As with all healthcare services, the home health care service sector continues to expand; however, the 1997 Balanced Budget Act caused a dramatic decrease in the number of healthcare visits per Medicare enrollee (from a high of 8,376 per 1,000 Medicare enrollees in 1996 to 2,295 per 1,000 in 2001).² Many community-dwelling older adults do not require nursing care but more than 30% of them need some assistance with activities of daily living or instrumental activities of daily living (eg, light housework, laundry, meal preparation, grocery shopping).² Here, too, the situation is not good. In my own, as well as surrounding counties, local Area Agencies on Aging have long waiting lists of financially eligible people who need help in their homes. While the average income of older adults has increased substantially during the past 30 years, so have costs — particularly some non-discretionary expenses such as housing and medical care. For example, in 1987, older adults at the lowest income levels spent 33.4% of their income on basic housing, compared to 20% for those at the highest income levels. By 2002, these numbers had increased to 40% for the lowest and 28% for the highest income groups.² Similarly, in 2000, Medicare enrollees’ average out-of-pocket expense for prescription drugs was $562 — a significant increase from the $312 average just 8 years earlier.² In 2001, 21% of all Medicare enrollees’ healthcare services were paid out-of-pocket: 80% of dental, 48% of nursing home/long-term care, and 41% of prescription drug costs.

    Additionally, just like many states’ Medicaid budgets, social service budgets at the state and local levels continue to feel the effects of lost revenue and federal funding as the demand for services continues to increase. One response has been to keep wages low — a big mistake, says the Institute for the Future of Aging services in their report “Better Jobs Better Care.”⁴ Low pay results in a high turnover rate at a direct cost of $2,500 per front line worker in long-term care (including home and community-based care). According to the Better Jobs Better Care program, funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies, evidence suggests that turnover in long-term care costs government payors roughly $2.5 billion. This figure does not include increased healthcare costs due to lower care quality for consumers or higher injury-related medical costs for workers.⁴

    While research to increase our understanding of turnover rates (and their cost) is needed, agencies would be wise to immediately invest in existing proven retention strategies. Of course, this does not begin to address current and future needs for caregivers and healthcare professionals. Curriculums in nursing, public health, and medicine must include more emphasis on aging-related issues and encourage students to study aging. Some demonstration projects to increase the quality of long-term care are already underway and some programs have changed. Nevertheless, policy revisions and research, among other types of study, to examine the effects of Medicare and Medicaid changes on recruitment and retention are still needed. Also needed are millions of feet to fill the shoes of caregivers and healthcare providers for the elderly. At this time, strategies to fill these shoes must range from broad public policy changes to creative solutions for recruiting “young” older adults to help others age in place. Strategies should include a range of programs, from developing effective programs that delay to providing rehabilitation services that reduce the deleterious effects of chronic disease and disability.

    Thus, new graduate, whether you are interested in acute, long-term, home, community-based, or public healthcare, job security is in your future, especially if you have or plan to acquire the knowledge needed to work with older adults. Welcome! We’re glad you’re here.

1. National and local impact of long-term demographic change on inpatient acute care: a report from Solucient, LLC [white paper].2002. Available at: http://www.solucient.com/forms/demochange.shtml. Accessed on May 9, 2005.

2. Key indicators of well-being. Federal Interagency Forum on Aging-related Statistics. Washington, DC: US Government Printing Office. November 2004. Available at: http://www.agingstats.gov. Accessed May 9, 2005.

3. Krisberg, K. Public health workforce not prepared for aging population. The Nation’s Health. 2005;May:1,20-21. Also available at: http://www.thenationshealth.org.

4. Institute for the Future of Aging Services. Better Jobs Better Care. 2004. Available at: http://www.bcbj.org. Accessed on May 6, 2005.