The Role of Community Colleges in an Aging Society

Retooling for an Aging America: Report by the Institute of Medicine; 2008 AGHE Community College Task Force Leadership Document February 22, 2009

The Role of Community Colleges in an Aging Society: An Assessment of the IOM Retooling for an Aging America Report (2008)1

This summary is based on the IOM 2008 Retooling for an Aging America Report, which focuses significantly on healthcare related workforce to meet the older workers needs for services. This report states that the aging of America will require a significant increase of the healthcare workforce. To that end, this Institute of Medicine’s 2008 Report provides recommendations that focus on increasing (1) competence; (2) retention and recruitment; and (3) flexibility for geriatrics care workers. This summary attempts to distill from the Report, special reference to the role of community colleges.

Role of Community Colleges

“Innovative community college programs have great potential for playing a role in both the initial and the continuing geriatrics education of certain professionals. Community colleges may provide career ladder programs for entry-level workers and partner with nursing homes and home health agencies to develop programs for continuing education and refresher courses.” (page 163-164)

“Community colleges have also been essential in the development of many new certificate programs and education courses. Community colleges have the advantage of being able to tailor programs to local needs and state-based requirements and to use approaches that will be most acceptable to workers in that community. Community college programs offer one approach to standardizing curricula for new types of workers who care for older patients and to ensuring the competency of those workers.” (Page 163-164)

Direct Care Workers

One of most important target groups of importance to community colleges is direct care workers. According to the report, this “chapter describes the direct-care workforce—nurse aides, home health aides, and personal- and home-care aides—which is in many respects the linchpin of the formal health care delivery system for older adults. This collection of workers supplies a major portion of the direct care provided to older adults, including the provision of some clinical services plus assistance with bathing, dressing, housekeeping, and food preparation”. Due to the aging of the population, the “plateauing” of the female population and the increased emphasis on home and community- based placements, there will be rapid growth for more direct care workers. Moreover, direct care workers in the future will require more skilled care training to handle increasingly complex client needs as they work more independently.

Direct-care workers are often grouped into three categories: nurse aides (also known as nursing assistants); home health aides; and personal- and home-care aides (Harmuth and Dyson, 2005). Forty-two percent (42%) of direct-care workers care for patients in the home setting, 41% work in nursing homes, and the remaining 17% are employed in hospitals (Smith and Baughman, 2007). Table 1 provides details about the various types of direct-care workers, including their most common employers, the types of services they provide, and typical supervision requirements.

1 Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. The National Press: Washington, D.C. (2008) Retooling for an Aging America: Report by the Institute of Medicine; 2008 AGHE Community College Task Force Leadership Document February 22, 2009

Nurse Aides and Home Health Aides: The occupation of nurse aide goes by a number of job titles, which vary by state, setting, and situation; these titles include certified nursing assistant (CNA), geriatric aide, orderly, and hospital attendant (BLS, 2008c). Nurse aides are employed primarily in nursing homes but also work in other institutional settings, such as hospitals and assisted living facilities. They assist residents with Activities of Daily Living (ADLs), including bathing, dressing, eating, and toileting, and they can perform such clinical tasks as taking blood-pressure readings and, in some states, administering oral medications (Reinhard et al., 2003). These workers have a major role in institutional settings, providing 70 percent to 80 percent of direct-care hours to those older Americans who receive long-term care (Harmuth and Dyson, 2005).

Home health aides (HHAs) are generally hired through a home health agency and assist individuals with ADLs in their homes. They may also assist with food preparation and housekeeping [considered to be 2 of the Instrumental Activities of Daily Living (IADLs)]. Both nurse aides and home health aides provide a degree of clinical services (e.g., wound care) and work under the supervision of a registered nurse (RN).

Personal- and Home-Care Aides: Personal- and home-care aides may work in a group or individual home settings and are somewhat more difficult to classify. These aides may be referred to as personal-care attendants, personal assistants, or direct support professionals, and they may be employed through an agency or hired directly by an individual (BLS, 2008d; Harmuth and Dyson, 2005). They help older adults maintain their independence and remain in their homes and communities by providing assistance with both ADLs and IADLs, providing 70% to 80% of direct-care hours to those older Americans who receive long-term care (Harmuth and Dyson, 2005).

Home health aides (HHAs) are generally hired through a home health agency and assist individuals with ADLs in their homes. They may also assist with food preparation and housekeeping. Both nurse aides and home health aides provide a degree of clinical services (e.g., wound care) and work under the supervision of a registered nurse (RN).

As patients move rapidly away from institutional long-term care and toward home- and community- based settings, they are increasingly relying on direct-care workers to provide needed care, including more complex services than previously provided in these settings. Assisted-living facilities, which are community-based facilities that provide more services than a typical home setting but less than a nursing home, are a rapidly growing option for the residential care of older adults (Lyketsos et al., 2007), and the workers serving patients in these settings (including the patients with more complex needs) are typically personal- and home-care aides rather than home health or nurse aides. There is little to no federal regulation regarding the training or staffing requirements for assisted- living facilities; instead, each state regulates workers in these settings.

Workforce Characteristics: Direct-care workers are overwhelmingly female (89%) and are typically between the ages of 25 and 55, unmarried (including those who are widowed, divorced, or separated), without college degrees, and citizens of the United States (Montgomery et al., 2005; Smith and Baughman, 2007; Yamada, 2002). Approximately 30% of direct-care workers are African American and 15% are of Hispanic or Latino origin (BLS, 2008a), although this can vary by setting and job title. Black women, for example, make up a disproportionately large percentage of the female direct-care workforce relative to their presence in the female workforce overall (29% versus 13%). A second difference is that female direct-care workers are more likely to be single mothers than are female workers in general (24% versus 14%); of those who are single parents, 35% to 40% are below the poverty line (GAO, 2001b). Retooling for an Aging America: Report by the Institute of Medicine; 2008 AGHE Community College Task Force Leadership Document February 22, 2009

Education and Training Requirements: The education and training of the direct-care workforce is insufficient to prepare these workers to provide quality care to older adults. Although there are a number of state and federal requirements for the education and training of nurse aides, home health aides, and personal- and home-care aides, these requirements are minimal (Table 5-4). Many direct-care workers have no more than a high school education, and some have even less (Montgomery et al., 2005; Smith and Baugham, 2007). Minimum training requirements for these workers are often inadequate or non-existent, and they vary across occupational categories and settings of care as well as among states. A number of other training-program characteristics vary among states as well, including the specific qualifications that instructors are expected to have, maximum student/instructor ratios, and the required program approval and oversight processes (AARP, 2006).

This section describes the current requirements for education and training of direct-care workers. Where possible, direct-care education and training issues that are particularly relevant to the older patient population are highlighted.

TABLE 1 - Education and Training Requirements for Direct-Care Occupations

Nurse Aides, Orderlies, and Personal- and Home- Attendants Home Health Aides Care Aides Federal requirements of 75 Per federal rules, if employer receives Dependent on state, hours of training (for nurse Medicare/Medicaid reimbursement, with some requiring no aides); competency evaluation workers must pass competency test (75 formal training; high results in state certification; hours of classroom and practical training school diploma and high school diploma and suggested); high school diploma and previous work previous work experience not previous work experience not always experience not always always required required required SOURCES: BLS, 2008c,d; Fishman et al., 2004.

Other HealthCare Related Fields Possibly Trained at Community Colleges

The Report has also attempted to address various other types of healthcare workers that may be trained at some community colleges. These include Physician Assistants, LPNs and RNs.

Physician Assistants: Physician assistants (PAs) represent an important part of the workforce for the elderly population (Olshansky et al., 2005). PAs work under the supervision of a physician, but they can often work apart from the physician’s direct presence and can prescribe medications and bill for health care services.

PAs are an especially important source of care in underserved areas, where they often act as the principal care provider in clinics, with physicians attending on an intermittent basis. In this vein, they are a potential source of care to meet the increased need that is projected for long-term care settings. Their use may be a particularly attractive strategy since, as with Nurse Practitioners (NPs), the use of PAs has been shown to be cost-effective (Ackermann and Kemle, 1998; Brugna et al., 2007).

The overwhelming majority of the 136 accredited PA programs are located within universities and colleges, but a few exist within hospitals, community colleges, and military institutions. (Page 166). Retooling for an Aging America: Report by the Institute of Medicine; 2008 AGHE Community College Task Force Leadership Document February 22, 2009

LPN: “With about 26 percent of all LPNs working in nursing homes, LPNs are especially important to the care of older adults in long-term care settings (BLS, 2007b). LPNs often provide more hours of care per nursing home resident per day than do RNs (Harrington et al., 2006). LPNs receive about 1 year of training through technical or vocational schools or through junior or community colleges. With experience and training, LPNs may supervise nurse aides. For example, the Institute for the Future of Aging Services is developing a leadership training program to teach LVNs the necessary skills and competencies to be more effective supervisors (IFAS, 2008). Some of the elements of this training include communication, critical thinking, conflict resolution, and cultural competency. Little is known about the geriatric training of LPNs. (Pp. 141)

Associates Degree Nurse Training ... Indeed, community colleges have already been instrumental in the education and training of large parts of the health care workforce for older patients. For example, community colleges educate a large number of the nurses who receive associate degrees (Mahaffey, 2002) (Page 163).

For the next step on the career ladder, LPNs receive online education along with clinical training at local community colleges that prepares them to take the required examination to become RNs. This program has resulted in increased retention, reduced recruitment costs, and decreased worker shortages (CAEL, 2005, 2008). (Page 224)

Other Areas of Opportunity for Community Colleges

The Report has also attempted to review others avenues of training via distance learning, targeting of older workers and grant opportunities from the U.S. Department of Labor.

Distance Education - This section in the Report describes alternatives to traditional education, including the greater use of distance education and community colleges. Distance education is an efficient way to spread geriatric knowledge held by a small number of experts to large numbers of professionals, while community colleges can train certain types of new and existing workers, providing a source of education for some professionals who might have previously received only on- the-job training and also offering a way to standardize training. (Page 162)

Distance-education programs and community colleges are providing viable alternatives for the education and training of many professionals in geriatric principles. The future workforce will likely need to fulfill new roles, be more flexible, and possess new skills. The committee recommends that more be done to increase the breadth of geriatric experiences among health care professionals and to ensure the geriatric competence of all providers. (Page 182)

Older Worker Jobs - The recruitment and retention of older workers may require the creation of positions with fewer physical demands. Parsing CNA responsibilities might enable the productive use of older adults in the workforce who lack the strength to do all CNA tasks. In one example of such an approach, McKesson, a health care services company, has recruited older workers for their call centers to advise patients on medication use (Taylor, 2007). Similarly, strategies to retain existing older workers in clinical positions will likely demand the creation of health care delivery processes that are more ergonomically oriented (Buerhaus et al., 2000). Emerging technologies may assist in this regard (see Chapter 6). (Page 229)

Grant Opportunities from US Dept of Labor - Department of Labor supports Community-Based Job Training Grants that increase the capacity of community colleges to provide training in high-demand industries. Examples include a $2 million grant to Polk Community College in Florida to address the shortage of cardiovascular technologists and technicians to meet the demand from older patients and a $2.1 million grant to Manchester Community College in Connecticut to produce a larger number of graduates in nursing and allied health (DOL, 2006) (Page 164) Retooling for an Aging America: Report by the Institute of Medicine; 2008 AGHE Community College Task Force Leadership Document February 22, 2009

There are a number of programs that help to prepare students for careers in high-growth industries (DOL, 2008b). In March 2008 the DOL awarded $125 million to 69 community colleges, and 24 of these grants (totaling almost $40 million) were for developing workers for the health care industry (DOL, 2008a,d) (Page 209)

Major Challenges for Community College Work with Direct Care Workers

In this last section, I wish to point out that that while community colleges’ forte may be with direct healthcare workers, the Report indicated most of these jobs are of poor quality or dead-end jobs. Consider the following deficits that were identified with these careers:

a. Very low salaries (wages are typically 1/3 the median wage in the U.S.) b. Few benefits c. High levels of physical and emotional stress

Direct-care workers are more likely to live in poverty, to lack health insurance, and to rely on food stamps than other workers (GAO, 2001b). Additionally, these workers have high rates of job-related injury, most often due to overexertion in the care of a patient (BLS, 2007a). All of these factors contribute to the unacceptably high rates of vacancies and turnover among these occupations, which can, in turn, lead to poor quality of care for patients.

1. Given these challenges, the question is whether we can transform “dead-end” to become “entry”? 2. Can we transform low pay to articulate to advance professional levels and career development opportunities? 3. Can we promote difficult, high turnover jobs into career opportunities for long-term advancement? 4. Can community colleges also expand on its flexible models of training with distance education programs? 5. Can Community colleges also promote non-health care careers to serve the older population?

Notes prepared by Cullen Hayashida2 Kupuna Education Center Kapiolani Community College December 29, 2008

NOTE: The Association for Gerontology Gerontology/Geriatrics Standards and Guidelines Document, 2008, outlines curricula guidelines for academic and training programs that may be helpful in designing Community College Programs as related to this report. Contact the AGHE office or the Website www.aghe.org [Publications] to access this document.

2 This is a summary of the 2008 IOM Report that were cut and pasted without proper documentation regarding their location in the original text. It is based on a internal search for all references to community colleges as a method of determining the role of community colleges in an aging society.