Learned Gerontology Skills
Elder Care: A Need for Learned Gerontology Skills for Informal
& Direct Care In-Home Health Aides.
Submitted in partial fulfillment of the requirements for
Cynthia K. Magelitz:
Introduction to the US Healthcare System
Shepherd University
MBA Studies: Health Concentration
11/20/2013
Elder Care: a Need for Learned Gerontology Skills for Informal
& Direct Care In-Home Health Aides.
I. Late Adulthood Years
A. Gerontology
B. Working With the Aging
C. A Growing Industry
II. Cost of In-Home Health Care
A. Expansion and Care
B. Medicare and Medicaid
C. Out of Pocket Cost
III. Legislation to Support Caregivers
A. In-Home Care Assessment
B. Direct Care: Federal and State
C. Family Caregiver …show more content…
Support
IV. Conclusion
Introduction: Late Adulthood Years In 1990, the Census Bureau recorded the senior population a little over 3 million. In 2010, the senior population was recorded at roughly 40 million. A significant growth in twenty years. The senior population for the United States is expected to continue to increase as the baby boomers of the past century turn sixty-five. The Elderly population has risen steadily in the last decade and is expected to continue to grow well into the twenty-first century. Those in the field of Gerontology and Geriatrics roughly estimate that by the year 2030, the senior population may climb to seventy million. Age related agencies and organizations express that a large portion of the senior population will be elderly, 85 and over. Activities of daily living may become a concern for many aging seniors and their families. The late adulthood years of life bring multiple facets in change such as; interpersonal problems, emotional instability, financial changes and social changes. Recognizing the reality of family life today, defining in-home elder care can mean a whole range of individuals as informal in-home care; family, friends, and neighbors, taking care of the elderly loved one, to the skilled direct care; Certified Nursing Assistance, Certified Home Health Aides, and Certified Personal Care Aides. There is a growing need for a skilled workforce in the areas of aging. The rising need for continued education with in-home elder care training through state agencies, organizations, and private care providers is important for preventing or reducing medical error, the possibility of accidental death, and or premature placement in nursing or assistant living home. Many seniors maintain residence in their homes and may find the need for informal and or direct in-home care to help with their ADL’s. The needs of this growing population with in-home care will need individuals who have been educated and continue to receive training in gerontology and geriatric skills for in-home care. In-home direct care services specialize in providing skilled nursing services and personal care aides. Educational institutions will have to make strides along with elder care agencies; state and private, to increase gerontology curricula for future elder care needs.
For many seniors it could be an understatement that aging may seem more of a burden than something to celebrate. In late adulthood successful aging means staying healthy while advancing in age. Enjoying gratifying activities and maintaining meaningful relationships. For many senior adults this is a truism, but for many others the onset of Alzheimer’s, depression, illness and injuries may have many seniors wondering how long they really want to live with their medical condition, (Furukawa, C., Shomaker, D. 257). Gerontologists study the impact of these aging issues on both the senior community and the senior individual. Age based advocacy groups such as; Advocacy Group for Elder, (AGE), Senior Life Services, and AARP, have increased the political and public perception of issues that face today’s senior population, (Hooyman, N., Kiyak, H. 5). Gerontology professionals can work in fields of social work, physical and occupational therapy, nursing, and direct in-home care. Those pursuing a career working with the elderly should have a strong ability to connect with senior adults, handle difficult situations such as but not limited to; Alzheimer’s, incontinence, and eyesight and hearing issues. Also, individuals who choose this field of study should be creative, emotionally stable, encouraging, and have good communication skills. According to Boston.com, by the year 2016, some of the fastest growing occupations in the United States will be in direct in-home care. Direct PCA’s do not have to have an advanced degree beyond a high school diploma but will be required to receive training by experienced aides or nurses. Also required will be monthly classroom instruction and workshops depending on state regulations for direct care training. The individuals who choose to become a Certified Nursing Assistant and depending on the state, require formal training which can be completed in 24 months or less through a community college, or health care agency. Both jobs are at the lowest level of the pay scale and sometimes net only minimum wage in some states. Medical advances have given many seniors a chance to live longer and healthier lives giving a rise to a fast growing industry. Unlike the needs of the younger generation, seniors in their late adulthood worry about their needs including the benefits of good health. But, by its own nature, aging is open-ended and aging becomes the price to pay in society for elderly individuals who want a simple life, (Furukawa, C., Shomaker, D. 98). Many young adults do not think about old age and many of these young adults may have thoughts of the elderly as a debilitated individual, almost always disagreeable, and possibly a burden. Yet within their own families the elderly relative may be the comfort of affection and care. Attitudes towards the elderly form early in childhood. The younger generation is not concerned with aging and may harbor a negative view of elderly individuals. Although attitudes toward aging and the elderly has improved over the decade partly because of public policy and age based advocacy groups, (Hooyman, N., Kiyak, H. 334). To achieve workable solutions those that work for this growing industry must understand the needs of the elderly population and the changing nature of elderly in-home care. As the senior population continues to grow the need for innovated in-home elder care services across the nation is growing in demand due to the number of seniors still living in their home. Florida has the highest percentage of seniors over 65, and West Virginia comes in a close second. The highest increase county wise varies; Douglas, Colorado has the largest population per county to Henry, Georgia with a senior population that falls under 100,000. The overall population of seniors in the United State is over 12% of total population. (U.S. Census Bureau, 2012). According to the National Alliance for Caregiving, and AARP, nearly one out of every four homes in the U.S, has informal or direct care giving to persons aged 50 and over. Close to 95% of elder in-home care givers are family members, (U.S. Department of Labor, 2010). The bureau of Labor statistics reported off their data from the American Time Use Survey, that nearly 39.6 million people, age 15 and over, provide unpaid elder care. The majority of these care givers are women. Close to 80% of elder care providers are not related to the family. In a national public opinion poll taken in the late nineties by the National Partnership for Women and Families, reported that over 50% of Americans would more than likely be responsible for their elderly relative through the next ten years, (Seaward, M.R., 1999). In the 21st century the term sandwich generation is not a new concept but a growing issue. The sandwich generation is the adult children of the elder parent who have full-time lives. The cost of the sandwich generation is much more than monetary. Adult children find that working full-time, and help maintain their elder parent/relative schedule is not always feasible. Adult children who are the main care giver for their aging parent/relative may find that their own family; children, husband, grandchildren, do not understand the amount of time spent with taking care of their aging parent/relative, and may not be willing to help. Although this form of care giving is not unheard of increased attention is being paid to the sandwich generation due in part that more middle aged adults still have living parents in the 21st century, (Pierret, C.R. 2006). Many adult children who find themselves having to care for their elderly loved one spend on average an additional 20 hours a week helping with basic ADL’s, and doctor appointments. The cost of informal care giving will always include the sacrifice of time and possibly the health of the care provider. An AARP study revealed that a high percentage of care givers have needed to take time off, come in late, reduce working from full-time to part-time or quit working altogether, (Seaward, M.R. 1999). Many adult children simply cannot afford to quit their job, reduce their hourly income, or provide the amount of time needed in helping their elderly loved one. It becomes a task for some in finding good and affordable care. Medicare estimates that roughly 5 million community dwelling seniors meet the definition of home bound, which restrict the seniors ability to perform ADL’s without the assistance of an aide, (Meyer, R.P., M.D. 2009). Home health programs vary and some studies suggest that medical care at home may contribute to shorter hospital stays and unnecessary move to a nursing home. It is true that not all seniors have the same needs and overall, a small percentage of senior adults over 70, is institutionalized, (Berk, L.E. 590). In the United States billions of dollars are spent yearly to provide care for the elderly. To reduce institutionalized care many seniors and their families are turning to alternatives for long-term at home care, (Van Steenwyk, J. 2003). With the increase of the elder population much of the focus in the field of gerontology is providing alternatives to institutional care. Many seniors find that their pride stands in the way for getting help. For many there may be a lack of knowledge with services offered in their community, the lack of eligibility requirements for any provision of services, and gaps in services provided through private organizations in their community. Family members who become involved with their elderly relatives care will find that the cost of maintaining the aging individual through direct in-home care may be cheaper than the total cost of an institution, (Weiner, M.G., Brok, A.J., Snadowsky, A.M. 198). Nationwide, senior care programs and services are fragmented and inadequate. Social Security, Medicare, and Medicaid are examples of programs that have suffered funding cuts for senior care and because of cuts in these services elderly individuals become their own advocate. Many elderly find self-advocacy extremely difficult and may not get the help needed which may lead to moving into a nursing home either from their own neglect, extended hospital stay, or the lack of family involvement. Most communities have services aimed at the senior population; transportation assistance, Meals on Wheels, and home-health delivery services. Expansion of the existing services is needed to optimize support for the elderly, their families and the primary care giver. In the early seventies Social Security benefits were expanded and the system of tracking benefits for inflation, the cost of living adjustment, was established. COLA is designed to protect individuals who receive SS from inflation and with a majority of seniors as SS recipients many have seen their buying power continue to deflate. The COLA increase for 2012 was 1.7%, (Hurley, Miles, 10/19/2012). For the year 2014, President Obama has proposed the Chained Consumer Price Index to reduce long term SS costs and will affect low income senior more so than high income seniors who may have other income. According to AARP, switching to CCPI will reduce the COLA’s by a significant percentage yearly. In the long run lower income seniors will face harder choices between paying for food, medicine, and utilities, (Rosenburg, Y. 2012). The cost of getting older just may be the most expensive phase of late adulthood. Many seniors have the use of Medicare; some seniors have both Medicare and Medicaid. Medicare is limited for long-term care such as; extended stays in nursing homes for physical and occupational therapy, home health benefits such as; physical therapy, and direct care provided by skilled nurse or a home health aide. By 2020, cost of government sponsored health insurance for the elderly is expected to double. Seniors over the age of 80, receive over 70% more benefits than younger senior adults, (Berk, L. 577). Elderly individuals who become ill may be incapacitated for weeks with several days spent in bed, or hospitalized. Close to 20% nursing home placements are incompatible with the elderly needs in which home-care is advocated to be the better alternative. It is estimated that nearly 50% of the elderly who must stay in a nursing home or assistant living facility for rehab purposes are able to return home, (Hooyman N.R., Kiyak, H.A. 724). Medicare has responded to the need of in-home care under certain conditions and usually under restricted conditions. Eligibility for Medicare home health benefits are:
1. The individual must be under a doctor’s care and getting services under a plan of care established by the doctor.
2. A doctor must certify that the individual needs skilled in-home nursing care.
3. The home health agency hired to care for the individual must be Medicare certified.
4. The senior individual must be certified home bound by a primary physician.
5. The senior must require only short-term care.
6. Medical equipment and all services must have a plan for recovery and all skilled services are medically necessary, (Furukaua, C. Shomaker, D. 103).
Hours and days of services provided by Medicare is limited and rarely goes over 21 days. Elderly individuals who have treatments through a Medicare approved home health agency will find that their out of pocket cost is reasonable because the agency is paid through Medicare. Expenses not paid by Medicare can often be paid by Medicaid. Unlike Medicare that assists mostly those over the age of 65, Medicaid assist the needy of all ages, (Furukaua, C., Shomaker, D. 98). Medicaid home care service must be provided by:
1. Medicaid certified home health agency.
2. Medicaid will provide semi-skilled and unskilled assistance with basic ADL’s.
3. Low in-come seniors who need home health care must meet income eligibility and require more than homemaker services, (Hooyman, N.R., Kiyak, H.A. 739). All states must have either one of two options to offer the low in-come elderly adult; Personal Care Services or Home and Community based Waiver Program, (U.S.
Department of Health and Human Services. 2013). The Medicaid Waiver Program has several core services: Case management, homemaker, home health aide, personal care, adult day care, rehabilitation, and respite care, (Hooyman, N.R., Kiyak, H.A. 739). Medicaid can cover long-term services provided by in-home aides three different ways: Under the Mandatory Home Health State Plan Benefit, the Personal Care Services Optional State Plan Benefit, and Home and Community Based Waiver Program. Only a handful of states finance a small amount of long-term home attendant care under the Home Health Benefit. Most states offer personal assistance services through the Personal Care Services Optional State Plan Benefit, (U.S. Department HHS. 2013). Most if not all are required to provide personal care services through state licensed home care agencies and many states allow the consumer to hire the PCA. For the consumer there is the freedom of choice built into the Medicaid program for home health care but are only extended to qualified providers of in-home care and leaves it up to each state to spell out the …show more content…
qualifications. Recorded in 2007, over 50% of national health care cost came from out of pocket, (Kovner, A.R., Knickman, J.R. 17). From 2007 to 2009, individuals between the ages of 65-74, out- of -pocket health expense averages close to $5000.00, roughly 11.4% of total out of pocket expenditures. Health insurance cost for seniors in this age group was a little over $3000.00, and health insurance coverage was at 62%. For the age group 74 and over, from 2007to 2009, seniors spent $127.00 less in out of pocket expense, yet was higher by 3.7% in total health care out of pocket expenditures. Insurance cost less by $31.00 dollars. And with this age group, health insurance coverage is 1% higher than those under the age of 74, (U.S. Census Bureau, Statistical Abstract of the US, 2012). Old age and the end of the working career bring financial changes and a feeling of uncertainty especially if the senior individual did not plan for retirement, or an illness/injury. Financial dilemmas especially with aging and the chance of something serious to disrupt the flow of ADL’s can become a considerable impact on the retirement income. Even though services through Medicare and Medicaid are offered to offset out -of -pocket medical cost these insurances are limited. The levels of out-of –pocket spending will vary greatly depending on the status of the elderly individual; marital status or single status. Single elderly individuals will spend whatever assets they have on medical cost more frequently than elderly individuals who are married, (Rosenburg, Y., 9/10/2012). Most elderly individuals do not plan on suffering from a late term disease such as Alzheimer’s. Nor do they plan on having a stroke, breaking a hip or suffering a heart attack. Therefore elderly individuals do not plan to pay for high out-of-pocket cost towards the end of their life and may find themselves cash strapped when there is a health care emergency. Medicare provides some relief to medical cost but Medicare does not cover co-payments, deductibles, extended homecare services, and extended non-rehabilitate nursing care, (Rosenburg, Y., 09/10/2012). According to a study by the Center for Retirement Research at Boston College, elderly couples over the age of 65 would need to save over $200 thousand dollars to pay for out of pocket medical cost, and more money just in case a nursing home is needed. Many seniors will face catastrophic out-of-pocket medical expenses that exhaust their saving, (Malone, R., 3/10/2010). More and more families in the U.S. are caring for an aging parent or loved one. Some finding the task to be a great burden. Whatever the circumstances surrounding the needs there are federal policies in place that are support systems for family care givers. The Family Medical Leave Act, (FMLA), and The National Caregiving Support Program, (NFCSP). When a family member resumes responsibility as the informal care giver of their elderly loved one usually affects the whole of their life. FMLA allows employees who have taken on the responsibility of caring for their elderly relative up to 12 weeks annually of unpaid leave. FMLA does provide security in job protection but only 60% of the private sector workforce is eligible for FMLA, (Malone, R., 2010). A barrier to FMLA is the unpaid nature of leave, and will only benefit those who can afford to go without wages for a significant amount of time. The Labor Department conducted a survey in 2013, and found that 17% of employees who did take FMLA received partial pay and 48% received full pay if the days taken off were less than 10, (Tyson, L., 2013). Researchers at the center for American Progress have introduced a plan to provide all workers with access to paid FMLA. This plan would be through SS and called Social Security Cares. SSC is a family and medical leave insurance program, (Tyson, L., 2013). SSC would be operated through SSA and would be paid for through a small increase in SS taxes. Since 2007, California has offered paid leave with 26 states to follow suit with some form of paid FMLA, (Hooyman, N.R, Kiyak, H.A, 401). Those who advocate paid FMLA suggest that employers will face less turn over and fewer paid sick days. Informal caregivers will gain peace of mind and may experience much less stress. In 2000, The National Caregiving Support Group developed out of and is funded by the Department of Administration of Aging, (AOA). NFCSP helps not only the elderly but care givers as well. States are expected to partner with local agencies that focus on aging and elder care. NFCSP provides grants to states based the population that is 70 and over, by funding support for families who are in need of direct in-home care givers for a long as needed. All states are different and have flexibility on services provided to their aging population. Each state has an organized Senior Life Services provided by the states Bureau of Senior Services. Under NFCSP, states are required to offer different programs for direct in-home care.
1. Each state must have information about care giving services.
2. Assistance for informal care givers through Senior Life Services.
3. Individual and group counseling for informal and direct care givers.
4. Respite Care.
These services help low income families and seniors reduce stress, and avoid or even delay institutional care, (AOA. 2013). In the state of West Virginia the Bureau of Senior Services offers several programs;
1. Lighthouse.
2. FAIR, (Family Alzheimer’s In-home Respite).
3. Private Care.
4. LIFE, (Legislative Initiative for the Elderly).
5. Medicaid Aged and Disabled Waiver.
6. Medicaid Personal Care.
7. West Virginia Transition Initiative.
Each program offered is designed in helping low income seniors. Eligibility is decided by the agencies Registered Nurse. Medical eligibility is determined by the ADL’s the elder is capable of performing on their own. A financial sliding fee is based on monthly income. A recipient who chooses not to disclose income may be charged the private payer fee. The RN determines if a referral to a program is indicated with completion of the program application and the RN client assessment form. The RN signature insures eligibility for all programs. Once the elderly client is approved through the assessment process a Certified PCA and or CNA depending on the clients health needs is assigned. PCA’s and CNA’s provide support and ADL service that allow the elder adult to reside comfortably in their homes, and continue if able to participate with activities outside of the home. Direct care aides have many titles; personal assistant, direct support professional, and in-home care provider. Surveys taken by senior adults reported that a high percentage would prefer to age gracefully in their own home over being institutionalized for their end years, (Hooyman N.R., Kiyak, H.A. 453). Another reason that seniors rather stay in their home leans toward cost consideration especially for those living on limited resources. In the last decade in-home care service has grown rapidly and is expect to continue this growth due to seniors living longer into their elder years and the residential options senior adults have to choose from. In-home care is now constituted as one of the fastest growing occupations in the U.S., (Marquand, A. 2012). Education in gerontology skills along with certification is going to be required for employment with a majority of elder care organizations, and state Medicaid programs: Medicaid State Plan Personal Care, and Medicaid Waiver Programs, (Marquand, A. 2012). As the nations senior population continues to increase, health care organizations, and health care workers such as; doctors, nurses, physician assistants, social workers, CNAs and PCA’s will be in demand. The American Geriatrics Society believes the field of Gerontology may experience a shortage in elder care professionals in the geriatric profession for the future senior population growth, (Hart, A. 2002). Direct care workers become almost like family as a primary provider of the in-home elderly care, yet many of these direct in-home care providers are under paid by the agencies and organizations they represent. CNA’s and PCA’s are expected to be compassionate in their care, patient, and have knowledge of best practices in coping with problems such as; eating, sleeping, becoming confused and falls as part of the everyday task of taking care of an elderly client, (Hart, A. 2002). CNA’s and PCA job performance may reflect on the type of care some clients will receive due to limited training and inadequate supervision, and low pay. Most direct care givers work independently and are trusted to make daily decisions about the care of the elderly client. Turnover rate in this field is very high, which causes disruptions in the continue care and cost to providers through recruitment, training, and lost productivity, (Hooyman, N.R., Kiyak, H.A. 416). In 2001, a report written by the Institute of Medicine indicated that direct care providers must continue to be educated, and train their staff with gerontology skills, (Hart, A. 2002). California, Oregon, and Washington are the only states to have a labor union work force for private direct care workers. Through Medicaid, CNA’s must be certified. Although there is not a federal training standard for PCA’s who are employed by publicly funded programs, (Marquand, A. 2012). PCA training varies from state to state which leads to a significant difference in the level of skills and pay around the nation. The IOM recommends that individuals training as PCA’s must take 120 hours of training as a direct care worker. As of 2013, only the District of Columbia and a handful of states meet this requirement, (Marquand, A. 2012). The position of the PCA is preferred to have a high school diploma. The individual must have reading comprehension and math skills, knowledge of personal care, good judgment, and patience. Educational requirements for PCA training standards in most states are; CPR, first aid, and OSHA standards for in-home care. State agency training requires 32 hours of paid training and monthly mandatory training workshops up to 18 months in order for new hires to earn a certification as a PCA in the state. A state agency trained PCA is expected to recognize a learned helplessness with their client and is also expected to help their client by promoting self-care. Training also includes behavior appropriate to the elderly client’s condition and age, and the PCA is expected to provide a safe clean environment, (Hart, A. 2002). Nationwide key findings conclude that without federal standards, states control and implement an assortment of PCA training requirements. Some states better than others and with many states having very little training requirements to be qualified as direct care PCA, (Marquand, A. 2012). Most states provide personal assistance services through the Medicaid State Plan and one or more Medicaid HCBS waivers. West Virginia legislation in 2012, through the Bureau of Senior Services instituted educational standards of certification for in-home direct care workers.
The state of California has a Medicaid State Plan and waiver programs that do not require training for agency employed direct care aides. Even though California is awarded federal grant money to develop a training and certification program for PCA’s as part of the Personal and Home Care Aide State Training Program, a provision of the ACA. In the District of Columbia, PCA’s are required to have a certification as a home health aide, 120 hours of training and pass a competency evaluation. The District of Columbia does not offer directed services under Medicaid, (Marquand, A. 2012). A report released by the IOM in 2008, emphasized that there is a poor retention of direct care workers, a 70% turnover rate nationwide due to low wages compared to high expectation and level of care within the job requirement. Roughly 60% of direct care workers stay on the job for more than 12months but less than 24, (IOM, 2008). Through this report the IOM indicates that direct care workers, state and private have minimal training in long term in-home elder care. In 2010, HHS Secretary Sebelius announced that $320 million grant dollars was assigned to strengthen the health care workforce through the ACA. Of this grant $4.2 million will be used for the Personal and Home Care Aide State Training Program. The program is to support states in
developing and evaluating a competency based training program for qualified individuals to become PCA’s, (U.S.HHS, 9/13/10). Many aging seniors who are in need of help with their ADL’s find themselves having to rely on friends and or neighbors to help them with their quality of life. Especially if their family does not live in the area or the senior does not have family. The National Alliance for Caregiving reported in 2010, that over 60 million people in the U.S serve as informal caregivers, with a majority of the care givers as non-family members,(Empire BlueCross BlueShield, 8/3/10). Informal care givers provide unpaid assistance to the elderly individual which may lead to medical errors. Research on informal care givers shows a high percentage of these individuals become highly stressed, very emotional, and display signs of physical burden, (Donelan K., Hill, C.A., Hoffman, C., Scoles, K., Feldman, P.H., Levine, C., Could, D., 2002). In data from a national survey conducted on informal caregivers by the Harvard School of Public Health and National Opinion Research Center, over 50% of informal care givers who helped with ADL’s received no formal training with task involved in elderly care giving; bathing, feeding, lifting, and using the toilet, (Donelan, K., Hill, C.A., @ el, 2002). An obstacle that prevents many informal care givers is the Health Insurance Portability and Accountability Act, (HIPPA). The health care system does not make it easy. Informal caregivers may be considered family to their elderly friend or neighbor but unless the informal care giver has authorization to disclose personal health information or Power of Attorney, medical issues may be a problem. The informal care giver needs to be able to retrieve information in case of a medical emergency. They need to know where to find insurance information, a list of doctors including specialist, a list of medicines and dosages, and information about the elderly relative, friend, or neighbor. For the informal care giver this lack of information can create a burden of taking care of their family, friend, or neighbor. In a report the IOM released in 2008, Retooling for an Aging America: Building the Health Care Workforce, sited that the unpaid informal care giver was not a new perspective of care giving but needed to be included in the definition of the health care workforce, (Levine, C., Hapler, D., Peist, A., Gould, D.A., 2010). This report also reveled that integrating the informal care giver into the workforce has yet to be fully discussed at a national level. Professional long-term care providers, federal and state agencies site that it may be a challenge breaking through old habits of an already established care giving routine, along with financial and professional barriers, (Levine, C., Halper, D. @ el, 2010). Age related agencies and organizations are aware of the growing population that is quickly shifting to informal care giving causing the concern for the potential for medical errors, (Hart, A. 2002). Public and national policy has traditionally viewed the informal care giver position as personal, moral obligations more so than an extension to the U.S. workforce, (IOM, 2008). Public policy focuses on controlling expenditures on nursing homes, and assistant living facilities due to the high percent of cost that is paid through Medicaid. The saving of money over shadows the positive efforts to support informal care givers.
In conclusion; the elderly population will continue to grow with an estimated 70 million by 2030. This growth in population will increase the need for more individuals to study in the field of Gerontology and Geriatrics. The rising need for continued elder care training through state agencies, organizations, and private care providers, and support training for informal care givers is important in preventing or reducing medical error, and possibly accidental death. A high priority on the agenda of policymakers should be measures to reduce re-hospitalization with elderly individuals, delay or avoid nursing home and or assisting living placement before exhausting other housing alternatives, improve transitional care, and mandatory training and support nationwide for informal care givers. Economic factors are an important issue in public policy formulations in the issues of direct and informal care giving such as but not limited to: health expenditures, inflation and cost of effectiveness. Those who are concerned and work with the aging are an important contribution to improving the health and well being of the elderly and therefore attention to areas of additional research in gerontology practice and enhanced educational studies in the field of gerontology and geriatrics should be a priority in the future for the health care industry in order to have a better skilled workforce with in-home elder care.
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Weiner, M.B., Brok, A.J., Snadowsk, A.M. (1987). Working with the aged: Practical approaches in the institution and community Norwalk, Connecticut. Appleton Century Crofts. P. 198
West Virginia Senior Services. (2009). Help at home. Retrieved from http://www.seniorservices.gov/tabid/56/default.aspx
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& Direct Care In-Home Health Aides.
Submitted in partial fulfillment of the requirements for
Cynthia K. Magelitz:
Introduction to the US Healthcare System
Shepherd University
MBA Studies: Health Concentration
11/20/2013
Elder Care: a Need for Learned Gerontology Skills for Informal
& Direct Care In-Home Health Aides.
I. Late Adulthood Years
A. Gerontology
B. Working With the Aging
C. A Growing Industry
II. Cost of In-Home Health Care
A. Expansion and Care
B. Medicare and Medicaid
C. Out of Pocket Cost
III. Legislation to Support Caregivers
A. In-Home Care Assessment
B. Direct Care: Federal and State
C. Family Caregiver …show more content…
Support
IV. Conclusion
Introduction: Late Adulthood Years In 1990, the Census Bureau recorded the senior population a little over 3 million. In 2010, the senior population was recorded at roughly 40 million. A significant growth in twenty years. The senior population for the United States is expected to continue to increase as the baby boomers of the past century turn sixty-five. The Elderly population has risen steadily in the last decade and is expected to continue to grow well into the twenty-first century. Those in the field of Gerontology and Geriatrics roughly estimate that by the year 2030, the senior population may climb to seventy million. Age related agencies and organizations express that a large portion of the senior population will be elderly, 85 and over. Activities of daily living may become a concern for many aging seniors and their families. The late adulthood years of life bring multiple facets in change such as; interpersonal problems, emotional instability, financial changes and social changes. Recognizing the reality of family life today, defining in-home elder care can mean a whole range of individuals as informal in-home care; family, friends, and neighbors, taking care of the elderly loved one, to the skilled direct care; Certified Nursing Assistance, Certified Home Health Aides, and Certified Personal Care Aides. There is a growing need for a skilled workforce in the areas of aging. The rising need for continued education with in-home elder care training through state agencies, organizations, and private care providers is important for preventing or reducing medical error, the possibility of accidental death, and or premature placement in nursing or assistant living home. Many seniors maintain residence in their homes and may find the need for informal and or direct in-home care to help with their ADL’s. The needs of this growing population with in-home care will need individuals who have been educated and continue to receive training in gerontology and geriatric skills for in-home care. In-home direct care services specialize in providing skilled nursing services and personal care aides. Educational institutions will have to make strides along with elder care agencies; state and private, to increase gerontology curricula for future elder care needs.
For many seniors it could be an understatement that aging may seem more of a burden than something to celebrate. In late adulthood successful aging means staying healthy while advancing in age. Enjoying gratifying activities and maintaining meaningful relationships. For many senior adults this is a truism, but for many others the onset of Alzheimer’s, depression, illness and injuries may have many seniors wondering how long they really want to live with their medical condition, (Furukawa, C., Shomaker, D. 257). Gerontologists study the impact of these aging issues on both the senior community and the senior individual. Age based advocacy groups such as; Advocacy Group for Elder, (AGE), Senior Life Services, and AARP, have increased the political and public perception of issues that face today’s senior population, (Hooyman, N., Kiyak, H. 5). Gerontology professionals can work in fields of social work, physical and occupational therapy, nursing, and direct in-home care. Those pursuing a career working with the elderly should have a strong ability to connect with senior adults, handle difficult situations such as but not limited to; Alzheimer’s, incontinence, and eyesight and hearing issues. Also, individuals who choose this field of study should be creative, emotionally stable, encouraging, and have good communication skills. According to Boston.com, by the year 2016, some of the fastest growing occupations in the United States will be in direct in-home care. Direct PCA’s do not have to have an advanced degree beyond a high school diploma but will be required to receive training by experienced aides or nurses. Also required will be monthly classroom instruction and workshops depending on state regulations for direct care training. The individuals who choose to become a Certified Nursing Assistant and depending on the state, require formal training which can be completed in 24 months or less through a community college, or health care agency. Both jobs are at the lowest level of the pay scale and sometimes net only minimum wage in some states. Medical advances have given many seniors a chance to live longer and healthier lives giving a rise to a fast growing industry. Unlike the needs of the younger generation, seniors in their late adulthood worry about their needs including the benefits of good health. But, by its own nature, aging is open-ended and aging becomes the price to pay in society for elderly individuals who want a simple life, (Furukawa, C., Shomaker, D. 98). Many young adults do not think about old age and many of these young adults may have thoughts of the elderly as a debilitated individual, almost always disagreeable, and possibly a burden. Yet within their own families the elderly relative may be the comfort of affection and care. Attitudes towards the elderly form early in childhood. The younger generation is not concerned with aging and may harbor a negative view of elderly individuals. Although attitudes toward aging and the elderly has improved over the decade partly because of public policy and age based advocacy groups, (Hooyman, N., Kiyak, H. 334). To achieve workable solutions those that work for this growing industry must understand the needs of the elderly population and the changing nature of elderly in-home care. As the senior population continues to grow the need for innovated in-home elder care services across the nation is growing in demand due to the number of seniors still living in their home. Florida has the highest percentage of seniors over 65, and West Virginia comes in a close second. The highest increase county wise varies; Douglas, Colorado has the largest population per county to Henry, Georgia with a senior population that falls under 100,000. The overall population of seniors in the United State is over 12% of total population. (U.S. Census Bureau, 2012). According to the National Alliance for Caregiving, and AARP, nearly one out of every four homes in the U.S, has informal or direct care giving to persons aged 50 and over. Close to 95% of elder in-home care givers are family members, (U.S. Department of Labor, 2010). The bureau of Labor statistics reported off their data from the American Time Use Survey, that nearly 39.6 million people, age 15 and over, provide unpaid elder care. The majority of these care givers are women. Close to 80% of elder care providers are not related to the family. In a national public opinion poll taken in the late nineties by the National Partnership for Women and Families, reported that over 50% of Americans would more than likely be responsible for their elderly relative through the next ten years, (Seaward, M.R., 1999). In the 21st century the term sandwich generation is not a new concept but a growing issue. The sandwich generation is the adult children of the elder parent who have full-time lives. The cost of the sandwich generation is much more than monetary. Adult children find that working full-time, and help maintain their elder parent/relative schedule is not always feasible. Adult children who are the main care giver for their aging parent/relative may find that their own family; children, husband, grandchildren, do not understand the amount of time spent with taking care of their aging parent/relative, and may not be willing to help. Although this form of care giving is not unheard of increased attention is being paid to the sandwich generation due in part that more middle aged adults still have living parents in the 21st century, (Pierret, C.R. 2006). Many adult children who find themselves having to care for their elderly loved one spend on average an additional 20 hours a week helping with basic ADL’s, and doctor appointments. The cost of informal care giving will always include the sacrifice of time and possibly the health of the care provider. An AARP study revealed that a high percentage of care givers have needed to take time off, come in late, reduce working from full-time to part-time or quit working altogether, (Seaward, M.R. 1999). Many adult children simply cannot afford to quit their job, reduce their hourly income, or provide the amount of time needed in helping their elderly loved one. It becomes a task for some in finding good and affordable care. Medicare estimates that roughly 5 million community dwelling seniors meet the definition of home bound, which restrict the seniors ability to perform ADL’s without the assistance of an aide, (Meyer, R.P., M.D. 2009). Home health programs vary and some studies suggest that medical care at home may contribute to shorter hospital stays and unnecessary move to a nursing home. It is true that not all seniors have the same needs and overall, a small percentage of senior adults over 70, is institutionalized, (Berk, L.E. 590). In the United States billions of dollars are spent yearly to provide care for the elderly. To reduce institutionalized care many seniors and their families are turning to alternatives for long-term at home care, (Van Steenwyk, J. 2003). With the increase of the elder population much of the focus in the field of gerontology is providing alternatives to institutional care. Many seniors find that their pride stands in the way for getting help. For many there may be a lack of knowledge with services offered in their community, the lack of eligibility requirements for any provision of services, and gaps in services provided through private organizations in their community. Family members who become involved with their elderly relatives care will find that the cost of maintaining the aging individual through direct in-home care may be cheaper than the total cost of an institution, (Weiner, M.G., Brok, A.J., Snadowsky, A.M. 198). Nationwide, senior care programs and services are fragmented and inadequate. Social Security, Medicare, and Medicaid are examples of programs that have suffered funding cuts for senior care and because of cuts in these services elderly individuals become their own advocate. Many elderly find self-advocacy extremely difficult and may not get the help needed which may lead to moving into a nursing home either from their own neglect, extended hospital stay, or the lack of family involvement. Most communities have services aimed at the senior population; transportation assistance, Meals on Wheels, and home-health delivery services. Expansion of the existing services is needed to optimize support for the elderly, their families and the primary care giver. In the early seventies Social Security benefits were expanded and the system of tracking benefits for inflation, the cost of living adjustment, was established. COLA is designed to protect individuals who receive SS from inflation and with a majority of seniors as SS recipients many have seen their buying power continue to deflate. The COLA increase for 2012 was 1.7%, (Hurley, Miles, 10/19/2012). For the year 2014, President Obama has proposed the Chained Consumer Price Index to reduce long term SS costs and will affect low income senior more so than high income seniors who may have other income. According to AARP, switching to CCPI will reduce the COLA’s by a significant percentage yearly. In the long run lower income seniors will face harder choices between paying for food, medicine, and utilities, (Rosenburg, Y. 2012). The cost of getting older just may be the most expensive phase of late adulthood. Many seniors have the use of Medicare; some seniors have both Medicare and Medicaid. Medicare is limited for long-term care such as; extended stays in nursing homes for physical and occupational therapy, home health benefits such as; physical therapy, and direct care provided by skilled nurse or a home health aide. By 2020, cost of government sponsored health insurance for the elderly is expected to double. Seniors over the age of 80, receive over 70% more benefits than younger senior adults, (Berk, L. 577). Elderly individuals who become ill may be incapacitated for weeks with several days spent in bed, or hospitalized. Close to 20% nursing home placements are incompatible with the elderly needs in which home-care is advocated to be the better alternative. It is estimated that nearly 50% of the elderly who must stay in a nursing home or assistant living facility for rehab purposes are able to return home, (Hooyman N.R., Kiyak, H.A. 724). Medicare has responded to the need of in-home care under certain conditions and usually under restricted conditions. Eligibility for Medicare home health benefits are:
1. The individual must be under a doctor’s care and getting services under a plan of care established by the doctor.
2. A doctor must certify that the individual needs skilled in-home nursing care.
3. The home health agency hired to care for the individual must be Medicare certified.
4. The senior individual must be certified home bound by a primary physician.
5. The senior must require only short-term care.
6. Medical equipment and all services must have a plan for recovery and all skilled services are medically necessary, (Furukaua, C. Shomaker, D. 103).
Hours and days of services provided by Medicare is limited and rarely goes over 21 days. Elderly individuals who have treatments through a Medicare approved home health agency will find that their out of pocket cost is reasonable because the agency is paid through Medicare. Expenses not paid by Medicare can often be paid by Medicaid. Unlike Medicare that assists mostly those over the age of 65, Medicaid assist the needy of all ages, (Furukaua, C., Shomaker, D. 98). Medicaid home care service must be provided by:
1. Medicaid certified home health agency.
2. Medicaid will provide semi-skilled and unskilled assistance with basic ADL’s.
3. Low in-come seniors who need home health care must meet income eligibility and require more than homemaker services, (Hooyman, N.R., Kiyak, H.A. 739). All states must have either one of two options to offer the low in-come elderly adult; Personal Care Services or Home and Community based Waiver Program, (U.S.
Department of Health and Human Services. 2013). The Medicaid Waiver Program has several core services: Case management, homemaker, home health aide, personal care, adult day care, rehabilitation, and respite care, (Hooyman, N.R., Kiyak, H.A. 739). Medicaid can cover long-term services provided by in-home aides three different ways: Under the Mandatory Home Health State Plan Benefit, the Personal Care Services Optional State Plan Benefit, and Home and Community Based Waiver Program. Only a handful of states finance a small amount of long-term home attendant care under the Home Health Benefit. Most states offer personal assistance services through the Personal Care Services Optional State Plan Benefit, (U.S. Department HHS. 2013). Most if not all are required to provide personal care services through state licensed home care agencies and many states allow the consumer to hire the PCA. For the consumer there is the freedom of choice built into the Medicaid program for home health care but are only extended to qualified providers of in-home care and leaves it up to each state to spell out the …show more content…
qualifications. Recorded in 2007, over 50% of national health care cost came from out of pocket, (Kovner, A.R., Knickman, J.R. 17). From 2007 to 2009, individuals between the ages of 65-74, out- of -pocket health expense averages close to $5000.00, roughly 11.4% of total out of pocket expenditures. Health insurance cost for seniors in this age group was a little over $3000.00, and health insurance coverage was at 62%. For the age group 74 and over, from 2007to 2009, seniors spent $127.00 less in out of pocket expense, yet was higher by 3.7% in total health care out of pocket expenditures. Insurance cost less by $31.00 dollars. And with this age group, health insurance coverage is 1% higher than those under the age of 74, (U.S. Census Bureau, Statistical Abstract of the US, 2012). Old age and the end of the working career bring financial changes and a feeling of uncertainty especially if the senior individual did not plan for retirement, or an illness/injury. Financial dilemmas especially with aging and the chance of something serious to disrupt the flow of ADL’s can become a considerable impact on the retirement income. Even though services through Medicare and Medicaid are offered to offset out -of -pocket medical cost these insurances are limited. The levels of out-of –pocket spending will vary greatly depending on the status of the elderly individual; marital status or single status. Single elderly individuals will spend whatever assets they have on medical cost more frequently than elderly individuals who are married, (Rosenburg, Y., 9/10/2012). Most elderly individuals do not plan on suffering from a late term disease such as Alzheimer’s. Nor do they plan on having a stroke, breaking a hip or suffering a heart attack. Therefore elderly individuals do not plan to pay for high out-of-pocket cost towards the end of their life and may find themselves cash strapped when there is a health care emergency. Medicare provides some relief to medical cost but Medicare does not cover co-payments, deductibles, extended homecare services, and extended non-rehabilitate nursing care, (Rosenburg, Y., 09/10/2012). According to a study by the Center for Retirement Research at Boston College, elderly couples over the age of 65 would need to save over $200 thousand dollars to pay for out of pocket medical cost, and more money just in case a nursing home is needed. Many seniors will face catastrophic out-of-pocket medical expenses that exhaust their saving, (Malone, R., 3/10/2010). More and more families in the U.S. are caring for an aging parent or loved one. Some finding the task to be a great burden. Whatever the circumstances surrounding the needs there are federal policies in place that are support systems for family care givers. The Family Medical Leave Act, (FMLA), and The National Caregiving Support Program, (NFCSP). When a family member resumes responsibility as the informal care giver of their elderly loved one usually affects the whole of their life. FMLA allows employees who have taken on the responsibility of caring for their elderly relative up to 12 weeks annually of unpaid leave. FMLA does provide security in job protection but only 60% of the private sector workforce is eligible for FMLA, (Malone, R., 2010). A barrier to FMLA is the unpaid nature of leave, and will only benefit those who can afford to go without wages for a significant amount of time. The Labor Department conducted a survey in 2013, and found that 17% of employees who did take FMLA received partial pay and 48% received full pay if the days taken off were less than 10, (Tyson, L., 2013). Researchers at the center for American Progress have introduced a plan to provide all workers with access to paid FMLA. This plan would be through SS and called Social Security Cares. SSC is a family and medical leave insurance program, (Tyson, L., 2013). SSC would be operated through SSA and would be paid for through a small increase in SS taxes. Since 2007, California has offered paid leave with 26 states to follow suit with some form of paid FMLA, (Hooyman, N.R, Kiyak, H.A, 401). Those who advocate paid FMLA suggest that employers will face less turn over and fewer paid sick days. Informal caregivers will gain peace of mind and may experience much less stress. In 2000, The National Caregiving Support Group developed out of and is funded by the Department of Administration of Aging, (AOA). NFCSP helps not only the elderly but care givers as well. States are expected to partner with local agencies that focus on aging and elder care. NFCSP provides grants to states based the population that is 70 and over, by funding support for families who are in need of direct in-home care givers for a long as needed. All states are different and have flexibility on services provided to their aging population. Each state has an organized Senior Life Services provided by the states Bureau of Senior Services. Under NFCSP, states are required to offer different programs for direct in-home care.
1. Each state must have information about care giving services.
2. Assistance for informal care givers through Senior Life Services.
3. Individual and group counseling for informal and direct care givers.
4. Respite Care.
These services help low income families and seniors reduce stress, and avoid or even delay institutional care, (AOA. 2013). In the state of West Virginia the Bureau of Senior Services offers several programs;
1. Lighthouse.
2. FAIR, (Family Alzheimer’s In-home Respite).
3. Private Care.
4. LIFE, (Legislative Initiative for the Elderly).
5. Medicaid Aged and Disabled Waiver.
6. Medicaid Personal Care.
7. West Virginia Transition Initiative.
Each program offered is designed in helping low income seniors. Eligibility is decided by the agencies Registered Nurse. Medical eligibility is determined by the ADL’s the elder is capable of performing on their own. A financial sliding fee is based on monthly income. A recipient who chooses not to disclose income may be charged the private payer fee. The RN determines if a referral to a program is indicated with completion of the program application and the RN client assessment form. The RN signature insures eligibility for all programs. Once the elderly client is approved through the assessment process a Certified PCA and or CNA depending on the clients health needs is assigned. PCA’s and CNA’s provide support and ADL service that allow the elder adult to reside comfortably in their homes, and continue if able to participate with activities outside of the home. Direct care aides have many titles; personal assistant, direct support professional, and in-home care provider. Surveys taken by senior adults reported that a high percentage would prefer to age gracefully in their own home over being institutionalized for their end years, (Hooyman N.R., Kiyak, H.A. 453). Another reason that seniors rather stay in their home leans toward cost consideration especially for those living on limited resources. In the last decade in-home care service has grown rapidly and is expect to continue this growth due to seniors living longer into their elder years and the residential options senior adults have to choose from. In-home care is now constituted as one of the fastest growing occupations in the U.S., (Marquand, A. 2012). Education in gerontology skills along with certification is going to be required for employment with a majority of elder care organizations, and state Medicaid programs: Medicaid State Plan Personal Care, and Medicaid Waiver Programs, (Marquand, A. 2012). As the nations senior population continues to increase, health care organizations, and health care workers such as; doctors, nurses, physician assistants, social workers, CNAs and PCA’s will be in demand. The American Geriatrics Society believes the field of Gerontology may experience a shortage in elder care professionals in the geriatric profession for the future senior population growth, (Hart, A. 2002). Direct care workers become almost like family as a primary provider of the in-home elderly care, yet many of these direct in-home care providers are under paid by the agencies and organizations they represent. CNA’s and PCA’s are expected to be compassionate in their care, patient, and have knowledge of best practices in coping with problems such as; eating, sleeping, becoming confused and falls as part of the everyday task of taking care of an elderly client, (Hart, A. 2002). CNA’s and PCA job performance may reflect on the type of care some clients will receive due to limited training and inadequate supervision, and low pay. Most direct care givers work independently and are trusted to make daily decisions about the care of the elderly client. Turnover rate in this field is very high, which causes disruptions in the continue care and cost to providers through recruitment, training, and lost productivity, (Hooyman, N.R., Kiyak, H.A. 416). In 2001, a report written by the Institute of Medicine indicated that direct care providers must continue to be educated, and train their staff with gerontology skills, (Hart, A. 2002). California, Oregon, and Washington are the only states to have a labor union work force for private direct care workers. Through Medicaid, CNA’s must be certified. Although there is not a federal training standard for PCA’s who are employed by publicly funded programs, (Marquand, A. 2012). PCA training varies from state to state which leads to a significant difference in the level of skills and pay around the nation. The IOM recommends that individuals training as PCA’s must take 120 hours of training as a direct care worker. As of 2013, only the District of Columbia and a handful of states meet this requirement, (Marquand, A. 2012). The position of the PCA is preferred to have a high school diploma. The individual must have reading comprehension and math skills, knowledge of personal care, good judgment, and patience. Educational requirements for PCA training standards in most states are; CPR, first aid, and OSHA standards for in-home care. State agency training requires 32 hours of paid training and monthly mandatory training workshops up to 18 months in order for new hires to earn a certification as a PCA in the state. A state agency trained PCA is expected to recognize a learned helplessness with their client and is also expected to help their client by promoting self-care. Training also includes behavior appropriate to the elderly client’s condition and age, and the PCA is expected to provide a safe clean environment, (Hart, A. 2002). Nationwide key findings conclude that without federal standards, states control and implement an assortment of PCA training requirements. Some states better than others and with many states having very little training requirements to be qualified as direct care PCA, (Marquand, A. 2012). Most states provide personal assistance services through the Medicaid State Plan and one or more Medicaid HCBS waivers. West Virginia legislation in 2012, through the Bureau of Senior Services instituted educational standards of certification for in-home direct care workers.
The state of California has a Medicaid State Plan and waiver programs that do not require training for agency employed direct care aides. Even though California is awarded federal grant money to develop a training and certification program for PCA’s as part of the Personal and Home Care Aide State Training Program, a provision of the ACA. In the District of Columbia, PCA’s are required to have a certification as a home health aide, 120 hours of training and pass a competency evaluation. The District of Columbia does not offer directed services under Medicaid, (Marquand, A. 2012). A report released by the IOM in 2008, emphasized that there is a poor retention of direct care workers, a 70% turnover rate nationwide due to low wages compared to high expectation and level of care within the job requirement. Roughly 60% of direct care workers stay on the job for more than 12months but less than 24, (IOM, 2008). Through this report the IOM indicates that direct care workers, state and private have minimal training in long term in-home elder care. In 2010, HHS Secretary Sebelius announced that $320 million grant dollars was assigned to strengthen the health care workforce through the ACA. Of this grant $4.2 million will be used for the Personal and Home Care Aide State Training Program. The program is to support states in
developing and evaluating a competency based training program for qualified individuals to become PCA’s, (U.S.HHS, 9/13/10). Many aging seniors who are in need of help with their ADL’s find themselves having to rely on friends and or neighbors to help them with their quality of life. Especially if their family does not live in the area or the senior does not have family. The National Alliance for Caregiving reported in 2010, that over 60 million people in the U.S serve as informal caregivers, with a majority of the care givers as non-family members,(Empire BlueCross BlueShield, 8/3/10). Informal care givers provide unpaid assistance to the elderly individual which may lead to medical errors. Research on informal care givers shows a high percentage of these individuals become highly stressed, very emotional, and display signs of physical burden, (Donelan K., Hill, C.A., Hoffman, C., Scoles, K., Feldman, P.H., Levine, C., Could, D., 2002). In data from a national survey conducted on informal caregivers by the Harvard School of Public Health and National Opinion Research Center, over 50% of informal care givers who helped with ADL’s received no formal training with task involved in elderly care giving; bathing, feeding, lifting, and using the toilet, (Donelan, K., Hill, C.A., @ el, 2002). An obstacle that prevents many informal care givers is the Health Insurance Portability and Accountability Act, (HIPPA). The health care system does not make it easy. Informal caregivers may be considered family to their elderly friend or neighbor but unless the informal care giver has authorization to disclose personal health information or Power of Attorney, medical issues may be a problem. The informal care giver needs to be able to retrieve information in case of a medical emergency. They need to know where to find insurance information, a list of doctors including specialist, a list of medicines and dosages, and information about the elderly relative, friend, or neighbor. For the informal care giver this lack of information can create a burden of taking care of their family, friend, or neighbor. In a report the IOM released in 2008, Retooling for an Aging America: Building the Health Care Workforce, sited that the unpaid informal care giver was not a new perspective of care giving but needed to be included in the definition of the health care workforce, (Levine, C., Hapler, D., Peist, A., Gould, D.A., 2010). This report also reveled that integrating the informal care giver into the workforce has yet to be fully discussed at a national level. Professional long-term care providers, federal and state agencies site that it may be a challenge breaking through old habits of an already established care giving routine, along with financial and professional barriers, (Levine, C., Halper, D. @ el, 2010). Age related agencies and organizations are aware of the growing population that is quickly shifting to informal care giving causing the concern for the potential for medical errors, (Hart, A. 2002). Public and national policy has traditionally viewed the informal care giver position as personal, moral obligations more so than an extension to the U.S. workforce, (IOM, 2008). Public policy focuses on controlling expenditures on nursing homes, and assistant living facilities due to the high percent of cost that is paid through Medicaid. The saving of money over shadows the positive efforts to support informal care givers.
In conclusion; the elderly population will continue to grow with an estimated 70 million by 2030. This growth in population will increase the need for more individuals to study in the field of Gerontology and Geriatrics. The rising need for continued elder care training through state agencies, organizations, and private care providers, and support training for informal care givers is important in preventing or reducing medical error, and possibly accidental death. A high priority on the agenda of policymakers should be measures to reduce re-hospitalization with elderly individuals, delay or avoid nursing home and or assisting living placement before exhausting other housing alternatives, improve transitional care, and mandatory training and support nationwide for informal care givers. Economic factors are an important issue in public policy formulations in the issues of direct and informal care giving such as but not limited to: health expenditures, inflation and cost of effectiveness. Those who are concerned and work with the aging are an important contribution to improving the health and well being of the elderly and therefore attention to areas of additional research in gerontology practice and enhanced educational studies in the field of gerontology and geriatrics should be a priority in the future for the health care industry in order to have a better skilled workforce with in-home elder care.
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