Retooling for the Aging America Health Care Crisis

May 2013Kate Darby Rauch

Five years ago, the Institute of Medicine (IOM) at the National Academy of Sciences peered into the future and predicted a crisis.

The population of older adults in the US was growing faster than the number of health care providers trained to work with the elderly. The result, said the IOM in its watershed 2008 report Retooling for an Aging America, would be an overwhelming increase in sickness, debilitation, depression and discomfort. A data-driven call to arms, the report called for more and better geriatric preparation for all caregivers, from physicians to nurse practitioners to family caregivers.

UCSF School of Nursing was listening. School faculty reviewed their curriculum, conferred with colleagues nationwide and weighed in at policy sessions responding to the report.

One of the most significant results, which took effect in the fall of 2012, was the merger of what was a separate gerontology specialty master’s degree program with other adult advanced practice nursing programs (nurse practitioners, clinical nurse specialists) for combined degrees. The aim: an advanced practice adult nursing force trained to care for their patients across the adult life span.

Meg Wallhagen “It’s great that all the nurses are getting gerontology,” says Meg Wallhagen, director of the School’s John A. Hartford Center of Geriatric Nursing Excellence. “But I’m very concerned that after gerontology finally became recognized as a specialty, we could be going back to where nurses may not get the necessary depth of training that’s essential to care for the complex needs of older adults.”

Demographics Portend Complex Needs

Between 2010 and 2050, the number of people age 65 and older in the US will more than double, to 88.5 million, according to the US Census Bureau.

Aging, of course, brings an increase in comorbid medical conditions, many of them chronic. It often also brings disability, decreasing independence, social isolation and depression.

The IOM report and many other studies, including some at UCSF, argue that general training in adult medical and nursing care isn’t sufficient for the swelling numbers of seniors.

“I think what gerontological nurses bring to the fore is an understanding of the unique needs of older adults, who bring complex health issues to the clinical setting, many of which we have to consider together,” says Wallhagen. “You have to be a detective to find out what’s wrong.”

Louise Walter You also have to be collaborative, as you attend to a person’s physical, social, emotional and even economic needs, says Louise Walter, interim chief of the UCSF Division of Geriatrics, co-director of the UCSF Geriatrics Research Program – and a research partner of Wallhagen’s.

“We have expertise in complex chronic illness and palliative care, and we’re different in our approach from other adult providers,” says Walter. “Most of the time when you think of a medical specialty, it’s very organ specific. We’re more the whole person perspective – when you get older, what’s best for the organ isn’t necessarily best for the person. Taking a person-centered approach rather than an organ-centered approach is better for the older patient.”

Spreading Their Wisdom

A primary recommendation of the IOM report was to improve the geriatric competence of all health care workers. It went so far as to suggest that competence in geriatrics should be a requirement for professional licensure and certification at many levels. The National Council of State Boards of Nursing, a nonprofit educational and research organization that develops licensing requirements, has embraced the concept, with schools nationwide revising their programs.

At UCSF this translates to the new, combined master’s programs for advanced adult care, but it doesn’t mean special training in gerontology has disappeared. Students in the School’s multidisciplinary PhD programs can still choose to focus on older adults. And the School’s Institute for Health & Aging helps promote multidisciplinary research in the field, with an emphasis on affecting policy.

While Wallhagen and her colleagues mourn the loss of the gerontology specialty, they’re hoping the School’s strength in the field will enable it to adapt well to the change – continuing to excel in research, and preparing adult nurse leaders to care for the elderly.

Being home to a National Hartford Center of Gerontological Nursing Excellence helps. Established in 2001 and one of eight nationwide, the center offers seminars, leadership training and some scholarships. Its primary mission is to build nursing capacity and faculty strength in gerontology. Nursing schools were chosen for centers in large part for their commitment to the care of the elderly. The philanthropic John A. Hartford Foundation funds the center, with a UCSF match.

“The Hartford Foundation recognized the problem of not having enough nursing faculty with the expertise to teach our next generation of leaders. Our piece is to build capacity. Not just with hiring new faculty, but with the academic development of all faculty,” Wallhagen says.

UCSF’s School of Medicine also receives funding as a Hartford Center of Excellence in Geriatric Medicine and Training, and the two UCSF centers often collaborate on research and teaching.

“I believe very strongly that this mission remains essential to meet the health care needs of the future; we still don’t have enough faculty, we still face shortages in geriatric nurses and physicians, and we still need a great deal of study to build the scientific base for the care of older adults,” Wallhagen says.

Waiting for Lessons from the Future

The first class of UCSF’s combined adult-gerontology advanced practice nurses will graduate in a couple of years, and their experiences in the work world will provide key feedback to educators about the choices they’ve made.

JoAnne Saxe, co-director of the Adult-Gerontology Nurse Practitioner (AGNP) program, understands how the new direction brings concerns.

JoAnne Saxe “Depth versus breadth does pose a challenge,” Saxe says. Still, she hopes that nurses wanting to work exclusively with older adults will seek ongoing learning experiences to dig deeper in the specialty. She’s confident that the School’s training encourages this approach.

“Fortunately, at UCSF we pay close attention to developing transferable knowledge and skill sets across the adolescent and adult life span, with additional attention to skills that foster lifelong learning,” Saxe says.

Walter is also hopeful the new model is heading in the right direction.

“I really believe we need geriatric specialists to care for the sickest 5 percent of older adults, who have multiple complex chronic illnesses and functional impairments, and that the other 95 percent need the doctors and nurses who are caring for them to have geriatric training,” she says. “It shouldn’t be either-or; it should be both.”