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Sen. Bob Casey (D-PA)

On May 26, the U.S. Senate Special Committee on Aging, chaired by Senator Herb Kohl (D-WI), hosted a hearing on the pending reauthorization of the Older Americans Act of 1965 (OAA).

The law governs a nationwide network of agencies and programs to deliver social services to older adults to help them maintain independence in their homes and communities.

The hearing, entitled “Meals, Rides, and Caregivers: What Makes the Older Americans Act So Vital to America’s Seniors,” featured testimony by:

• Kathy Greenlee, assistant secretary, Administration on Aging (AoA); U.S. Department of Health and Human Services [testimony];
• Rosalynn Carter, former First Lady and president of the Rosalynn Carter Institute for Caregiving; and
• others, including an advocate, a service provider, a state long-term care ombudsman, and a beneficiary of OAA programs.

The witnesses addressed a wide range of topics, including:

• the needs of family caregivers;
• new programs to be administered by AoA (the CLASS program, the State Health Insurance Assistance Program, and the Senior Community Service Employment Program);
• increased responsibilities of long-term care ombudsmen; and
• options for administering OAA programs more efficiently.

Specialized Training Necessary

Senator Bob Casey (D-PA), a member of the Committee, asked Carter to comment on evidence-based programs for the specialized training necessary for caregivers –- especially direct-care workers.

Casey paid tribute to the commitment of direct-care workers, saying “I have been…overwhelmed by the kind of care that is delivered by direct-care workers — how strong they are, how dedicated they are — willing to do back-breaking and sometimes seemingly impossible work on behalf of those who need that care and on behalf of their families.”

Carter responded by sharing information about approaches the Institute is testing to provide training to family caregivers of individuals with Alzheimer’s Disease, referred to in their October 2010 report, “Averting the Caregiving Crisis: Why We Must Act Now.”

Supporting the Direct-Care Workforce

Responding to the same question from Senator Casey, Assistant Secretary Greenlee commented that it “will take many different federal organizations working together” in order to address how the U.S. will “support the public programs — the CLASS Act, Medicare and Medicaid programs, the programs we have under the OAA, disability programs — with a paid workforce and provide enough support to that workforce so that they have meaningful career ladders, but also so that they have the skill set to serve an increasingly aging population.”

The Leadership Council of Aging Organizations, of which PHI is a member, submitted recommendations (pdf) on the reauthorization of OAA, some of which will bolster the direct-care workforce.

– by Gail MacInnes, PHI National Policy Analyst

The SCAN Foundation has released the first two curricula in a series designed to enhance the skills of California’s direct-care workforce, including “Strengthening Communication and Problem Solving Competencies,” which was designed by PHI.

Each of the curricula in the series employs adult learner-centered methods of teaching to enhance the learning of participants and improve the quality of care provided by the state’s 150,000-plus certified nursing assistants (CNAs) and home health aides.

“Strengthening Communication and Problem Solving Competencies,” a six-hour in-service training, “focuses on active listening and problem-solving skills, which are the building blocks of culture change” in long-term care facilities, said Peggy Powell, PHI National Director of Curriculum and Workforce Development. The PHI training supports the Centers for Medicare and Medicaid Services‘ (CMS) guidelines to provide more resident-centered care.

The six hour-long modules are:

• Introduction to Resident-Centered Care and Active Listening
• Active Listening: Paraphrasing
• Active Listening: Asking Open-Ended Questions
• Managing Emotions: Pulling Back
• The Exploring-Options Approach to Problem-Solving
• Giving Constructive Feedback

“The SCAN Foundation’s efforts to fund the development and dissemination of these adult learner-centered training curricula have resulted in an important resource to enhance direct-care worker caregiving competence,” Powell said.

“Although tailored to the California direct-care workforce, our curriculum can be adapted for direct-care workers in any state,” she continued.

Other Trainings

The other curriculum that is currently available is “Care at the End of Life,” which prepares direct-care staff to help residents and their families cope with death and dying.

Each of the trainings in the series is interactive, outcome-based, and designed to be taught in an in-service setting in a relatively short period of time. “Care at the End of Life,” for example, comprises three modules, each lasting roughly 15-20 minutes.

The SCAN Foundation will release another four curricula in the series:

• Dementia: Understanding and Responding to Behaviors;
• Strengthening Communication and Building Partnerships with Family Caregivers;
• Managing Pain in Older Adults; and
• Pills and Spills (which focuses on medication administration and falls prevention).

The development of the trainings was funded by a series of grants awarded by The SCAN Foundation in 2009. In addition to PHI, grant recipients included Aging Services of California; San Diego Hospice and the Institute of Palliative Medicine; the University of Southern California’s Schools of Gerontology and Pharmacy; and the University of California, Irvine’s Program in Geriatrics.

– by Matthew Ozga

Elder abuse is a growing and largely unnoticed problem in the U.S., according to a report (pdf) by the Government Accountability Office (GAO).

The report was the focus of a March 2 hearing by the Senate Special Committee on Aging.

Elder abuse can take many forms, including physical, sexual, or psychological abuse; neglect; and financial exploitation. It has been linked to shorter life spans, depression, and other health problems.

An Under-the-Radar Problem

The most recent study on the subject found that 14.1 percent of elders had been abused in the last year. The GAO’s report, however, determined that this figure almost certainly underestimates the problem, since the vast majority of elder abuse cases go unreported.

The GAO report further states that “as the American population ages, the extent of abuse will likely grow.”

The March 2 hearing included testimony (pdf) from actor Mickey Rooney, who said that his “daily life became unbearable” due to abuse he experienced at the hand of his wife and stepson.

Rooney said that they took control of his finances without his consent, leaving him feeling “trapped, scared, used, and frustrated.”

Elder Protection Programs Face Challenges

While there are state and federal programs in place to prevent elder abuse, they “may not be able to meet the needs of the increasing number of older Americans,” the GAO report suggests.

The report identifies numerous problems with the current elder protection programs. One major issue is a lack of funding. In FY 2009, only $11.9 million in federal funding was allotted to elder justice activities; state Adult Protective Services (APS) programs received a small fraction of that money.

The report also points out that the Administration on Aging has been lax in establishing federal guidelines for collecting data on elder abuse. “Without these data, states cannot benefit from their collective experience in this area,” the report’s authors write.

Training Materials in Development

National health reform is likely to have a positive impact on the issue of elder abuse, however.

Included in the legislative package signed into law by President Obama in March 2010 is the Elder Justice Act — which, among other things, will fund the design and development of training resources addressing elder abuse.

These resources will eventually be distributed to all Medicare- and Medicaid-certified nursing homes in the U.S.

Abuse Prevention Curriculum Already Available

A free curriculum on preventing elder abuse and neglect, geared toward employees in all long-term care settings, is already available at the PHI Training and Organizational Development Services website.

“Proper education is essential to eradicating elder abuse from long-term care settings,” said Peggy Powell, PHI National Director of Curriculum and Workforce and Development. “This curriculum provides trainees with the tools necessary to recognize, report, and ultimately prevent elder abuse.”

This training was developed through a grant from the Centers for Medicare & Medicaid Services (CMS) to the Michigan Department of Community Health. Partners in its development included Michigan State University, the Michigan Office of Services to the Aging, BEAM (a wholly owned subsidiary of MPRO, Michigan’s federally designated quality improvement organization), and PHI.

– by Matthew Ozga

PHI and about 50 other national organizations voiced their opposition to the proposed $3.8 billion cuts to employment and training funding in H.R. 1, the House-passed FY 2011 Continuing Resolution (CR).

On March 2, the groups sent a letter (pdf) to the chairmen and ranking members of the Senate Appropriations Committee and the House Subcommittee on Labor, Health and Human Services, Education, and Related Agencies, stating, “we urge you in the strongest possible terms to reject the proposed cuts to WIA and other critical job training programs under H.R. 1.”

The budget cuts in the CR would completely eliminate funding for the Adult, Dislocated Worker, and Youth programs under the Workforce Investment Act (WIA) in Program Year 2011. The proposal would also slash or completely eliminate funding for programs such as Job Corps, YouthBuild, and Community Service Employment for Older Americans.

WIA funding supports programs that help to develop and train the direct-care workforce. Programs such as Pennsylvania’s Health Care Industry Partnerships, a sectoral strategy that was made possible in part by the state’s use of the discretionary Title 1 WIA funds, for example, would be hard hit.

The organizations wrote that “the cuts included in the House CR impact current and future workers at all ages, incomes, and skill levels, and will be felt across the entire country.”

They call the proposed cuts “draconian” and explain that both workers and employers would suffer if the employment and training funding was slashed.

The National Skills Coalition, National Law Center on Homelessness & Poverty, American Association of Community Colleges, United States Conference of Mayors, and Wider Opportunities for Women were among the many organizations that signed onto the letter.

– by Deane Beebe

The number of Ohio’s nursing home residents age 60 and below has grown significantly as young people with mental illness have increasingly been placed in this setting.

According to an article published in the Dayton Daily News on January 10, the shift to nursing home placements is the result of state budget cuts in recent years to the behavioral health support system.

As many as 16 percent of Ohio’s nursing home residents were age 60 and below in 2009, up from 4 percent in 1994. Three-fourths of these residents have been diagnosed with a severe mental illness.

Staff Lack Behavioral Health Training

Despite the increase in the number of nursing home residents with severe mental illness, “staff often don’t have the expertise or time to meet the needs of those with behavioral issues,” Bob Applebaum, Ph.D., director of the Ohio Long-Term Care Research Project at Miami University’s Scripps Gerontology Center, told the Daily News.

While some direct-care workers are trained in behavioral health (pdf page 6), these workers are typically employed in substance abuse or mental health settings. Training for these workers (pdf) is usually limited and declining.

“Training has eroded dramatically over the past decade for the behavioral health direct-care workforce,” said Michael Hoge, Ph.D., Yale University School of Medicine, and the senior science and policy advisor for the Annapolis Coalition. “Funding has been reduced and there are few mandates for training other than accreditation standards that require basics in fire safety and similar topics.”

Huge and Growing Problem

There has been a national trend toward placing younger, physically able people with mental illness in nursing homes, which poses a risk to older, frailer residents, the Associated Press reported in March 2009.

Younger people with mental illness comprised 9 percent of the nation’s nearly 1.4 million nursing home residents in 2009, up from 6 percent in 2002.

“The issue of mentally ill persons in nursing homes is a huge and growing problem because the direct-care workers on the frontlines are not trained in behavioral health,” Hoge said.

– by Deane Beebe

The deaths of six residents over six months at an assisted living facility in North Carolina have intensified the state’s debate on the adequacy of training and supervision of unlicensed medication aides.

Medication aides are direct-care workers who are permitted to administer medications in assisted living facilities in North Carolina.

Thomas Goldsmith of the News & Observer reports that state public health officials concluded in December that poorly trained staff and unsafe diabetic care resulted in the transmission of a hepatitis B infection amongst diabetic residents, who were on average age 70.

An investigation by the North Carolina Division of Public Health found that the infection was spread between residents by unlicensed “med techs” who reused glucose monitors and other devices. The agency also found that no staff member was designated to coordinate infection control.

Med techs who work at North Carolina assisted living facilities, formerly known as adult care homes, are not required to be licensed or have state-approved infection control training. Goldsmith reports that they “may get only one-on-one training from a nurse on diabetic care.”

In the 1990s, the North Carolina Board of Nursing had proposed a uniform set of standards for medication aides working in all long-term care settings, but such standards have only been required in nursing homes.

Scope of Practice

The tragedies also fueled the discussion on whether med techs employed at North Carolina assisted living facilities should be permitted to administer glucose tests and insulin injections.

John Buse, M.D , Ph.D., former president of medicine and science at the American Diabetes Association, advised that many people manage their own diabetes but cautioned that facility owners and managers should “understand that insulin is a drug where the margin for error is very small.”

PHI commented on the case for this article, noting that quality long-term care depends on “not only training but decent wages and benefits and career advancement opportunities.”

North Carolina is one of six states to receive a Personal and Home Care Aide State Training Program demonstration award to develop and pilot test curricula for personal care aides working in homes and facilities.

– by Deane Beebe