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62–692 PDF 2011

S. HRG. 111–820 

TAKING CARE OF MOM AND DAD: 

WHY WE NEED A QUALITY WORKFORCE TO 

SERVE OUR OLDER AMERICANS 

FIELD HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

WILKES–BARRE, PA 

AUGUST 2, 2010 

Serial No. 111–22 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html 

SPECIAL COMMITTEE ON AGING 

HERB KOHL, Wisconsin, Chairman 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

BILL NELSON, Florida 

ROBERT P. CASEY, Jr., Pennsylvania 

CLAIRE McCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

MARK UDALL, Colorado 

KIRSTEN GILLIBRAND, New York 

MICHAEL BENNET, Colorado 

ARLEN SPECTER, Pennsylvania 

AL FRANKEN, Minnesota 

BOB CORKER, Tennessee 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

GEORGE LeMIEUX, FLORIDA 

ORRIN HATCH, Utah 

SAM BROWNBACK, Kansas 

LINDSEY GRAHAM, South Carolina 

SAXBY CHAMBLISS, Georgia 

DEBRA WHITMAN, Majority Staff Director 

MICHAEL BASSETT, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Bernard Graham, Ph.D., Dean, Nesbitt College of 

Pharmacy and Nursing, Wilkes University ....................................................... 1 

Opening Statement of Senator Robert Casey ........................................................ 2 

PANEL I 

Statement of Janet Heinrich, DrPH, Associate Administrator, Bureau of 

Health Professionals, Health Resources and Services Administration, Rockville, MD ............................................................................................................... 6 

PANEL II 

Statement of Robert D’Alessandri, M.D., Executive Officer and Chief Academic Officer, The Commonwealth Medical College, Scranton, PA ................. 22 

Statement of Vera Salter, Ph.D., Professional Development Director, the Direct Care Alliance, New York, NY ...................................................................... 35 

PANEL III 

Statement of Melissa Lear, President, Beck N’Call and President, Allen Lear 

Home Care Associates, East Stroudsburg, PA ................................................... 45 

Statement of Connie Kreider, Direct Care Worker, Columbia, PA ..................... 55 

APPENDIX 

Dr. Heinrich’s Responses to Senator Casey’s Questions ...................................... 65 

(III) 

(1) 

TAKING CARE OF MOM AND DAD: 

WHY WE NEED A QUALITY WORKFORCE TO 

SERVE OUR OLDER AMERICANS 

MONDAY, AUGUST 2, 2010 

U.S. SENATE, 

SPECIAL COMMITTEE ON AGING, 

Wilkes-Barre, PA. 

The Committee met, pursuant to notice, at 10 a.m., at Wilkes 

University (Hon. Robert P. Casey Jr.) presiding. 

Present: Senator Casey [presiding]. 

STATEMENT OF BERNARD GRAHAM, PH.D., DEAN, NESBITT 

COLLEGE OF PHARMACY AND NURSING, WILKES UNIVERSITY 

Dr. GRAHAM. Good morning. My name is Bernie Graham, and I 

am the Dean of the Nesbitt College of Pharmacy and Nursing here 

at Wilkes University. 

The college is the home to the School of Pharmacy, which has 

graduated approximately 700 Doctors of Pharmacy since the first 

graduating class in the year 2000. These graduates have mainly 

settled in northeastern Pennsylvania and are having a positive impact on the healthcare of our population, especially in the area of 

immunization and medication therapy management, areas in which 

pharmacists have gained the knowledge and experience and now 

have the privileges in the Commonwealth. 

We are also the home of the School of Nursing. Nursing education, in one form or another, has been a hallmark of Wilkes University since 1952. Since inception, Wilkes University has awarded 

over 1,500 degrees in nursing. Wilkes currently awards a B.S. in 

nursing, has an accelerated entry-level Master’s degree for careerchange adult learners with a Bachelor’s degree in other fields, has 

a traditional Nursing Master’s of Science programs and, most recently, the Doctor of Nursing Practice. 

At the master’s level and now the doctoral level, Wilkes has concentration areas to prepare clinical nurses, nurse specialists in geriatrics, which is the care of the aged population, and psychiatric 

mental health. We also prepare graduates for the areas of nursing 

management and nursing education. 

We in education also see this train of aging citizens fast approaching. The need for a larger workforce of well-trained 

healthcare individuals is obvious, but also perplexing. We have responded to the well-publicized need, but something, probably the 

economy or lack of money, has led to an interesting problem. 

Some—not many, but an increasing number—of our graduates are 

2 

having a hard time finding employment. This is both in nursing 

and pharmacy. 

We see the workload of the existing workforce increasing almost 

beyond capacity, but yet employment market is very slow. This has 

also led to a very interesting problem with the training of the bachelor-level nurses in Wilkes-Barre. This problem is with all B.S. programs here in the region. 

The local hospitals are so overworked that they cannot precept 

any senior-level nursing students. These students, in their last 

year, need individual mentoring and leadership experiences, which 

can only be accomplished at bedside. This is a problem that we, as 

educators, are trying to address. 

As you can see that this hearing today will be informative and 

extremely timely, and we thank the Senator for his concern. Senator Bob Casey, who will soon be the senior Senator from Pennsylvania, will chair this U.S. Senate Special Committee on Aging field 

hearing, entitled ‘‘Taking Care of Mom and Dad: Why We Need A 

Quality Workforce to Serve Our Older Americans.’’ The hearing 

will focus on legislative action in the Senate and taking measures 

to ensure that Pennsylvanians have access to a quality workforce 

to care for an aging population, with a focus on medical education 

in the frontline healthcare workforce. 

Senator Casey. 

OPENING STATEMENT OF SENATOR ROBERT CASEY 

Senator CASEY. [Off-mike.] I call this hearing of the Senate Special Committee on Aging to order. 

I do want to, first of all, thank Wilkes University and President 

Gilmour and Dr. Bernie Graham for having us here, for welcoming 

us and giving us this opportunity—— 

OK. We want to thank Dean Graham and President Gilmore and 

others for welcoming us here to Wilkes University today to focus 

on a series of challenges that the people of northeastern Pennsylvania, the people of our Commonwealth, and, indeed, our country 

face as it relates to caring for older citizens throughout our Commonwealth and our country. 

There are many, many challenges, but there are also, as we will 

find out today, a lot of solutions to those difficult challenges. We 

have in Pennsylvania one of the fastest-growing populations in the 

country over the age of not only 65, but also the age of 85. We 

know that, for example, when you compare that to the United 

States of America, we know that the baby boom generation will 

start turning 65 next year. 

By the year 2030, all 78 million—that is hard to believe—but 78 

million will have reached that age, the age of 65 by the year 2030. 

Between 2005 and 2030, the number of adults age 65 and older will 

almost double—almost double, just imagine that—from 37 million 

to over 70 million, accounting for an increase of 12 percent of the 

population to 20 percent. 

So what that means is that the country will look like Lackawanna County or Luzerne County because, as you know, now about 

12.5 percent roughly of our U.S. population is over 65. Pennsylvania is above 15 percent, just about 15.5 percent. But here in 

Luzerne County and next door in Lackawanna County, consistently 

3 

over the last 20 or 30 years, but it is certainly in the last 10 to 

20 years, both counties have been right about 19 or 20 percent over 

65. 

So that increase nationally will mean that the country will have 

a percent over 65 that we have had here for many, many years. 

What we have to do, though, is not just recite those numbers and 

list the many challenges we have. We have to recommit ourselves 

to make sure that those who are, as Hubert Humphrey said a long 

time ago, in the twilight of life, that those who are in that age 

bracket get all the help that they need. 

Who are we talking about here? We are talking about people who 

fought our wars, worked in our factories, taught our children, and 

gave us life and love. All of those Pennsylvanians and all of those 

Americans, we have an obligation to make sure that they are taken 

care of in the best way possible. 

We have the blessing in this country of the best education systems in the world, the best schools in the world. When it is working as it should and when we are focused on the best parts of it, 

our healthcare is the best in the world. We have to bring all of that 

learning, all of that knowledge, all of that expertise and ability to 

strategies to care for, to take care of those in the twilight of their 

lives. 

In Pennsylvania, we have a particularly significant challenge 

over the age of 65. We are fourth in that category for the country. 

This puts us in a unique position to be able to be, in a sense, a 

laboratory for all kinds of great strategies, all kinds of new ideas, 

all kinds of new pathways of learning to make sure that we are 

taking care of people who have contributed so much to Pennsylvania and to our country. 

I remember reading a story, a series of stories in the Philadelphia Inquirer about a decade ago, about I want to say it was 1998, 

or 1999. I will get the date, but it was in that time period. The 

writer of the story was Michael Vitez, and he was talking about 

long-term care in Pennsylvania and across the country. I will never 

forget something he wrote in that story, that series. 

I think I am quoting him accurately. He said, ‘‘Advocates for the 

frail elderly say that life can have quality and meaning even until 

the very last breath.’’ Life can have quality and meaning even to 

the very last breath. Sometimes we forget that. Sometimes we 

think of long-term care, nursing home care, care for older citizens 

as somehow—oh, I don’t know, I guess somehow just kind of managing old age and figuring out a way to make it as comfortable as 

possible. 

Well, we don’t really believe that if we think about it for a little 

while. We don’t believe that. We believe that life does have quality 

and meaning, even to the very last breath. That means that people 

can have full lives, lives of great contribution and lives of great 

promise even when someone is very old. That there is not just a 

dignity and a worth, but also a lot of opportunity and a lot of promise in the life of someone much older. They can contribute so much 

if we have the strategies in place to take care of them. 

So, first of all, it is a necessity that we get this right. The people 

of our country who are in that age bracket know that we have not 

4 

just an obligation to them, but this is critically important that we 

get this right for our workforce and for our quality of life. 

In Pennsylvania, we know that the trend, just like it is across 

the country, those who are over the age of 85 are going to increase 

even faster than the population over 65. Pennsylvania is expected 

to grow by 50.6 percent between the years—we are 10 years into 

this now—2000 and 2030. So in that 30-year time period, the population over 85 is supposed to grow by more than 50 percent. 

We also believe that when we are focused on these sets of challenges, this is an opportunity for our State of Pennsylvania. We 

were talking just earlier this morning about our healthcare infrastructure. We have a lot of it in Pennsylvania. A big workforce, you 

can make an argument, pretty good argument, that healthcare is 

our biggest employer if you set aside the jobs that are in agriculture or the economic impact of agriculture or tourism, Government employment. 

But you can make a very good argument that healthcare is either 

the biggest employer or a very close second. The bill that we passed 

in Congress and the President signed into law this year, the 

healthcare reform bill, presents an opportunity to create new models of care for people across this country. 

We know that in Scranton, for example, we have a medical 

school. A lot of people didn’t think that would happen. But because 

of the leadership of a number of people, including Dean 

D’Alessandri, who is here with us today, will provide testimony, 

this school allows us to test some of those new models of care in 

primary care, comparative effectiveness research, all kinds of new 

discoveries and new ways of approaching the care for older Americans, to benefit them. 

We know that collaboration will be critically important with 

other healthcare providers and other experts in the field to make 

northeastern Pennsylvania a leader, literally a leader in this field 

in the world. Not just in the State or the country, but indeed across 

the world. 

So this isn’t just some problem we have got to manage. This is 

an opportunity. It is an opportunity for Pennsylvania, and it is an 

opportunity especially for northeastern Pennsylvania. For that reason, we should embrace it, not just hope we can deal with it. We 

should embrace it as an opportunity. 

Third, I think we are also at the same time, as much as we think 

of this as both a necessity in terms of demographics and opportunity because of our values, it is also something that calls us to 

be summoned by our conscience and our commitment to get it 

right. We will not be the kind of community that we have been in 

northeastern Pennsylvania and across the State unless we get this 

right. 

The good news is we know exactly how to get it right, and we 

can do this. Our parents and our grandparents who raised us and 

cared for us and built this region, built this Commonwealth, and 

really built the country, when you think of the generations two or 

three that just preceded ours, how they got us through World War 

II. We weren’t prepared for World War II. But they fought that battle, and they built our economy. They built the middle class. 

5 

They made us the envy of the world—our economy, our way of 

life, our ability to defend freedom. All of that came from one or two 

generations of Americans. So we have a great opportunity not only 

to improve and grow strategies to care for older citizens, but also 

to build a very strong economy. 

We are told that the American Association of Medical Colleges 

predicts that the United States is expected to face a shortage by 

the year 2025 of between 124,000 and 159,000 physicians across 

the country. The American Association of Colleges of Nursing reports that the number of registered nurses needed will grow, will 

grow by 260,000 nurses by that same year, 2025. 

So we are going to need more doctors. We are going to need more 

nurses, and we are also going to need more direct care workers in 

roughly that same time period. Direct care workers are often not 

given the respect they deserve for the work that they do. It is the 

direct care workforce that provides most of the care to our loved 

ones. They help every day of the week a quarter of a million Pennsylvanians and their families, every single day. 

It is one of the fastest-growing populations. According to the Bureau of Labor Statistics, employment of home health aides and personal and home healthcare aides is expected to grow between 46 

and 50 percent between the years of 2008 and 2018. Just imagine, 

in one decade in one part of our healthcare workforce, direct care 

workers is going to grow by roughly 50 percent in Pennsylvania. 

So it is our responsibility to make sure these jobs are both personally rewarding, but also that they provide an opportunity for advancement and economic stability. So, for that reason, tomorrow I 

will introduce in the U.S. Senate the Direct Care Workforce Empowerment Act. This legislation will do three things. 

First of all, ensure that home care workers receive the Federal 

minimum wage and overtime protections of the Fair Labor Standards Act. That is a good idea. I can’t believe we haven’t done it already. It doesn’t make any sense that we haven’t done it. No. 2, 

improve Federal and State data collection and oversight with respect to the direct care workforce. Three, establish a grant program 

to help States improve direct care worker recruitment, retention, 

and training—three or four words that we hear over and over again 

when it comes this part of our healthcare workforce. 

So we are here to talk about how we care for Pennsylvanians and 

Americans in the twilight of their lives, just as we hear a lot of talk 

about folks that we worry about in the dawn of their lives, our children. Both ends of our age spectrum, young children and older citizens, both need our help, both need our attention, and both need 

much more of our focus. 

So we will have three panels today. Our first panel will be one 

person, but someone who I think will be able to give us a great 

overview of some of the opportunities we have, especially in relationship to the new healthcare bill. Dr. Janet Heinrich, the Associate Administrator of the Bureau of Health Professionals of the 

Health Resources Services Administration. 

Dr. Heinrich is a former executive director of the American Academy of Nursing. She is here today to discuss many of the important 

changes that the Affordable Care Act, the health reform bill I reVerDate Nov 24 2008 10:31 Jan 21, 2011 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 H:\DOCS\62692.TXT SAG PsN: JOYCE
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ferred to earlier, has made to improve and support the healthcare 

workforce. 

As I will tell her and I will remind our other witnesses, if we can 

keep your testimony to about 5 minutes, you should know, each of 

the witnesses should know that your entire testimony will be made 

part of the record. So if there is a part of it that you want to make 

sure is part of the record, don’t worry, it will be part of the record. 

If you can keep it to around 5 minutes, Doctor, we would appreciate it. So, Doctor, why don’t you start us off? Thank you very 

much for being here. 

[The prepared statement of Senator Senator Casey follows:] 

STATEMENT OF JANET HEINRICH, DRPH, ASSOCIATE ADMINISTRATOR, BUREAU OF HEALTH PROFESSIONALS, HEALTH 

RESOURCES AND SERVICES ADMINISTRATION, ROCKVILLE, 

MD 

Dr. HEINRICH. Senator Casey, Mr. Chairman, thank you for the 

opportunity to testify today on behalf of the Secretary of Health 

and Human Services and the Administrator of Health Resources 

and Services Administration, which I will refer to as HRSA. 

The Affordable Care Act provides us many opportunities, especially as we think about expanding the essential healthcare workforce and the importance of the direct care worker, as you so eloquently described. 

HRSA is the primary Federal agency for improving access to 

healthcare services for people who are uninsured, isolated, medically vulnerable, including the elderly. Our programs help Americans receive quality care without regard to ability to pay. HRSA 

programs also help train the future nurses, doctors, and other clinicians so essential to providing our healthcare services. 

My testimony today will focus on new activities related to the 

Prevention and Public Health Fund, our programs to improve access, the new programs we have for the frontline direct care workers, and specific programs for training people to care for older people. I want to give examples of organizations in this area especially 

that are taking advantage of these new opportunities that are 

made possible through the Affordable Care Act. 

Let us start with the Prevention and Public Health Fund. We 

know that communities across the country have suffered from a 

shortage of primary care workers. Without action, experts continue 

to say that we will have a shortfall in our needs to care for the 

aging population, with a decline in the number of students selecting primary care. 

To address this, Secretary Sebelius announced a series of new investments worth $250 million, made possible by the Affordable 

Care Act, to increase the number of providers in primary care. Specifically, we will be funding additional primary care residency slots 

to train new primary care physicians. We will be supporting physician assistants training for primary care, as well as nurse practitioner training programs—nurses who will be going into primary 

care, and one of those specialties, of course, is geriatrics. 

There will be $5 million to fund States to plan and implement 

innovative strategies to expand their primary care workforce. This 

is a terribly important program, again made available under the 

7 

Affordable Care Act, to encourage our States to address barriers to 

expanding the healthcare workforce, especially for primary care. So 

that, in fact, States can address issues of scope of practice which 

limit what providers other than physicians can provide, especially 

to older populations. Certainly, we know that Pennsylvania is a 

leader in this area of addressing scope of practice issues. 

Let us focus now on the programs we have to increase access to 

care. HRSA’s mission to improve health and achieve health equity 

through access to health services includes the administration of the 

Community Health Center Program, and the National Health Service Corps. 

With the community health centers, their mission is to provide 

primary care to vulnerable populations, including older citizens, no 

matter their ability to pay. Across the country, we have a network 

of over 1,100 healthcare centers. In fact, there are more than 20 

HRSA-funded community health center service sites within 50 

miles of where we are today. 

Community health centers are a vital source of healthcare for 

aging populations. In 2009, health centers served over 1 million patients age 65 years and older. 

The Affordable Care Act provides $11 billion in funding over the 

next 5 years to increase support for community health centers. 

About $9.5 billion of that will increase services at existing sites, 

provide funds for new community health center sites, and fund 

plans to create more community health centers in underserved 

areas. 

With the National Health Service Corps, HRSA seeks to 

strengthen primary care by placing healthcare providers in communities where they are needed most. For example, the National 

Health Service Corps, through scholarship and loan repayment programs, help address specific shortage areas for medicine, dentistry, 

and mental health providers. 

In fact, there are currently 12 National Health Service Corps 

providers serving across northeastern Pennsylvania. Moreover, in 

recognition of the aging of the U.S. population, geriatricians were 

included recently as a physician category in the National Health 

Service Corps to help provide more of these essential services in 

underserved areas. 

The Affordable Care Act increases and extends funding for this 

corps. Through the loan repayment program, we now offer 

$145,000 over 5 years to repay student loans that treat uninsured 

and underinsured citizens. This is a substantial increase from what 

was available to students before. 

With the scholarship program, there is payment for tuition, fees, 

a living stipend to students enrolled in accredited programs for 

dentistry, nurse practitioners, nurse midwives, and physician assistants, as well as physicians. 

Let us now talk about the frontline worker and the needs that 

you just spoke about. Across the United States, there is growing 

concern about current and projected shortages of frontline workers, 

direct care workers such as nursing and home health assistants 

who provide the services for the elderly, chronically ill, and disabled. The number of older and disabled patients with very comVerDate Nov 24 2008 10:31 Jan 21, 2011 Jkt 000000 PO 00000 Frm 00011 Fmt 6633 Sfmt 6633 H:\DOCS\62692.TXT SAG PsN: JOYCE
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plex healthcare needs is outpacing the supply of workers trained to 

meet these needs. 

As a result, the need to train personal and home health aides is 

ever increasing. The Affordable Care Act addresses some of these 

challenges in training for frontline workers. Let me describe three 

new programs that we are administering. 

We have now, as a result of the Affordable Care Act, the Personal and Home Healthcare Aide State Training Program. This 

program is designed to address the challenges that you have just 

described. The Personal and Home Care Aide State Training Program aims to ensure the supply of competent personal and home 

health aides with acquired skills that would be transportable to 

any job market in the Nation, thus strengthening the direct care 

workforce. 

This program will support the development, evaluation, and demonstration of competency-based uniform curriculums to train qualified personal and home health aides. That program is now in the 

review process, and we will be making awards by the end of September. 

Another new program is the Nursing Assistant and Home Health 

Aide Program. This program establishes a new initiative to train 

nursing home aides and home health aides. It will support the development, demonstration, and evaluation of, again, competencybased uniform curriculum to train qualified assistants, strengthen 

the direct care workforce, making sure that they have the necessary skills that can be transportable and building blocks for moving up to other higher paying professions in healthcare. 

Awards and grants will be made to colleges and communitybased training programs for development, testing, and training of 

these programs and emphasize telehealth and new communication 

methodologies for training. 

Another program is the Patient Navigator Outreach and Chronic 

Disease Prevention Program. This program is reauthorized under 

the Affordable Care Act and expanded. This program supports individuals serving within communities to assist patients in overcoming barriers to receiving healthcare services. 

Patient navigators help patients coordinate healthcare services, 

determine whether clinical trials are right for them, conduct outreach to populations to make sure that they have access to the care 

they need. 

We have several geriatric programs, and I will be brief here in 

consideration of time available. In addition to supporting the frontline workers, the Affordable Care Act reauthorizes HRSA programs 

specifically focused on training the healthcare workers we need 

with the special skills in geriatrics. 

Moreover, it is important that we appreciate the fact that these 

training programs, as a result of the Affordable Care Act, are more 

focused than ever before on interdisciplinary training. We need to 

be able to work in teams. No one profession can do it alone. We 

are not only relying on physicians or nurses, but an array of health 

professionals that we will be needing. 

So one of our programs, the Comprehensive Geriatric Education 

Program, really targets nurses and nurses who will receive degrees 

in geriatric nursing, long-term care, geropsychiatric nursing, and 

9 

other nursing areas that specialize in elderly populations. In 2009 

in Pennsylvania, HRSA awarded these grants to the Community 

College of Allegheny County and the University of Pennsylvania. 

We also have a Geriatric Education Center Program. These programs provide interdisciplinary training for health professionals in 

assessment, chronic disease syndromes, care planning, emergency 

preparedness for elderly, and cultural competencies unique to caring for older Americans. 

The Affordable Care Act authorizes supplemental grants to these 

programs in geriatrics, chronic care management, long-term care 

for faculty in a broad array of health professions schools, as well 

as training for frontline, direct care workers and family caregivers. 

The Affordable Care Act authorizes these short-term intensive 

courses to assist in these areas. 

Currently, in 2010, we have awarded grants to the University of 

Pennsylvania, University of Pittsburgh, and Thomas Jefferson University. Interestingly enough, Thomas Jefferson University provides these geriatric education programs through a consortium that 

includes Marywood University and The Commonwealth Medical 

College in Scranton, and The Commonwealth Medical College then 

expands these through three regional campuses in Scranton, here 

in Wilkes-Barre, and Williamsport. So a broad reach that I think 

is very innovative. 

We also have the geriatric training program for physicians, dentists, and behavioral and mental health professionals. This program supports geriatric training to train these professionals who 

will go into the geriatric specialties in their professions. We also 

have a Geriatric Career Award that provides career development 

for faculty who will be training in these programs. 

Another program that you have in this area is the Area Health 

Education Center Program. We fund the Area Health Education 

Center programs to really encourage the establishment and maintenance of community-based primary care training in off-campus 

rural and underserved areas. One goal is to educate and train students to become culturally competent primary care providers. 

The Pennsylvania Area Health Education Center has seven 

AHEC centers, including northeastern Pennsylvania center, which 

is located on the campus of Keystone College and serves a ninecounty regional area that includes Wilkes-Barre and Scranton. The 

northeast Pennsylvania center also offers programs to spark interest in science and preparing for health careers among students in 

the high school and lower grades and encourages students to enter 

the health professions careers. 

In this area, there are consortium that include East Stroudsburg 

University, Wilkes University, and the University of Scranton to 

provide these experiences for students still in their high school 

years. I can’t stress enough that we really do need to encourage the 

pipeline to go into the health professions careers. 

Whether we like it or not, in medicine and nursing for sure, we 

have a huge cadre that are just at the cusp of retirement. So, as 

fast as we are bringing in the health professions on the front end, 

we are losing them to retirement on the other end. 

So, in conclusion, we are extremely proud of our programs, look 

forward to continuing to work with you, Mr. Chairman, to ensure 

10 

the provision of quality care to all Americans and by ensuring the 

availability of highly competent, adequately prepared healthcare 

workers, especially workers who can care for our older citizens. 

Thank you very much. I am happy to answer any questions. 

[The prepared statement of Dr. Heinrich follows:] 

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Senator CASEY. Doctor, thank you very much. 

I wanted to ask you a few questions that relate to northeastern 

Pennsylvania in particular. We have, fortunately, passed the Affordable Care Act. It took a lot of work to get that bill passed. I 

spent a substantial amount of time working on a lot of different 

parts of the bill. 

We are happy it passed. In fact, we are very happy it passed. But 

we know that if this were a five-chapter book, as hard as passage 

and enactment was, there are probably four chapters after that 

that are all going to be difficult. A lot of those chapters, a lot of 

the challenges are on implementation. 

We have an opportunity I think in northeastern Pennsylvania 

and throughout the Commonwealth to take advantage of parts of 

the bill that, frankly, not enough people have heard a great deal 

about, which is true of a lot of parts of the bill. I think there is 

a chance, as we begin to implement different parts of the Affordable Care Act, that people will have a better sense of what those 

provisions are all about. 

As it relates to the whole series of programs that you outlined, 

we have a lot of program names, a lot of acronyms, and fortunately, 

a lot of funding to be able to help move those programs forward, 

either new programs, new strategies, or existing programs that will 

be expanded or reauthorized. 

I guess one question a lot of people might have is if someone 

bumped into you walking out of here today and said I heard you 

passed this big healthcare bill, and I know here in northeastern 

Pennsylvania, we have got a number of healthcare challenges. One 

of them is this challenge of taking care of and providing quality 

care for older citizens. How would you rank or prioritize the programs within the legislation that would be most helpful in the near 

term? 

In addition to the programs, what Health and Human Services 

resources do you think could be made available for the people of 

northeastern Pennsylvania? 

Dr. HEINRICH. It almost sounds like you are asking me to choose 

among my children. [Laughter.] 

The fact is that there are themes, I think, in the Affordable Care 

Act that are very important to this area, as well as the rest of the 

country. But it seems as though you may have a head start on 

some of these areas. 

So I think there is definitely the theme of expanding the primary 

care workforce. With the primary care workforce, we have to emphasize the fact that it is physicians, yes, but it is also nurses. It 

is also pharmacists. It is also physician assistants. They all play a 

critical role in providing primary care access, especially for older 

and a growing older population. 

Senator CASEY. Can I just stop you there? 

Dr. HEINRICH. Yes. 

Senator CASEY. Just so we kind of go program by program. You 

stated in your testimony with the Prevention and Public Health 

Fund, and you spoke there about primary care workforce. The bullet points you have, it is $168 million for residency slots, $32 million for physician assistants training, money for nurse practitioners, innovative strategies, nurse-managed health clinics. 

19 

What is the best way for individuals—well, let me say what is 

the best way for institutions in northeastern Pennsylvania to take 

advantage of the Prevention and Public Health Fund? Let me just 

start with that. 

Dr. HEINRICH. OK. The Prevention and Public Health Fund was, 

in fact, a one-time—the $250 million was a one-time initiative that 

may be, in fact, repeated in the future, but we are not sure. It depends on the availability of funding. But I think that the message 

for the institutions in this area is that you have a new and developing medical school. You have nursing programs. I haven’t heard 

about physician assistant programs. 

But there are, in fact, opportunities for different levels of training for healthcare providers. It sounds like the School of Nursing 

here at Wilkes is already taking advantage of a lot of the increasing, expanding programs in nursing. I would hope that they would 

continue to do so in the future. I learned, as I came in this morning, that, in fact, the new expanding medical school is also taking 

advantage of some of the ongoing programs. 

So the message is that primary care is interdisciplinary and that 

there are monies that are available for expanding the numbers, 

and we would hope to continue that in the future. 

Senator CASEY. So for all those areas that I just talked about, 

this fund is a 5-year program, right? 

Dr. HEINRICH. Right. 

Senator CASEY. It will support 16,000 new primary care providers. So there are obviously opportunities. 

What is the best way to access these programs? In other words, 

how do you apply? What is the process? 

Dr. HEINRICH. There is a Web site called www.grants.gov, and on 

that Web site, you will see all of the initiatives, all the competition 

for all of our grants. You can also go to HRSA, hrsa.gov, and look 

for grant opportunities, and they will be listed there as well. 

Senator CASEY. Obviously, you mentioned before the impact that 

the community health centers will have. I don’t think many people 

understand that we have had a very successful community health 

center program, strategy—I don’t know how you want to define 

that. But it has been in place for years. In your testimony, you 

pointed to some of that history and the network of sites all around 

the country. 

But this community health center part of the healthcare bill is 

$11 billion more that will be provided over 5 years to support that. 

It is almost impossible to calculate, in my judgment, the positive 

healthcare benefits that will provide to the country. That community health center part of the healthcare bill could be its own bill, 

and it would be considered a substantial piece of healthcare legislation. 

So it is a part of the bill that I don’t think people know much 

about yet, but it will be of tremendous help. As you said, you said 

there are more than 20 HRSA-funded community health center 

service delivery sites within 50 miles of Wilkes-Barre, as we sit 

here today. That is substantial. 

I wanted to also go to the part of your testimony on page 4 and 

5. You talked there about increasing the number of frontline direct 

care workers as a major priority. 

20 

Dr. HEINRICH. Right. 

Senator CASEY. You talked about in particular I highlighted 

‘‘older and disabled patients with very complex healthcare needs.’’ 

Sometimes I think we forget that it is not just demographics, but 

the complexity of the healthcare needs is significant. 

Obviously, the rates of vacancy and staff turnover. We talk about 

that over and over again. I have always found that in a long-term 

care facility, when you walk in the door—and I know I am simplifying this a bit, but it tells you a lot. You walk in the door, one 

of the first questions you should ask is what is your turnover rate? 

Interestingly, in my experience, and I am not a professional, but 

in my experience you can have a very successful long-term care facility even though the turnover rates are pretty high—40, 50 percent. A lot of them have 90 percent, right? 

Dr. HEINRICH. I was going to say that would be good. 

Senator CASEY. Much higher. I mean 40, 50 percent would be— 

it is hard to believe that that would be actually a good number 

compared to a lot of other sites. 

But in this category, I wanted to clarify something on page 4. 

You have two sections here, two programs. Personal and Home 

Healthcare Aide State Training Program. That is No. 1 on that 

page. It is a $5 million program. No. 2, you have the Nursing Assistant and Home Health Aide Program. That is $2.5 million. 

What I wanted to know was, and get a better description of, the 

difference between home care aide, that part of the first program, 

and home health aide? I think people can get confused by the overlap in the terminology. What is the difference between those two? 

Dr. HEINRICH. In fact, you have a number of terms that are used 

for people who are direct frontline workers, and it is one of the 

issues that we hope to address in our programs, as a matter of fact. 

So you have your personal assistant. You have home health aides. 

You have nursing assistants who work in nursing homes. Then you 

also have assistants who work in hospitals. 

Each of those areas have been looked at separately, and it seems 

to me very few people, very few organizations have looked across 

all of these siloed areas and said what are the basic competencies? 

Can you build those competencies as you move from, say, personal 

assistant, personal care assistant on through to maybe the more 

complex activities you would be expected to perform in a nursing 

home or even a hospital? 

What we would hope is that through our model curriculums, we 

could actually look at competency-based skills where an individual 

could build their skill base and progress forward, even to thinking 

about entry into new types of jobs, new jobs in the healthcare provider disciplines. 

Senator CASEY. Both these programs are 2 years, 2010 to 2012? 

Dr. HEINRICH. Yes. Well, one is 3, I think. 

Senator CASEY. OK. I also—I wanted to ask you as well. We have 

obviously the great opportunity, which is to say that it might be 

one of the few, if the only place in the country to be able to say 

this is accurate, and that is because we have a new medical school 

that is just getting off the ground. 

21 

The medical school has their second class coming in. Is that 

right, Doctor? I don’t mean to jump ahead to panel No. 2. I want 

to make sure we are right. 

As that school develops—and it is a tremendous opportunity, and 

that is an understatement—it just happens to be developing and 

growing as we are beginning to implement the healthcare bill. So 

it is a tremendous opportunity for lots of reasons. 

But what role can medical schools play in developing this workforce that we have spoken about this morning already? Especially 

when we have both a significant challenge, but also a tremendous 

opportunity here at the medical school but even nationwide the 

new strategies, the new programs that the healthcare bill provides? 

Dr. HEINRICH. Right. Well, again, with the new focus on primary 

care and the new focus on interdisciplinary education, it seems to 

me that there are many opportunities, as a new school is developing curriculum and thinking about how they are going to meet 

the needs of the population in different ways, and it sounds like 

you are very fortunate that the leadership of the medical school is 

really moving in that direction. 

So for many of our medical schools, it is very difficult to fight tradition. So, here you are with the opportunity to think about how 

you train together medicine, pharmacy, nursing, and the area of 

mental health. I was just so excited to hear about the program in 

pharmacy and nursing that you have here where you already have 

training programs, basic science programs where people are 

leveraging your existing resources so that you are much more efficient in the training programs. 

Sad to say, though, that you still have issues with the preceptorship and the placement because you have to have the clinical training, and it sounds like that is still a challenge for many of these 

programs. So we have to find ways of addressing the barriers that 

we have there with our expanding student populations but still 

needing the excellent preceptors and the clinical sites for the training. 

Even when we expand physician clinical traning beyond the hospital walls, which is wonderful to hear is happening in this community, into home care, into skilled nursing care, you still need to 

have hospital clinical sites to have an excellent program. It sounds 

like that is the direction that people are going. 

Senator CASEY. Well, we are fortunate to have these opportunities. 

Doctor, I know we are over time by a little bit, and I have a lot 

more questions. But what we will do is I and, I think, others will 

submit questions for the record. If you could answer those in writing, we are grateful. I wish we had more time to spend, but we 

have got two more panels. 

Dr. HEINRICH. Thank you very much. Appreciate it. 

Senator CASEY. Doctor, thank you for your testimony. We are 

grateful for your service. Especially at this time in our Nation’s history, we are confronting a lot of difficult healthcare challenges. So 

thanks for your service. 

Dr. HEINRICH. But it is fun doing all that implementation. Thank 

you very much. 

Senator CASEY. Thank you. 

22 

We will move to our second panel. What I will do by way of introduction, as our witnesses are moving to the witness table, I would, 

first of all, like to welcome, as I mentioned him before, Dr. Bob 

D’Alessandri, the Executive Officer and Chief Academic Officer of 

The Commonwealth Medical College, who is responsible for setting 

priorities, institutional direction, and management, and functioning 

of The Commonwealth Medical College, as well as the curriculum 

development and execution, the student experience, faculty recruitment, and the execution of the research agenda at the medical college. 

Dr. D’Alessandri is an educator with over 18 years of experience 

in senior leadership positions at West Virginia University, including almost 15 years as dean of the West Virginia University School 

of Medicine. 

Our other witness today on our second panel, Dr. Vera Salter, 

Professional Development Director of the Direct Care Alliance. Dr. 

Salter was the founding director of the National Clearinghouse on 

the Direct Care Workforce at PHI, where she worked from 2001 to 

2007. Before that, she co-owned a national planning and marketing 

firm with clients across the continuum of health and long-term care 

services. 

She has served as vice president of a multi-institutional 

healthcare system and has held a number of health planning and 

research positions. Dr. Salter, thank you. 

Dr. D’Alessandri, thank you. I think we will start with Dr. 

D’Alessandri. 

STATEMENT OF ROBERT D’ALESSANDRI, M.D., EXECUTIVE OFFICER AND CHIEF ACADEMIC OFFICER, THE COMMONWEALTH MEDICAL COLLEGE, SCRANTON, PA 

Dr. D’ALESSANDRI. Thank you very much. 

Good morning, Senator Casey, Dr. Heinrich, staff, and honored 

guests. I am delighted to be here this morning to speak to you 

about our aging population and the need for more medical personnel to care for them. 

While we have all seen the statistics—the percentage of the population aging, the increased demand because of chronic diseases, 

the aging of the provider population—those challenges are different 

in rural and small-town America. We, as a Nation, need to come 

up with solutions that are not one-size-fits-all because our needs 

and challenges are unique. 

I would like to take just a minute and introduce myself and my 

school to you because why we were created is specifically relevant 

to these interests. Wilkes-Barre, Scranton, Pennsylvania, northeast 

Pennsylvania has many small communities. Like many small communities in the United States, we suffer from a number of concerns. 

We have an aging population with many chronic diseases. In 

fact, Pennsylvania has the third-oldest population in America. Our 

physician population is also aging. In fact, almost half of the current physicians in this region will retire in the next decade. It is 

estimated that by 2025 this region will lack almost 1,500 needed 

physicians to care for our population. 

23 

We have a very fragile healthcare system. Hospitals incapable of 

investing capital in infrastructure improvement. 

We have had a poor track record of recruiting physicians, both 

primary care and specialists, to the region. Almost half of Pennsylvania physicians practice either around Philadelphia or Pittsburgh 

despite the fact that only one-quarter of the population resides 

there. Not surprisingly, that is where Pennsylvania’s medical 

schools have traditionally been located. Northeastern Pennsylvania 

suffers from a shortage of almost every type of physician and has 

fewer physicians per capita than national averages. We have over $1 billion in care. Yes, that is $1 billion leaving 

the region because people cannot get appointments with physicians 

or cannot get access to physicians for the type of care they need. 

This involves increased expense, hardship, and inconvenience for 

families and patients. 

We also have a region that has experienced tough economic 

times. The heyday of coal has been and gone. The economy here is 

not made up of major corporations. It is small companies, businesses trying to hang on. We don’t have a lot of wealthy people to 

support healthcare, the arts, and community civic programs. 

As I said at the beginning, we have a scenario that is typical of 

most of America’s small cities and towns—nothing remarkable, significant, or special, just people who work hard, who are trying to 

carve out good lives for their families and get their loved ones good, 

high-quality healthcare. What is unique about this community is 

how it decided to address the problem of physician aging, lack of 

access to care, and their relative lack of success in recruiting replacements for these aging physicians. 

This community came to the conclusion it needed to grow its own 

physicians and thus start its own medical school. The community 

had several goals for the school that included improving healthcare 

in northeast Pennsylvania by increasing the number of area specialists and primary care physicians; improving the quality of care 

in the region; improving access to care, especially in underserved 

and rural areas; generating economic impact by creating high-paying, sustainable jobs and attracting fresh dollars into the economy; 

increasing the education of the area residents; and providing the 

region with ‘‘intellectual capital.’’ 

I was hired in 2007 from West Virginia University to take these 

ideas and help create the school. In 3 years, we have obtained degree-granting authority from the State, received provisional accreditation from the LCME, the Liaison Committee on Medical Education, and the Middle States Higher Education Commission. We 

offer two degrees, a Master’s in Biomedical Sciences and a Doctor 

of Medicine Degree. 

We have hired 160 full-time faculty and staff. We have over 700 

community-based physicians participating on a volunteer basis to 

train our M.D. students and have graduated our first class of Master’s students. Next week, our second class of M.D. students—65 of 

them like the first class—begins. 

Our 40 Master’s students began in July. Our second-year medical 

students begin in late August. It has been a very busy 3 years. 

Now we are not a model that is easily replicable in America. 

Starting a freestanding medical school is not a model that is really 

24 

economically feasible. We exist because Blue Cross of Northeastern 

Pennsylvania invested $25 million in funding our startup and another $45 million in our new building. Our State invested $35 million in our building, funded our feasibility study, and gives us an 

important, but modest grant every year. 

Thanks to Senators Casey and Specter and our congressional 

representatives, the Federal Government has supported TCMC, 

helping us with grants to fund our Clinical Skills and Simulation 

Center and other small projects. Ongoing funding is a challenge not 

only for us, but for the other dozen or so new startup schools across 

the country. But solving the problems of communities such as ours, 

the small towns and cities in America, and having enough doctors 

and other health providers to take care of our aging population is 

a complex issue. 

The solution starts, like many problems, with changing our educational process because we don’t just need more doctors, we need 

doctors with different skills. We need to address the problem of 

fragmentation in the healthcare system by training physicians, 

nurses, pharmacists, physical therapists, and others to work as a 

team. 

As Dr. Heinrich mentioned, this is the interdisciplinary model. 

We need each of these individuals to understand not only their 

role, but others as well. We need to train physicians not just to 

lead, but how to work effectively as a team member. 

At TCMC, we have created the first Consortium of Health Professions Education Program with all the regional schools that have 

health education programs to develop opportunities for our students to learn to work as a member of an interdisciplinary team. 

We need physicians who can communicate effectively. Effective 

communication is essential for safe and effective care. This is one 

of the major complaints we hear from seniors. ‘‘My doctor doesn’t 

listen to me.’’ We need to develop these skills as rigorously as we 

teach molecular biology. 

We need physicians who know how to find information on stateof-the-art care and then incorporate it into their practice. One of 

our faculty told our students recently that he is not doing one procedure the same way he learned in medical school or his residency. 

What we teach today has a very short shelf life. We need to develop 

their interest in being lifelong learners and their skills at finding 

the information on care that they need, when they need it. 

We need physicians who understand the process of care improvement, how systems of care work and how to improve quality and 

safety as members of the healthcare team. Concepts like 6 Sigma 

and other quality improvement strategies and processes need to be 

learned by students, and they need to see they play a role in care 

and process improvement so care is both effective and cost efficient. 

Students need to understand critical thinking and systems thinking. 

We need physicians who understand when care should be standardized and when patients need proven therapies modified for their 

particular issues. Standardization of care flies in the face of how 

many schools select and train physicians. They are selected because they are independent thinkers, not because they can follow 

a formula. But data shows that, in many cases, standardization imVerDate Nov 24 2008 10:31 Jan 21, 2011 Jkt 000000 PO 00000 Frm 00028 Fmt 6633 Sfmt 6633 H:\DOCS\62692.TXT SAG PsN: JOYCE
25 

proves care and improves costs. We need physicians to know when 

each is important. 

Physicians need to be trained in cultures that are collaborative, 

transparent, outcomes focused, accountable, team based, patient focused, and service oriented. They need to see this culture modeled 

not only at their medical school, but in their community sites 

where they train. 

To do that will take a culture change in many of our healthcare 

organizations. They need to see models of care that work, first and 

foremost, for the patient, but also for the care team. They need to 

see innovative, cost-effective models, and we need a system that 

supports the development of these models, another place the Federal Government could provide support perhaps. 

Physicians must understand the critical issues facing our seniors—polypharmacy, end-of-life issues, depression, dementia, and 

the need to feel that you can still contribute in some way. Each of 

our students is assigned to a multi-generational family. The student follows this family for 4 years, makes house visits, hears from 

family members about how they have to make choices between 

medicine and food. 

I have to tell you that I have learned a great deal from my mother, who is 92. She keeps teaching me all the time. In recent years, 

she continues to get her Medicaid bills when she sees a physician, 

and frequently, she hands me the bill and tells me, ‘‘Pay this.’’ I 

look at it and say, ‘‘Mom, this is not a bill. I don’t have to pay this.’’ 

She said, ‘‘No, no, pay it.’’ I say, ‘‘No. I’m not paying. It’s not a 

bill.’’ A month later, she receives another bill, and she says, ‘‘Pay 

it.’’ I say, ‘‘It says, Mom, this is not a bill.’’ 

The next month, of course, she gets a letter from the collection 

agency saying that she is late. So I pay the bill. Then 6 months 

later, she gets a check from the provider saying you have overpaid. 

She says to me, ‘‘Don’t you know what you are doing?’’ I said, ‘‘No, 

I really don’t.’’ 

This is a complicated system, and seniors face this all the time. 

We would like our students to hear that from the families that they 

follow. We would like them to actually see what healthcare is all 

about in the home, not just in the clinic. 

So the very first part of this program is that the student visits 

the family in the home, and one of the first things we ask them 

to do is look in the medicine cabinet because that is where you will 

find an entire history of healthcare. It is a very important part of 

the educational experience, and to my knowledge, this may be 

unique in the education of medical students. 

We also want our students to follow healthcare providers, not 

just physicians, but many of the direct providers that we are talking about. Experiences in nursing homes and in other facilities 

where care is provided, that is part of our new curriculum. 

Our country needs a cadre of physicians specialized in the problems of our seniors. To that end, we are also planning a special 

training program in geriatrics. These specialists become resources 

for primary care physicians as well as seniors. Part of that program 

is not merely learning about the diseases and the illnesses that relate to seniors, but it is also learning about the social problems and 

also the health policy issues. 

26 

We want these geriatricians of the future to relate not only to the 

diseases and illnesses that affect our seniors, but also the economic 

and social problems as well. We want them to become leaders in 

policy changes as well. This is an important new aspect of geriatric 

training. 

We need to view medical education as a continuum of competency. We need an educational program that is cost effective and 

allows students to move through it not in lockstep, but as they develop competencies that build through the educational process. We 

are in some danger of pricing the cost of medical education out of 

the marketplace. 

Finally, we need to connect the education of physicians to their 

community and to service. We need to select bright students who 

want to serve, who want to make healthcare better, stronger, more 

effective—who want to care not only for the individual but improve 

the care in their community. We need to prepare physicians in 

their educational program to do that. 

I would recommend to the Committee three excellent resources— 

the new Carnegie Foundation Report, entitled ‘‘Educating Physicians: A Call for Reform of Medical School and Residency,’’ the Josiah Macy Foundation’s reports on medical education and the new 

medical schools, and a wonderful book by Boston physician Atul 

Gawande, entitled ‘‘The Checklist Manifesto,’’ that addresses how 

healthcare can be safer and the importance of team communication. All these resources discuss what physicians need to know to 

care more effectively for patients. 

At TCMC, we are addressing many of these issues and recommendations. Our curriculum was easy to adjust to current needs 

since we could start from a clean slate and attracted faculty who 

want to teach state-of-the-art curriculum. 

Our model also has a community benefit. Since most of our faculty are community practitioners, they learn state-of-the-art care 

and thinking in their faculty development courses. Changing the 

way they deliver care will change over time the quality of care in 

our communities. Our educational model is deeply rooted in our 

goals and our reason for being. Our students are assigned a multigenerational family that they follow for 4 years. I mentioned that. 

They are exposed to an integrated curriculum from the very beginning where science and patient care are constantly tied together 

to create relevance. They are deeply embedded in our region’s communities. In the first 2 years, they have a clinical mentor, they do 

community research projects, and they learn about quality and 

safety processes all in a community-based setting. 

In their third and fourth years, they actually live in those communities and learn directly from over 700 volunteer clinical faculty 

who have been specially trained to teach students communitybased medicine. Our students learn how to work in teams in our 

Clinical Skills and Simulation Center and develop their professionalism and community service skills as part of the educational 

process. 

It is good public policy for the Federal Government to support 

new schools—to support new models of education, innovative models that seek to educate the students differently. The answer to our 

problems is not just to have more resources to train more doctors. 

27 

We need to provide new models of medical education that lead and 

support new, effective models of care. 

We need to support educational innovation and the programs 

that are trying to do that and educational programs that are trying 

to change community-based care. We need to give our students the 

tools that they are going to use to take care of us and our children 

and grandchildren. 

Then we need to invest in our hospitals and clinics who are barely hanging on. We need to make it possible for them to innovate 

and support quality improvement. If we are going to keep these 

newly trained physicians in this community, the places they practice must support the way they have been taught to practice. 

Our hospitals and clinics need infrastructure, information technology, training in systems thinking, quality improvement, improved communication. They must be examples of innovation, not 

just places that are themselves on life support. 

Then our small cities and towns will be able to care for our aging 

population. Our students who train in these communities will want 

to stay and raise their families in these communities. The answer 

is not just more money. It is money we spend differently to creatively meet the needs of an aging America in an effective and sensitive manner. 

The medical schools in this country committed to innovation and 

reengineering the educational and care delivery models deserve 

your consideration and support. The new medical schools can be a 

community-based catalyst for change, creating a national model 

that will enhance the efficiency and effectiveness of healthcare that 

is available to all Americans of every age. 

Our aging population must have access to the latest, most effective treatments, to providers who are sensitive and knowledgeable 

about their special needs, and we will be able to provide the kind 

of healthcare that works for everyone. 

Thank you very much. 

[The prepared statement of Dr. D’Alessandri follows:] 

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Senator CASEY. Thank you, Dean. Thank you, Dean, for that testimony. 

Dr. Salter, thank you. 

STATEMENT OF VERA SALTER, PH.D., PROFESSIONAL DEVELOPMENT DIRECTOR, THE DIRECT CARE ALLIANCE, NEW 

YORK, NY 

Dr. SALTER. Thank you, Senator Casey. 

I want to start by thanking you for your announcement that you 

are going to introduce the Direct Care Worker Empowerment Act 

tomorrow. That is very exciting news for us, and I think the very 

title is critical because what is so important is to recognize that 

there will soon be 4 million direct care workers working daily, one 

on one, with elders and people with disabilities. 

It is only if direct care workers have the resources and are empowered to take the actions that are needed to improve the quality 

of life for those they are working with, that is the way we are going 

to get quality care. I work with Direct Care Alliance, and I am 

proud to work for an organization that is the advocacy voice for direct care workers throughout the country. 

I won’t go through the statistics again of the greatly increasing 

aging population, but I think one theme I have heard from many 

of the panelists is that as the population ages, the cohorts of people 

that are available to do the work to care for them is shrinking. 

Senator CASEY. You might want to move that mike a little closer. 

Dr. SALTER. Saying that there is a gap between the care needs 

and the number of people who will be available to do that work, 

whether they are family caregivers or paid caregivers because you 

were talking of the physicians aging out of the profession and this 

is aging out of the profession. So the crisis becomes amplified by 

that care gap. 

I want to add that in 2008, there were 3.2 million nursing assistants, home health aides, and personal assistants in the United 

States. That number is projected to increase to 4.3 million by as 

early as 2018. I would like to also comment on the question you 

asked about the difference between home care aides and personal 

assistants and home health aides. 

In some ways, if you think of an elder or a person with disabilities that needs care in their home for a long period of time, the 

complexity of the work that a personal assistant has to provide 

may be greater than a home health aide, who is defined as someone who is working for a home care agency under the Medicare 

program. 

So, in some ways, the definitions of workers are created by the 

funding stream and not by the competencies that are required to 

do the work. That is why I think it is so important that the training and the compensation be based on competencies, as many of 

you have already said. 

So who are direct care workers? There are 165,000 direct care 

workers employed in Pennsylvania, and these are among the largest and fastest-growing occupations in the Commonwealth, projected to increase by 50 percent in the next 10 years. Most direct 

care workers receive low wages—on average, $10 an hour—little or 

no benefits, and insufficient training and professional development. 

36 

As a result, as we have said already, this profession is plagued 

by high turnover rates that compromise the quality of care of the 

people they serve. If we are to retain direct care workers in this 

profession and make it an occupation that people want to enter, we 

will need to provide basic labor protections as are provided in the 

bill that you are introducing, livable wages and benefits, training 

and opportunities for advancement. 

I was asked to address the issues of what is needed in terms of 

training, certification, and advancement to make direct care a desirable profession. First, I want to stress that all direct care workers should be required to receive adequate training. 

Currently, Federal regulations require only 75 hours of training 

for nursing assistants and home health aides, and there are no 

Federal requirements for personal care assistants who provide 

services under the Medicaid program or to private individuals. We 

recommend, in line with a recent Institute of Medicine report, that 

all direct care workers receive at least 120 hours of training, either 

before they start work or while they are working on the job. 

We also think it is very important that direct care workers have 

competency-based credentialing and recognition of their professional competency. The Direct Care Alliance has just established a 

National Professional Credential for personal assistance workers, 

the group that is not currently federally regulated. We also recommend that specialty credentials in such areas as dementia, peer 

mentoring, wound care, diabetes management, and many other 

areas be available to direct care workers. 

I would love to see more recognition of the role of direct care 

workers in the care team because while they are the people who 

are spending all day with an elder in their home, they are often 

not included as part of the medical team. 

One of the things that struck me as we look at the competencies 

of this workforce, this is difficult work. The same issues of communication, knowledge of a variety of medical background are critical 

for people to do their work well. Yet, as you know, under the Fair 

Labor Standards Act, they have been—home care workers have 

been categorized as ‘‘companions’’ and not as professionals that are 

a necessary part of the team. 

One of the most critical things is respect and opportunities for 

advancement. There have been numerous evaluative studies of 

what it takes to retain direct care workers, and it is really in some 

ways blazingly obvious. But I just want to tell you about some of 

those studies. 

There was a program funded through the Robert Wood Johnson 

Foundation called the Better Jobs, Better Care program, and there 

was a special edition of the Geriatric Journal that gave the results 

of some of those studies, and the message gets repeated. For example, a study in Massachusetts found that nursing assistants were 

more committed to their jobs when they perceive their jobs as having more autonomy, use of knowledge, and teamwork. 

In another study at Cornell, a retention specialist program demonstrated that assigning a manager with expertise in all of the 

techniques of retaining people improved retention when compared 

to facilities without such a program. The WIN A STEP UP program 

37 

in North Carolina provides continuing education and compensation 

for education modules, also had great success. 

There are numerous career ladder programs throughout the 

country, and at Genesis Healthcare, headquartered in Kennett 

Square, PA, they have had a geriatric nursing assistant specialist 

program for 21 years that trains and compensates nursing assistants for their advanced knowledge. 

There have been many studies of what direct care workers are 

looking for, and in one study conducted by Dr. Peter Kemper, a 

professor at Penn State, he summarized what is important to direct 

care workers. What they want is more pay, better work relationships, being appreciated, listened to, and treated with respect, 

which is basically what we all want in our work. 

Unfortunately, recognition of these issues and efforts to create 

the right work environment is limited and sporadic. What is needed is a broad public policy that changes the way direct care work 

is managed and compensated so this becomes a respected profession that people want to enter. 

[The prepared statement of Dr. Salter follows:] 

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Senator CASEY. Well, Doctor, thank you very much. 

I want to thank both of our witnesses for your testimony. I just 

had a couple of questions, and in light of our time, probably just 

maybe about 5 minutes of questions. 

First of all, Dr. D’Alessandri, I wanted to ask a basic question 

about—kind of a ‘‘where we are’’ question. I know the medical 

school is up and running. You have got your second class coming 

in. But can you give us a little update on the construction, kind of 

where that is. 

Dr. D’ALESSANDRI. Construction is proceeding very nicely. We 

will be occupying the building by April 11, 2011, in plenty of time 

to accept our third class. At that time, the class will increase in 

size to 100 and eventually 120 students per year. So we are right 

on target for that and feel very, very good about that. 

Senator CASEY. This incoming class is? 

Dr. D’ALESSANDRI. Sixty-five. 

Senator CASEY. Last year’s was 65? 

Dr. D’ALESSANDRI. That is correct. We are currently at Lackawanna College, utilizing their temporary space there, and that is 

really the limit that we could manage at the present time. 

Senator CASEY. You mentioned the students working with a 

multi-generational family. We don’t hear enough about those kinds 

of approaches, and I wanted to have you expand on that and why 

you think that is so critically important to expose a young medical 

student to that kind of experience? 

Dr. D’ALESSANDRI. Right. It really is a very important concept. 

Our students are relatively young. Not relatively, they are young. 

Most of them, if not all of them, have very little experience with 

the healthcare system. Their parents are young. 

By the time they become familiar with the healthcare system 

from a patient perspective, they are physicians and treated differently. Physicians don’t really understand healthcare from the 

patient perspective, and we see the patient in the clinic, in the office, and patients just won’t tell you things. 

So the young mom who takes her two children, waits in the waiting room for 2 hours, then sees the doctor in a skimpy gown, waits 

there for 20 minutes, and her doctor walks in and looks at her and 

wonders why her kids are running around and she can’t take care 

of them. That young lady will never say a word to the doctor about 

all of that. 

But she will go home, complain about that. Our students, we 

hope, will hear that and will learn about the problems about the 

healthcare system from the patient’s perspective. It isn’t learning 

about medical knowledge. It is really learning about the social-economic impact that this has on a family and on their health, and 

that is really why we think this is so critical. 

It will also bond those students to those families, and we hope 

those families will also play a role in recruiting those students and 

keeping them in our community. 

Senator CASEY. I also want to note for the record that in Dr. 

D’Alessandri’s testimony, starting on page 3 and going through 

most of page 5, when he walked through those various points about 

working effectively as a team member, helping physicians to communicate better, finding information on state-of-the-art care, how 

42 

a system of care works, standardization of care, collaborative and 

transparent outcomes-focused, accountable team-based focused 

strategies, critical issues facing seniors—when he went through 

that whole list, he starts with the word on page 3, ‘‘solutions,’’ 

which we want to hear about. 

We know that sometimes, especially in Washington, we can be 

very good at diagnosing problems and challenges and not often 

enough outlining solutions and then pushing forth ways to implement those solutions. So we are grateful for that kind of roadmap 

or list of solutions that we can all work on together. 

Dr. Salter, I wanted to ask you about—and a lot of your testimony is very consistent with my own unprofessional observations, 

but I think significant experience as a public official. I am not sure 

there is any public official in the State over the last decade or so 

who has spent as much time on some of these issues as they relate 

to direct care workers and older citizens as I have. I still don’t consider myself an expert, but I learned a lot along the way. 

Your testimony was very consistent with experiences I have had, 

as both a public official and as a member of the family. As Dr. 

D’Alessandri and others have noted, we learn a lot more about 

healthcare and the work and the policy as members of the family 

than we do sometimes in our professional lives. 

But one observation, one insight that you and others have had 

is that the direct care worker wants to be seen as a professional, 

wants to be valued more, and sometimes one of the ways to get 

there is to develop what people in the industry have said not a career ladder necessarily—it could be that, I guess—but a career kind 

of lattice. In other words, they can move almost laterally or—can 

you explain that, what your sense of that is? 

Dr. SALTER. Well, we have found that when somebody enters an 

occupation, at the beginning they are learning the basics of doing 

it. But when you have spent 10, 20 years in the occupation, you 

have learned a lot of skill. There can be lots of ways to recognize 

people’s advanced knowledge so that people can have specialty 

training in geriatrics, in dementia, in diabetes management, and be 

compensated for it so that people are moving up a ladder, as it 

were, within the direct care profession. 

There are also some people that do want to take that learning 

and move on to LPN or RN programs, but we have found that that 

is a minority. Many people who do this work do it because they 

love the work but find it impossible to stay in the occupation because it is so poorly compensated and regarded. So I think there 

are a lot of different pathways for different people, which is why 

the word ‘‘lattice’’ has been introduced. 

There has also been a lot of success with peer mentoring programs because one of the biggest turnover times is in the first 6 

months of the work. People enter the work in the nursing home, 

for example, and leave within 6 months. Whereas if there is a senior aide who has already done this work who is assigned to support 

them, they are much more likely to stay. Again, that peer mentoring role can be trained and supported with compensation. 

So I think there are opportunities for people to move ahead in 

the profession and also to work in more supervisory ways because 

there is a shortage of RNs and a shortage of people to take on some 

43 

of the management functions because a lot of self-scheduling where 

people are allowed to schedule their own work that can be organized. So, there are many ways that people can be empowered 

more and compensated for their knowledge and their advanced 

work. 

Senator CASEY. Well, I can’t tell you how many times over the 

last it is now 15 years since I have been a public official that people have told me that are experts in long-term care that run nursing homes about a whole myriad of problems. It would be complicated enough if this were just a worker, direct worker, direct 

care worker problem, but this is a big employer problem. 

Dr. SALTER. Right. 

Senator CASEY. We haven’t gotten our public policy right to the 

extent that you have a nursing home might train over the course 

of a year or more, or maybe more than a year, they might train 

10 people and retain 1. 

Dr. SALTER. Yes. 

Senator CASEY. So they spend all that time, all those dollars 

training someone who leaves within months. So it is obviously bad 

for the worker, bad for the employer in a significant way, and bad 

for the person in that bed who is dealing with Mary or John for 

a couple of months, maybe longer, and then they have a turnover 

and then another turnover, another turnover. 

So the family is confused. The person who is the recipient of that 

care is not getting the quality of care they should get. The employer is out money, and the worker is bouncing around to different 

jobs. So we need to get it right, and there is a lot more to do to 

get it right. 

I did want to ask Dr. D’Alessandri one more question. Just about 

the—you did mention the training program in geriatrics. Can you 

talk about that for a moment just a little more? 

Dr. D’ALESSANDRI. Sure. Also, I wanted to mention just a couple 

of things that relate to that, if I might? 

Senator CASEY. Yes. 

Dr. D’ALESSANDRI. One is that we think pipeline programs are 

really critical, and I know that Dr. Heinrich mentioned that. We 

are actually involved in and have applied for an HCOP program 

and have been working with Wilkes and LCCC, Luzerne County 

Community College, in developing those pipeline programs. 

So we think that has a real important aspect in terms of training 

workforce in healthcare for this region and really focusing on rural, 

first-generation, underserved minorities. So that is a really strong 

program for us. 

The second is that in residency programs—and I really applaud 

the effort that HRSA is making in increasing residency slots primary care. But very often, primary care residency slots go unfilled. 

Where the dollars would be better spent or at least equally well 

spent, let me put it that way, would be really encouraging medical 

schools to increase primary care training among their students and 

giving incentives for medical schools to really educate primary care 

physicians. 

The geriatric program is a very important one. Ninety-five percent of the care, primary care for seniors is really going to be with 

primary care providers, not with geriatricians. We see geriatricians 

44 

as being a resource for the primary care provider, as well as the 

patient and for other agencies that work with seniors. We see the 

geriatrician as the advocate in terms of public policy for the senior 

from the healthcare perspective. 

So, with that in mind, the training program involves not only the 

usual aspects of medical education, disease, and that sort of thing 

for the geriatrician, but it also involves an intense knowledge of the 

social agencies and other agencies that relate to seniors—— 

Senator CASEY. To be an advocate. 

Dr. D’ALESSANDRI. To be an advocate. An understanding from 

the senior’s perspective of how they may utilize and work with 

those. I was intrigued by the navigator concept that Dr. Heinrich 

talked about. In some ways, the geriatrician is also a navigator, 

helping the senior through the system, and maybe even helping the 

primary care provider through the system. 

So we think that the traditional model teaching knowledge-based 

content, skills, all of that is very important, but also the other aspect of this, health policy and also understanding dynamics within 

the community, are really important. 

For example, transportation is a huge problem in our area for 

not only seniors, but for everyone. Getting to an appointment, relying on family, those kind of things. Helping work through those 

problems with seniors, we see the geriatrician as being a very important part of that. 

Senator CASEY. Well, Doctor, thank you so much. Dr. 

D’Alessandri, Dr. Salter, I know we have more questions, but not 

enough time. But we will send questions for the record that will 

be additional to amplify your testimony. We are grateful for your 

time here today. Thank you very much. 

Dr. D’ALESSANDRI. Thank you, Senator. Thank you. 

Senator CASEY. We will move to our third panel. As our panelists 

are getting to their seats and we are transitioning to our third and 

final panel, we will be pleased to welcome Melissa Lear and Connie 

Kreider. 

Melissa is President of Beck N’Call Home Health and President 

of Allen Lear Home Health. In these positions, she has focused on 

providing in-home assistance to older citizens in the indigent, serving people whose activities of daily living are not covered under 

Medicare, Medicaid, or other insurance programs. 

Ms. Kreider is a Certified Nurse’s Assistant and since 1998 has 

worked at Luthercare, an assisted living facility in our Commonwealth. She is also the co-chair of the Pennsylvania Direct Care 

Workers Association. 

So, Ms. Lear, we will start with you. 

45 

STATEMENT OF MELISSA LEAR, PRESIDENT, BECK N’CALL 

AND PRESIDENT, ALLEN LEAR HOME CARE ASSOCIATES, 

EAST STROUDSBURG, PA 

Mr. LEAR. OK. Good morning and—I guess almost afternoon 

now. I can’t thank you enough for letting me come here and do 

this. 

Senator CASEY. Let me interrupt for one second. I know your 

printed testimony is longer than 5 minutes. 

Mr. LEAR. I am going to make this amazing for you. 

Senator CASEY. Summarize as best you can. 

Mr. LEAR. The fact of the matter is that I am one of the faces 

of home care. I am not only the CEO, I am a registered nurse. As 

the CEO of two companies, I still see patients on a regular basis. 

I could talk about home care from now until years after I am 

dead and gone. I think that the reason that it is important for me 

to be here today is to let you know that recruitment has always 

been a problem in home health for both aide—direct care workers, 

home health aides and nurses. But my agencies have been successful over the years by making the rewards and benefits of working 

in home care a primary focus. 

I don’t believe that the financial rewards of doing this kind of 

work are ever going to match the personal satisfaction that the 

people who do it get. So a few of the real important factors of working in home care is our one-to-one patient relationships. I graduated with a bunch of nurses who work in hospitals. They see 10, 

12, 14 patients a shift. I see one at a time. They have my undivided 

attention for the amount of time that I am there, and I am there 

however long I need to stay to get done what I am there to do. 

If you would imagine for a moment sitting in the kitchen with 

Miss Vivian in her late 90’s, and she cries and speaks softly to you 

about how cruel it is for her to continue living. She has lost most 

of her sight. She has outlived all of her friends, and her family 

lives too far away to help. She knows and you know that without 

home care she would be placed in a nursing facility, being forced 

to leave her home. 

Imagine working with Miss Margaret, performing wound care on 

a dressing and listening as she tells the story of how her husband 

built the home she still lives in with her son. She reminds you that 

your agency took care of her husband also, and it has been a few 

years since he passed away. 

She lets you know that what she wants most for her 100th birthday, which is right around the corner, is a record number of birthday cards. So you head back to the office. You spread the word. All 

the employees that can get a card in the mail to her do so. Miss 

Margaret got an unbelievable number of cards, a spot on the local 

news, huge bouquets of flowers, and one more birthday before she 

passed away at 101 years of age. 

In total, your agency provided almost 9 years of care to Mr. and 

Mrs., but they rarely required more than 3 or 4 hours per day because their son, in his 80’s, bridged the gap between our services. 

The only difference between you and I is that I don’t have to 

imagine these stories. These are not the stories of my employees 

or employees of other agencies. For me, they are real events, and 

they belong to me. 

46 

Benefits to working in home care include flexible schedules that 

work for patients as well as staff. It is a process of care that I have 

kind of coined the phrase ‘‘wholistic,’’ meaning W-H-O-L-E, because 

we solve care management problems that stem across the entire 

family dynamics. We find many problems in home care that we can 

fix that we have talked about earlier today that physicians don’t 

know about, hospital discharge planners don’t know about, clinics 

don’t know about because families are either too embarrassed to 

share it or don’t believe that anyone has the solution. 

I can offer to you that the first single-biggest impact you can 

make in the future recruitment of individuals is to encourage and 

support a growing influx of available nurses, home health aides, 

and caregivers, and that would be to show firsthand potential pool 

of individuals the impact that they can make on another person’s 

life. 

What makes a young man or woman at the age of 18 enlist in 

the military is not a paycheck. It is a deep-seated love for their 

country and the freedom that being part of this country brings 

them. It is the need to be part of something bigger than is just 

themselves. It is a lifestyle that is presented to them when they are 

very young. 

This is what we need to do for the home care agency. I was not 

a nurse since a long, long time ago when I was 18. I quit college 

three times before I finally finished. I didn’t finish in nursing. I 

have a Bachelor’s degree in computer information systems. I have 

a Master’s in business. I didn’t graduate from nursing school until 

I was in my late 30’s, when I went back and decided this is what 

I wanted to do. 

I spent 21⁄2 years working full time while I attended classes and 

did clinical rotations. During my 2 years of clinical care work, I 

spent weeks in nursing homes learning to apply what I had 

learned. I moved to a hospital clinical rotation. I spent three semesters, did clinical rotations in four or five different hospital settings. I spent one day in home care and hospice. That was not 

enough to change my life. 

I already knew home care. I already loved home care. That is 

what keeps me in home care today. Most people that I meet still 

have no idea what a home care nurse is, what a home care aide 

is. They don’t understand what we do or the impact that we make. 

My very small agencies employ 75 people, and we see approximately 200 patients a day. We make a huge difference in the community that we serve. 

Picking through to see what I really want to add. I think that 

home care also has a very serious place in chronic care management, and I would hope that as different issues of the healthcare 

reform come through that home care is not left off the table. We 

are a very important resource to kind of spread that physician avenue for patients out geographically. 

I know that there are a lot of initiatives under the healthcare reform legislation that focus on chronic care management, and I 

would like to let everybody know that home care would certainly 

love to partner in many of these endeavors in reaching out to people from telehealth right on up through any other demonstration 

47 

projects that are going on. We certainly would be appreciative to 

be present at the table when those are put forth. 

The only other thing I can share is that we serve a large number 

of populations who are squeezed between Medicaid and Medicare. 

When you cross over, just over the Medicaid border of financial eligibility is a population of individuals who are making hardcore 

choices between taking their meds every other day, between doing 

their lab work as regularly as they should because they can’t afford 

to have someone come into their home and do it. Medicare doesn’t 

cover it in many, many cases for them, and they don’t have the 

ability to get out to a physician or a lab to do this kind of testing. 

The example would be like a Coumadin patient, someone who 

takes blood thinners, requires frequent blood monitoring. Right 

now, you can have a Medicaid patient who gets that service covered 

for them. They could be monitored every 2 weeks like a physician 

would order. 

Somebody who just misses those financial eligibility guidelines is 

negotiating with their physicians, trying to stretch that time period 

out because they don’t have the resources available or the means 

to get that kind of medical care as regularly as they should. 

The one final note I will toss in is if there is an opportunity at 

some point in the near future to allow Pennsylvania physician assistants and nurse practitioners to order and write home care services, that would be a huge help for us. We work with a lot of nurse 

practitioners who right now are not permitted to sign our home 

care orders, and it slows down a patient’s availability of services. 

[The prepared statement of Ms. Lear follows:] 

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Senator CASEY. Thanks very much. You did a good job staying 

within the time, and I know, as I said before, your whole testimony 

will be part of the record. 

Connie? Thank you very much. 

STATEMENT OF CONNIE KREIDER, DIRECT CARE WORKER, 

COLUMBIA, PA 

Ms. KREIDER. Hi. Good morning. What an honor it is to be here 

today, and I would like to thank everybody for the opportunity. 

I am a direct care worker. I have been in the field for roughly 

13 years, and my background started in retail, which I intended to 

stay in. But with the overwhelming amount of stress and long 

hours and managing a family, a husband, and family’s multiple 

schedules, it got to be harder and harder to stay in that field. 

So I decided to look for a career change. Someone I had run into 

had said I should try to get into the nursing field because, of 

course, that is the cutting edge of the future, of a growing future. 

So I went down to the area nursing home, which I had never actually entered a nursing home before. So this was my first time ever. 

This turned out to be a very rewarding and blessing area for me. 

I believe that people want to provide a positive way of life for the 

elderly. I believe that people want to actually give back. It is almost like a sense of giving to others. 

I really am a firm believer of doing unto others as you would 

have them do unto you—the Golden Rule. Treat someone with love 

and respect, and they will treat you back with love and respect. If 

you work in this mindset, everything else really falls into place. 

It is really sad that the Federal Government—Federal law only 

requires 75 hours of training in this field when, really, that is not 

near enough. You really need to have additional communication 

skills, compassion training, and good customer service, also with 

multitasking with several things going on at the same time. 

On a daily basis, you may have anywhere between 8 to 12 to 

sometimes more residents. The high turnover for nurses aides in 

the first year is roughly 60 percent and in the second year is roughly 80 percent. They are not nearly prepared for the physical work, 

the emotional demands, and the stress that comes with this line of 

work. 

So when there is this high turnover rate, who really suffers? 

Well, we all suffer. The residents are very upset that someone new 

has just come in to take care of them. The quality of care that is 

provided to the elderly and to people with disabilities is so important that change is very difficult on them and also difficult for the 

family members who have also formed a close relationship with the 

caregivers. 

They form a close relationship with their caregivers and become 

emotionally attached with them. We become a part of their lives, 

and so many caregivers are often thought of as an extended member of the family. We are the eyes and the ears of the many different places we choose to work from. It takes a qualified, adequate, positive caregiver to stay focused on the issues. It requires 

a large amount of teamwork and communication and also a great 

sense of humor to pull this work off. 

56 

Direct care workers are roughly 90 percent female, and many 

work more than one job in order to support their families. Many 

do not have adequate healthcare, or if they do, it is so high in the 

cost of things that they really can’t afford it. Many are great providers of others, but they lack the ability to provide for themselves. 

I can’t stress that enough. 

Stress takes a toll of your mind, body, and spirit. It can consume 

you and leave you feeling burned out. This is also seen across the 

board as ‘‘compassion fatigue.’’ So who takes care of the caregiver? 

We need to be kind to each other, have a peaceful work environment, work as a team. 

I am a member of the Pennsylvania Direct Care Workers Association, and we promote compassion and quality care for people living with disabilities and the elderly, the chronically ill, and the terminally ill. The association strengthens the quality of professional 

personal care for all Pennsylvanians by providing education, advocacy, and support for the direct care worker profession. 

I am also very proud to be a supportive member of the Direct 

Care Workers Alliance. Vera had talked earlier. The DCA provides 

direct care workers with advocacy and leadership training. They 

support all direct care workers in assisting in the development of 

associations and coalitions with technical support and leadership 

training. They also work toward improving the direct care workforce and support initiatives like the Direct Care Workforce Empowerment Act. 

So what does this mean for all direct care worker? It means a 

better workplace and a better way of life. We are not alone. There 

are many of you who want to stay connected. We want to learn to 

give of ourselves. We learn to give to ourselves and celebrate our 

successes, love where we work, and work where we love. 

So what is a good direct care worker worth these days? Anybody 

have a clue? Just ask your one and only best friend in the world, 

one of your residents, and they will say that you are absolutely 

priceless. 

[The prepared statement of Ms. Kreider follows:] 

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Senator CASEY. Connie, thanks so much. 

I was struck by your testimony in a number of ways. One is just 

the language that you used to describe your work and the work of 

so many direct care workers across our Commonwealth and across 

the country. Words like you said at one point earlier in your testimony—I am not sure this is part of your prepared testimony. You 

said ‘‘the sense of giving to others. People want to provide a positive way of life for others, a way of giving back.’’ 

A little later in your testimony, ‘‘Love and respect, compassion.’’ 

You used that word several times ‘‘compassion.’’ You used that 

word on page 2 as well. 

We don’t often see that language associated with the profession 

and with healthcare. God, we need more of it. We need a lot more 

of that kind of passion for the work that you are doing and passion 

for the care that you and others have provided. 

I wanted to ask you about some of the mechanics of how you prepare. This has always mystified me, and I know that you mentioned it about the 75 hours of training not being enough. 

Now 75 hours of training is not insignificant. That is basically 

two solid weeks of doing nothing but training. So I don’t want to 

downgrade it, but it is clearly not enough for the work that you 

have to do and others have had to do to care for people where, let 

us face it, in that long-term care setting with that resident, you are 

providing most of the care. Most of the kind of hands-on care, I will 

say. 

But talk for a moment about that training question because I 

know, for example, in Pennsylvania, in other professions that often 

don’t involve as much direct care giving, per se, the requirements 

are much, much higher. Also in professions that don’t provide any 

care giving. 

For example, my recollection is to be a barber or a beautician in 

Pennsylvania, you need my recollection is 1,000 hours, but I could 

be wrong about that. But it is a lot more than 75. It is multiple 

times higher than 75. My recollection was more than 1,000. 

So talk to me about the hours of care—or the hours of training. 

Not just that, but the preparation itself in a broader way. Or lack 

of preparation, as I would characterize it. 

Ms. KREIDER. Right. You know, the 75 hours gives you the basic. 

Really, your hands-on care and your hours of working with a seasoned caregiver is really where your training comes from and from 

having an open line of communication with your family members 

and your residents, also with the required in-service hours that you 

put forth in your year of training. 

There is also several programs out there that have continuing 

education that is really essential to tap into also. 

Senator CASEY. Connie, I think what causes so many of us to be 

in awe of the work that direct care workers do every day, although 

our policy doesn’t always reflect that awe and respect that we have, 

and we need to change that. That is why I and others have legislation to move in that direction. 

But we do have a tremendous respect for what you do. We do 

have a sense of awe. It is work that I would like to be able to think 

I could do, but I am not sure I could. I hope I could, but I am not 

sure I could. I think that is true of a lot of people. 

61 

What drives someone to enter this field of providing direct care 

and staying with it, despite all of the obstacles, all of the ways that 

our country has not put in place policy to be reflective of the care 

that you give. What motivates people to do it and to stay with it? 

Ms. KREIDER. Well, that is a very good question. I originally went 

into this field because of the convenience of it. But I quickly fell 

in love with this field. Early on, I wanted to think that perhaps it 

would lead into LPN or an RN position, but I quickly changed my 

mind after a couple of weeks. 

I think it has a lot to do with the relationships you have with 

your residents, just to work with them and to get to know them 

and to know their histories. Some of them are vets, and some of 

them have a long history of incredible stories to share, and just 

that relationship that you have with them is just priceless. They 

teach you lessons far beyond any textbook or history book you will 

ever be exposed to. 

So it is really fun, a learning experience. It humbles me many, 

many times because they have so much to offer and so much to 

give because they have seen so much. 

Senator CASEY. I remember years ago—I will tell a very quick 

story—my father was in a long-term care setting, and we would go 

to visit him. All four of his sons, when one or more of us were in 

the room, we are all pretty big, all over 6 feet tall and should have 

some degree of strength. 

He would be in the bed, and he would be on one side and, of 

course, would need to be turned. He was at a point where he didn’t 

have the strength to turn himself in a way that was appropriate, 

and he was someone who really valued expertise in a certain area 

or certain skill level. 

Once in a while, we thought we could be helpful, and we would 

pull—what seemed like an easy task, pulling the sheets or the pads 

underneath him to try to turn him. Invariably, we would do it, and 

we would do it wrong. So wrong that he would look at us like you 

made the situation worse, but he wouldn’t complain. 

Then a direct care worker came in the room, and invariably almost every one that I remember was a woman. She was a foot 

shorter and hundreds of pounds lighter, and she would pull that 

pad with a skill and expertise to make him feel comfortable. I 

couldn’t do it. My three brothers couldn’t do. My sisters couldn’t do 

it. It looked like we could, but we couldn’t. 

So that gave me an insight into just one, tiny—one small part 

of the work that gets done every day. Just to make someone feel 

comfortable in that bed was a big task, and he stopped asking us 

for help in that part of his care. He wanted a professional to do 

it, a direct care worker. 

Melissa, I wanted to ask you a question as well. You referred as 

well to what drove you to get into the business of caring for people 

and providing that kind of help in their homes. If you had an opportunity to write a piece of legislation or to draft a policy, what 

do you think is most needed as it relates not just to this field more 

broadly, but in particular to the work that you do, what you see 

every day? What do you think is our most pressing need or pressing challenge? 

62 

Mr. LEAR. Our pressing need is still staff. It is very hard to find 

nurses who want to come to the home care because I don’t think 

that they know enough about it. The other huge barrier that we 

have is what I mentioned with the physicians being the only ones 

right now in Pennsylvania who can sign home care orders. 

There are lots of wound care clinics that serve predominantly 

geriatric patients who are run by nurse practitioners, and their patients can’t get access to home care without a physician to sign off 

on it. The nurse practitioner is the one who sees the patient. The 

nurse practitioner is the one who should be ordering the home care 

and signing off on it so that we can get out there and do the dressing changes. So it is really slowing down that delivery system. 

I think those would be the most important things from a nursing 

standpoint. I am certainly onboard with the training for the home 

health aides and that component. Home health aides are near and 

dear to my heart. I mean, my 75 employees, 90 percent of them are 

home health aides. 

To the credit that some facilities have high overturn and things 

like that, we retired our first home health aide last year after 10 

years of service, recognized two others, and we have two more this 

year who are serving 10 years. 

Senator CASEY. I guess, over time, that profession, that part of 

our workforce will be growing substantially, right? As more and 

more people prefer to want to be cared for in the home, as more 

and more public policies incentivize that so you are getting in some 

ways less and less nursing home or institutional care, that workforce will become ever more important. Isn’t that correct? 

Mr. LEAR. It is ever more important. But I think it is not something that is—you don’t see the face of us a lot. We are standing 

next to you in the supermarket, and you don’t know who we are 

or what we do because we don’t look like other healthcare professionals. So I don’t think we are drawing enough young people into 

this. 

I frequently get calls for nurses who want to work in home care 

because they are burned out from their hospital setting, and they 

think that—I don’t know what they think, that we don’t see patients. But they want—they are looking for that desk job or case 

management job now that I can’t give them. People just don’t 

have—I can’t think of anyone in my graduating class who is working in home care besides me. That is kind of sad. 

Senator CASEY. You said very little of your training was directed 

at that, huh? 

Mr. LEAR. Very little of my? 

Senator CASEY. Very little of your own training. 

Mr. LEAR. Oh. No, one day. I spent one day in home care and 

hospice, and they shared it. I saw one home care patient, one hospice patient. 

Senator CASEY. I was noting in your testimony, you didn’t have 

a chance to go through all of it, but you had three major categories. 

The first one, in terms of the focus of your testimony, meeting the 

increased need for senior care and support was one. The second 

was preparing a workforce to support a growing elderly population. 

Third was retooling our healthcare system, including long-term 

care. 

63 

Is there anything that you wanted to, any point you wanted to 

make that you didn’t have a chance to before in either or one of 

those three areas? 

Mr. LEAR. I think maybe two points. I just think that somewhere 

in the Medicare system, it would be nice to fund chronic care conditions. Maybe not the traditional 60-day payment, well, that I am 

familiar with. We get one lump sum to care for somebody after hospital stay. 

If we could get in there before the hospital stays and provide 

some support, we have had a lot of success in home care with HIV 

patients who are frequent fliers in the hospital, of medication management patients who are frequent fliers in the hospital because 

they can’t get it right. 

But under the Medicare system, there is no vehicle to pay for 

that. So if we didn’t look at maybe traditional Medicare, but some 

kind of a new—and I say that cautiously, some kind of a new payment system to manage those chronic care conditions, that would 

be hugely important to keeping people at home. 

Senator CASEY. OK. Well, thanks very much. I know we are out 

of time. It is about 5 after 12 p.m. That is a record that we are 

pretty much on time. That is pretty good. 

We will have more questions for both of you. We will submit 

them for the record and ask that you answer them in writing, but 

we are grateful for your testimony and grateful for the testimony 

of all of our panelists. 

For those who were here for the basically 2 hours of testimony 

and discussion, we are grateful. I was saying as I was coming in 

here today, we don’t get a chance to do this very often. People 

think this is very common to have hearings like this in states like 

Pennsylvania or across the country. Its not, unfortunately it should 

be more common and even in Washington we have lots of hearings 

but sometimes not enough that are as focused as this one is, and 

has been and we are grateful for that. So thanks for your testimony 

and we are adjourned. 

[Whereupon, at 12:08 p.m., the hearing was adjourned.] 

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1 65+ in the United States: 2005, released by the U.S. Census Bureau. 

A P P E N D I X 

DR. HEINRICH’S RESPONSES TO SENATOR CASEY’S QUESTIONS

Question 1. Pennsylvania has the fourth highest percentage of residents over age 

65. This gives us a tremendous opportunity to play an important role as the nation 

decides how to care for our older citizens. How can we work together to allow Pennsylvania to be a model for other states with younger populations? 

Answer. We recognize that one of the major health care challenges facing the 

United States is providing appropriate care to the increasing number of older Americans with complex health needs. The Census Bureau estimates that the number of 

adults age 65 and older will almost double from 2005–2030.1 HRSA recognizes the 

need for additional health care providers with knowledge and training in the unique 

health needs of older Americans, and has several funding opportunities that support 

geriatric workforce development. Pennsylvania residents and institutions (including 

educational institutions) are eligible to apply for the varied funding opportunities 

that the Federal government has relating to elder care. HRSA offers consultation 

and technical assistance to anyone interested in these funding opportunities. 

Question 2. What HHS resources could be made available to the Scranton-WilkesBarre region to help guide our health professions training schools and healthcare 

providers in taking full advantage of the federal grant programs you cite in your 

testimony? How do we ensure that a comprehensive system of services and qualified 

healthcare professionals are available to this population, and that all of the programs you mentioned are leveraged, and not a few hit or miss? 

Answer. HRSA has an array of resources available to help identify grant opportunities to support health professions schools and healthcare providers in the Scranton-Wilkes-Barre region, as well as all other parts of the nation. The best starting 

place is HRSA’s website, http://www.HRSA.gov, which has information about 

HRSA’s programs and links to additional sources of information. It is also a good 

place to identify additional sources of assistance—toll-free numbers, written products, and contact information for federal program staff. 

Question 3. You mentioned in your testimony several federal grant programs that 

are assisting this region or that could soon assist this region in improving the 

healthcare of our older adults and their families. In issuing grant guidelines for applicants of HHS, HRSA, NIH or AHRQ programs, is there any preference afforded 

to new medical schools? What about a set-aside of a percentage of funds for new 

grantees, so repeat grant recipients are not the only ones being able to take advantage of scarce federal resources? 

Answer. None of HRSA’s programs have a statutory preference for new medical 

schools or set-asides for new grantees. We cannot address this question as it pertains to NIH or AHRQ. 

Question 4. You referenced several provisions to address the challenges we face 

in training frontline health care workers and especially direct care workers. What 

steps do you think a state like Pennsylvania with a high percentage of older citizens 

should do to best respond to these initiatives and become a model for other states 

around the nation? 

Answer. Pennsylvania is clearly a leader among States in caring for older Americans and poised to build upon this experience. HRSA encourages all qualified applicants to submit applications for funding opportunities like the State Health Care 

Workforce Development grant program. This program, created by the Affordable 

Care Act, will enable State partnerships to plan and implement innovative strategies to expand their primary care workforce by 10 to 25 percent over ten years to 

meet increased demand for primary care services. 

Question 5. Is our nation’s current approach to medical education sufficient to 

meet the growing demand for health care services? And related to that, what do you 

66 

think is the best way to expand the number of residency slots to meet the forthcoming physician shortage? 

Answer. Current projections suggest that there will be a shortage of providers, 

particularly primary care physicians, in the years ahead. The Administration has 

responded to the shortage by announcing $250 million for its workforce initiative, 

which is designed to increase the number of health care providers and strengthen 

the primary care workforce. Resources, made available by the Affordable Care Act 

and the American Recovery and Reinvestment Act, will support the training and development of more than 16,000 new primary care providers over the next five years. 

HRSA plays a key role in managing this initiative , and is currently implementing 

a multi-pronged approach to strengthen the numbers of primary care providers, including physicians, nurse practitioners and physician assistants. 

In addition, the Affordable Care Act funded several new grant opportunities for 

primary care providers, including the teaching health center program which will 

provide GME payments to support community-based training. Teaching Health Center GME payments will cover the costs of new residency programs in communitybased ambulatory primary care settings such as health centers. This will have a 

strong positive effect on the number, and quality, of primary care physicians in this 

country. 

Question 6. In many ways new medical schools present a clean slate for many of 

the new models we will be testing and utilizing under health care reform. How can 

we work together and with these schools to harness those resources and work to 

develop residency programs that complement what these students learn in medical 

school? 

Answer. HRSA recognizes that new medical schools are uniquely poised to create 

and implement innovative curricula. Residency programs and medical school curricula can be molded to incorporate competency-based models of care, including 

interprofessional team-based competencies and patient-centered medical homes. 

HRSA training programs for physicians are available to support these efforts and 

we look forward to working creatively with you and the medical school community 

to achieve these goals. 

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