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46–167 PDF 2009

S. HRG. 110–701 

CARING FOR OUR SENIORS: HOW CAN WE 

SUPPORT THOSE ON THE FRONTLINES? 

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

WASHINGTON, DC 

APRIL 16, 2008 

Serial No. 110–26 

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 

THOMAS R. CARPER, Delaware 

BILL NELSON, Florida 

HILLARY RODHAM CLINTON, New York 

KEN SALAZAR, Colorado 

ROBERT P. CASEY, Jr., Pennsylvania 

CLAIRE McCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

GORDON H. SMITH, Oregon 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MEL MARTINEZ, Florida 

LARRY E. CRAIG, Idaho 

ELIZABETH DOLE, North Carolina 

NORM COLEMAN, Minnesota 

DAVID VITTER, Louisiana 

BOB CORKER, Tennessee 

ARLEN SPECTER, Pennsylvania 

DEBRA WHITMAN, Majority Staff Director 

CATHERINE FINLEY, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator Herb Kohl ............................................................. 1 

Opening Statement of Senator Bill Nelson ........................................................... 3 

Opening Statement of Senator Susan Collins ....................................................... 3 

Opening Statement of Senator Ken Salazar ......................................................... 4 

Opening Statement of Senator Bob Casey ............................................................. 5 

Prepared Statement of Senator Gordon Smith ..................................................... 29 

PANEL I 

John Rowe, MD, professor, Department of Health Policy and Management, 

Mailman School of Public Health, Columbia University, New York, NY ........ 5 

Robyn Stone, DPH, executive director, Institute for the Future of Aging 

Services, American Association of Homes and Services for the Aging, Washington, DC ............................................................................................................. 20 

PANEL II 

Martha Stewart, founder, Martha Stewart Living Omnimedia, New York, 

NY ......................................................................................................................... 39 

Todd Semla, PharmD, president, American Geriatrics Society, Evanston, IL ... 50 

Mary McDermott, personal care worker and board of directors member, Wisconsin Home Care Commission, Verona, WI ..................................................... 64 

Sally Bowman, PhD, associate professor, Department of Human Development 

and Family Services, Oregon State University, Corvallis, OR ......................... 69 

APPENDIX 

Prepared Statement of Senator Susan Collins ...................................................... 83 

Prepared Statement of Senator Robert P. Casey .................................................. 84 

Prepared Statement of Senator Barbara Boxer .................................................... 85 

Dr. Robyn Stone’s Responses to Senator Smith Questions .................................. 86 

Martha Stewart’s Responses to Senator Smith Question .................................... 88 

Dr. Todd Selma’s Responses to Senator Smith Questions ................................... 89 

Mary McDermott’s Responses to Senator Smith Question .................................. 92 

Sally Bowman’s Responses to Senator Smith Questions ...................................... 94 

Statement from National Center on Caregiving, Family Caregiver Alliance ..... 96 

Statement of The American Health Care Association and National Center 

for Assisted Living ............................................................................................... 99 

Statement submitted from the Association of American Medical Colleges ........ 107 

Statement submitted by the American Association for Geriatric Psychiatry ..... 123 

Statement submitted by AARP ............................................................................... 128 

Final report from the Direct Care Workforce Issues Committee ......................... 142 

(III) 

(1) 

CARING FOR OUR SENIORS: HOW CAN WE 

SUPPORT THOSE ON THE FRONTLINES? 

WEDNESDAY, APRIL 16, 2008 

U.S. SENATE, SPECIAL COMMITTEE ON AGING

Washington, DC. 

The Committee met, pursuant to notice, at 3:02 p.m., in room 

SD–562, Dirksen Senate Office Building, Hon. Herb Kohl (chairman of the committee) presiding. 

Present: Senators Kohl, Carper, Nelson, Salazar, Casey, 

Whitehouse, Smith and Collins. 

OPENING STATEMENT OF SENATOR HERB KOHL, CHAIRMAN 

The CHAIRMAN. I want to thank you all for being here today. We 

will commence—Ranking Member Senator Smith from Oregon will 

be here shortly. Today, we will be discussing the need to train, support, and expand the range of those individuals caring for older 

Americans. The Aging Committee has a long and a proud history 

of moving Congress forward on issues of long-term care. 

Last year, this Committee held three hearings on the subject of 

long-term care in America. However, we primarily focused on the 

facilities themselves and the Federal standards that applied to 

them, rather than the people who fulfill the promise and meet the 

obligations of care. Today, we are shifting our focus to those caregivers. 

Millions of older Americans receive care in a medical facility 

from a licensed professional, such as a doctor or nurse, or from a 

certified nurse aide at a long-term care facility. You can also receive hands-on care in your own home by hiring a home-health aide 

or perhaps a live-in personal care attendant. However, the majority 

of older Americans in need of care rely on a third group, namely, 

their own family. 

There are more than 44 million people providing care for a family member or friend nationwide. These caregivers frequently do 

the same work as a professional caregiver, but they do so voluntarily and with little or no training. To their loved ones they are 

the doctor and nurse, the assistant, therapist, and oftentimes, the 

soul source of emotional and financial support. 

You probably know someone who cares for a family member. Perhaps a friend, a neighbor, or a co-worker. If you don’t, I am willing 

to bet that in 10 years you certainly will. In fact, in 10 years it 

might well be you or myself. By the year 2020, it is estimated that 

the number of older adults in need of care will increase by fully 

one-third. 

2 

The unfortunate fact of the matter is that, while our country is 

aging rapidly, the number of health care workers devoted to caring 

for older Americans is experiencing a shortage—one that will only 

grow more desperate as the need for these caregivers skyrockets. 

Given current workforce trends, it is expected that, in the coming 

decades, we will fall far short of the number of health care workers 

trained to treat older adults than what we will need. 

We indeed face many challenges. We know that few nursing programs require coursework in geriatrics, and that in medical 

schools, comprehensive geriatric training is a rarity. For the direct 

care workforce, which includes home health aides and personal 

care attendants, we know that Federal and State training requirements vary enormously, despite the fact that studies show that 

more training is correlated with better staff recruitment as well as 

retention. We also know that family caregivers want enhanced education and training to develop the necessary skills to provide the 

best possible care for an ailing family member. 

Fortunately, knowing what we need to change is just half the 

battle. After this hearing, we plan to incorporate today’s lessons 

into legislation to expand, train and support the workforce that is 

dedicated to providing care for the older members of our population. 

The Committee is honored to welcome two distinguished panels 

of witnesses to discuss how we can meet the needs of the long-term 

care workforce today and work toward its expansion by tomorrow. 

We will be reviewing the major recommendations released Monday 

by the Institute of Medicine for improving and expanding the skills 

and preparedness of the health care workforce. Also we will hear 

many other perspectives and suggestions from nationally recognized experts with backgrounds in policy, medicine, academics, 

business and even the art of living. 

The United States will not be able to meet the approaching demand for health care and long-term care without a workforce that 

is prepared for the job. 

Again, we would like to thank all our witnesses for their participation today. At this time, we will introduce our first panel. 

Our first witness today will be Dr. John Rowe, a professor in the 

Department of Health, Policy and Management at Columbia University School of Public Health. Dr. Rowe is testifying today as 

chairman of the Institute of Medicine’s Committee on the Future 

Health Care WorkForce for Older Americans. Throughout his distinguished career, Dr. Rowe has held many leadership positions in 

top health care organizations and academic institutions, including 

a stint as CEO of Mt. Sinai NYU Health System and as founding 

director of the Division on Aging at the Harvard Medical School. 

Our next witness will be Dr. Robyn Stone, executive director of 

the Institute for the Future of Aging Services. Dr. Stone is a noted 

researcher and leading international authority on aging and longterm care policy. Formerly, she served as executive director and 

chief operating officer of the International Longevity Center in New 

York. Dr. Stone also held several prominent roles in the field of 

aging under the Clinton administration, including assistant secretary for aging in the Department of Health and Human Services. 

3 

Before we commence with our first panel, I would like to call 

upon my colleagues who are sitting up here on the dais for any remarks and comments that they wish to have. 

Senator Nelson. 

OPENING STATEMENT OF SENATOR BILL NELSON 

Senator NELSON. Thank you, Mr. Chairman. 

I am concerned, as we look down the road, that we have the 

proper health care for older adults—geriatrics primary health care, 

and preventive medicine. That is certainly true in a constituency 

such as mine—Florida, where we have a high percentage of the 

population that is age 65 and older. 

Mr. Chairman, one that of the little spin-offs that we are having 

a problem with back on a Medicare bill in the late 1990’s, a freeze 

was put in place on all of the residency programs for medical 

schools that Medicare funds, the result of which—with no growth 

since 1998—your high population increase States, such as Florida 

and Nevada, have not had the residencies to train the doctors. 

Those States educating the doctors. 

But then these doctors go to another residency program. What 

we find is that a doctor is likely to stay and practice in the area 

in which they did their residency. As a result, States like mine and 

Nevada, and about half of the other States are educating the doctors and then losing them. Now, that is a terrible situation for a 

population like Florida’s that is aging. You need those residencies 

in geriatrics, regular care, internal medicine and preventive care. 

So it is one of the issues we are going to have to address. Thank 

you, Mr. Chairman. 

The CHAIRMAN. Thank you for that interesting comment, and a 

very important comment. 

Senator Collins. 

OPENING STATEMENT OF HON. SUSAN COLLINS, A U.S. 

SENATOR FROM THE STATE OF MAINE 

Senator COLLINS. Thank you, Mr. Chairman. I want to commend 

you for calling this hearing to examine our Nation’s future health 

workforce in the face of a rapidly aging population. I think this 

hearing is particularly significant in light of a recent report from 

the Institute of Medicine that sounded a warning that we are facing a dramatic and critical shortage of doctors, nurses and other 

health care professionals who are adequately trained to manage 

the special health care needs of our Nation’s growing population of 

seniors. 

We know that in this country, the most rapidly growing part of 

the population are those who are age 85 and older, the oldest old. 

Like Senator Nelson’s state, Maine is a State that is disproportionately elderly. I am very concerned about access to health care as 

my generation and others join this population segment. 

We know that older Americans consume far more health care resources than any other age group. We also know that there is a 

real shortage of health care provides who are trained in geriatrics. 

In fact, the numbers are truly astonishing. The experts have projected that we need some 36,000 geriatric doctors to care for our 

4 

70 million seniors by the year 2030. But only 7,000—about 1 percent of all physicians—are currently certified in geriatrics. 

Senator Boxer and I have introduced a bill to take the first steps 

in this area. It has the support of AARP and other organizations. 

I look forward to working with the Chairman who has been such 

a leader in focusing on this issue. I would ask that my full statement be put in the record. Again, thank you for focusing on this 

very important issue. 

The CHAIRMAN. Thank you. By unanimous consent, your full 

statement will be entered into the record, Senator Collins. 

Senator SALAZAR. 

OPENING STATEMENT OF SENATOR KEN SALAZAR 

Senator SALAZAR. Thank you very much, Chairman Kohl, for 

holding this hearing on the Aging Committee on this very important issue. I come today here to the Committee with you to address 

the severe shortage of long-term care professionals available to care 

for older Americans. 

Although the workforce shortage has been documented for many 

years, new reports that have been issued by the Institute of Medicine show that many workers who are working in long-term care 

settings are inadequately trained to do the job. Furthermore, vast 

improvements are needed in geriatric education and curriculums as 

well as new incentives, to recruit and retain a highly qualified 

workforce. 

Without a doubt, these are some of the greatest challenges facing 

long-term care today. The situation will only get worse. In three 

short years, 75 million baby boomers will begin to turn 65. Between 2005 and 2020, the elderly population of the U.S. is expected 

to double. We must ensure that our health care system include 

high-quality professionals to meet the growing demand for longterm and chronic care. 

Personally I have experienced taking care of many of our loved 

ones. My mother today is 86 years old. Fortunately, she continues 

to live on our ranch in southern Colorado. My siblings and I share 

the responsibility of caring for her. She is doing very well. 

Most individuals and families have to make tough decisions on 

how best to take care of their loved ones. At the very least, we all 

want the peace of mind that the caregiver we hire to do the job has 

been adequately trained and meets the highest possible standards. 

I am hopeful that the witnesses today will address that issue of the 

kinds of standards that we should have for professional caregivers. 

This hearing is critical for us to identify the most effective policy 

solutions to meet these health care challenges that we are now in 

the midst of and will only find to be more challenging in the days, 

weeks, months, years ahead. 

Again, I want to thank Chairman Kohl and Ranking Member 

Smith for holding this hearing. 

The CHAIRMAN. Thank you, Senator Salazar. 

Senator CASEY. 

5 

OPENING STATEMENT OF SENATOR BOB CASEY 

Senator CASEY. Mr. Chairman, thank you very much for holding 

this hearing. I will submit a longer statement for the record. But 

I did want to commend you for calling this hearing because, in my 

home State of Pennsylvania, we have a demographic challenge. 

Our fastest growing population is 85 and up, as it is in many 

states, I think. But we are, depending on how you count it, second 

or third in the ranking of the states for the number of people over 

the age of 65. It is a critically important challenge for Pennsylvania, and I know, for the nation as a whole. 

When I was in State Government, I spent a good deal of time on 

the issue of long-term care. Some of the most inspiring people I 

met were people who were delivering that care—certified nurses 

aides, nursing assistants, whatever categories you use or titles you 

use. They were people who did back-breaking work and delivered 

care in ways that—it is hard to describe how much they have benefited our families, doing that kind of work. 

After I was in State government for a while, I had the experience, I guess you would call it, that all of us have when a loved 

one is in the hospital. My father was in a long-term care setting 

before he died. I was able to see first-hand what that care delivery 

and care coordination and the quality of the care that we are talking about here today is all about. I realized then, more so than I 

did as a public official, the kind of skill that is required in delivering quality care to older citizens in the twilight of their lives. 

So this issue is important to me personally. But it is a major 

issue in our State. We need to roll up our sleeves and work on it. 

I am grateful you called this hearing. Thank you. 

The CHAIRMAN. Thank you very much, Senator Casey. 

We will now hear from our first panel. First Dr. Rowe and then 

Dr. Stone. 

Dr. Rowe. 

STATEMENT OF JOHN ROWE, PROFESSOR, DEPARTMENT OF 

HEALTH POLICY AND MANAGEMENT, MAILMAN SCHOOL OF 

PUBLIC HEALTH, COLUMBIA UNIVERSITY, NEW YORK 

Dr. ROWE. Senator Kohl and members of the Committee. Thank 

you for the opportunity to testify before you on the critical health 

care needs of older Americans. As noted by Senator Kohl, I am 

Chair of the Institute of Medicine’s Committee on the future 

healthcare workforce for older Americans. I am here to discuss the 

findings and recommendations of the report that we have released 

early this week. 

To start with, I think there is a great myth here in Washington 

about care of the elderly. The myth is that all we have to do to ensure older Americans’ access to care is to fix the issues related to 

the Medicare Trust Fund’s solvency and sustainability. I think that 

that is half of the problem. We first have to make sure that the 

health care workforce is adequate with respect to its numbers and 

its capacity to deliver the care. Even having the money in the system isn’t going to get the care to older people if there is no one to 

provide care. 

6 

So it is about time that we turned our attention to this. I compliment you, Senator Kohl and the Committee, for having us here 

today to discuss this. 

Now, the future demand—and I think we can look at this as a 

kind of demand side and supply side issue, Senator—the future demand for geriatric care is driven by basically two factors. The first 

is the dramatic increases in the number of elderly that all of you 

are very familiar with. The second, as noted by Senator Collins, is 

the fact that the elderly utilize a disproportionate proportion of 

health care resources. So the 12 percent of our population that is 

over 65 uses 35 percent of the hospital stays, and 34 percent of the 

medicines. By 2030, when the population of elders is 20 percent of 

our population, they will dominate our health care system. That is 

the demand side. How about the supply side? Well, on the supply 

side, the answer is quite simple. We are in denial. We are woefully 

unprepared. But fortunately, we think at the Institute of Medicine 

that it is not too late. The supply and the organization of the 

health care workforce for older individuals needs to be dramatically 

enhanced, or it will simply be inadequate. Let me give you a couple 

of facts. 

As Senator Collins noted, there are only about 7,000 certified 

geriatricians in the entire United States. More frightening is that 

this is 22 percent lower in the year 2000. So we are actually going 

in the wrong direction. 

With respect to geriatric psychiatry, there is currently one for 

every 10,000 older people in the United States. By 2030, at the current rate, there will be one for every 20,000 older people, whether 

he or she needs a psychiatrist or not. 

Less than one percent of the nurses, pharmacists and physician 

assistants we have currently specialize in geriatrics while only 4 

percent of the social workers do. This means that most health care 

professionals, including doctors, nurses, social workers and others, 

receive very, very little training in caring for the common problems 

of older adults. 

Standards for the training of nurse aides and home health aides 

must be strengthened. In the State of California, there are higher 

training requirements for dog groomers, crossing guards and cosmetologists than there are for nursing aides and home health 

aides. Informal caregivers, the family and friends of older adults, 

are also ill-prepared for their significant roles. Innovative new approaches to delivering care to older adults that have been shown 

to be effective and efficient are not being implemented. 

We suggest three approaches. The first approach is to enhance 

the geriatrics competence of all professional caregivers. We believe 

there needs to be more training in the schools of medicine, nursing 

and social work. We believe that these professionals all should 

demonstrate competence as a function of obtaining their licensure 

or certification—not just demonstrate that they had the hours of 

training, but demonstrate that they have the competence. 

In addition, we believe that the number of hours that direct 

workers and nurses aides be given in instruction be increased from 

the current level of 75 hours, which is the Federal standard, to 120 

hours. 

7 

The second bucket, if you will, of our three recommendations is 

to increase the recruitment and the retention of geriatric specialists. We need them. We are not saying that every old person needs 

a geriatrician any more than anybody with a heart needs a cardiologist. That is not what we are saying. 

What we are saying is we need specialists who can train the rest 

of the workforce on how to take care of the common problems of 

the elderly, who can do research and develop new models of care 

and, in fact, can take care of particularly complex and difficult patients. 

Unfortunately, there is an economic disincentive to going into 

geriatrics. In 2005 a geriatrician in this country made, on average, 

$163,000. An internist—with less training—made $175,000. So if 

you spend the extra year or two to do a fellowship in geriatric medicine, you are decreasing your future earning potential with our 

current reimbursement strategies for geriatric care. This suggests 

to me that our society does not value this additional training. 

We have a number of suggestions and recommendations in our 

report that go to specific ways that we can enhance loan forgiveness, provide scholarships and enhance payments. I would just 

mention one for you. The National Health Service Corps is well-established, and has been very effective in developing physician manpower for underserved populations. We are calling for a National 

Geriatric Health Service Corps using the same model. We think 

that is something that could be put in place pretty quickly. 

The third recommendation we have has to do with new models 

of care. We have a fascination with studying demonstration 

projects for new approaches to care. Many of these have been found 

to be effective and cost-efficient, and yet they languish on the shelf, 

because once the funding for the research project is over, there is 

no funding to promulgate or sustain them. Therefore, they are just 

dropped, and the next demonstration project is developed. 

We need some follow up and some commitment at CMS to 

change this so that new models of care which have been shown to 

be effective and efficient can in fact be sustained and can permeate 

to our society. Because even if we do the things we are recommending in this report, we are still going to fall short in the workforce. We have to be smarter, more effective and more efficient in 

how we deliver the care. 

We very much appreciate the opportunity to share our recommendations and our findings with you. Thank you very much. 

[The prepared statement of Dr. Rowe follows:] 

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The CHAIRMAN. Thank you, Dr. Rowe. 

Dr. Stone. 

STATEMENT OF ROBYN STONE, DPH, EXECUTIVE DIRECTOR, 

INSTITUTE FOR THE FUTURE OF AGING SERVICES, AMERICAN ASSOCIATION OF HOMES AND SERVICES FOR THE 

AGING, WASHINGTON, DC 

Ms. STONE. Chairman Kohl, Ranking Member Smith and members of the Committee, I am really pleased to have the opportunity 

today to testify on behalf of the Institute for the Future of Aging 

Services, which is the applied research institute of the American 

Association of Homes and Services for the Aging, where I am the 

senior V.P. for Research. 

From the beginning of our institute, and actually going back a 

heck of a lot longer than that—I have been trying to push this 

issue for the last 25 years—one of our signature areas has been the 

development of a quality long-term care workforce. 

I really commend you, this Committee and also the IOM for finally shining a light on what is the critical piece of our system. 

Without the people who do the work, all the financing and delivery 

in the world is not going to solve our problem. 

Based on our own work, some of which is included in the written 

testimony, and the efforts of others such as the IOM, I would like 

to spend my remaining time laying out for your consideration five 

broad workforce improvement goals and some possible strategies 

for achieving them, some of which Dr. Rowe has already alluded. 

The first is to expand the supply of new people entering the longterm care field. The need to do this is obvious. The traditional labor 

pool paid of caregivers is shrinking. Regardless of the vision of 

long-term care reform, the field will need new sources of personnel. 

The U.S. Departments of Health and Human Services and Labor 

should be working together to develop the data infrastructure to 

track workforce shortages and to report to Congress on the status 

of the long-term care workforce over time. 

Second, workforce development funding needs to be channeled to 

the recruitment and training needs of long-term care employers. 

Much of that money goes to other health sectors. Funneling more 

of those dollars specifically in the long-term care sector will help. 

Third, information on long-term care careers should be targeted 

to post-secondary education and professional schools. Long-term 

care employers need to be encouraged to zero in on labor that has 

been poorly tapped in long-term care, such as Hispanics and African-Americans who are underrepresented in nursing careers; young 

people coming out of high school, individuals with disabilities; and 

older people who either cannot afford to retire or who want to work 

part-time. 

We also need to think about expanding financial incentives such 

as tuition subsidies and debt relief and incentive payments for 

those who choose a long-term care profession. 

The second goal is to create more competitive long-term care jobs 

through wage and benefit increases, including exploring ways to 

achieve more wage parity between long-term care and acute care, 

and to explore how to leverage current Federal and State long-term 

care financing to raise wages and improve benefits, including imVerDate Aug 31 2005 15:01 Jan 26, 2009 Jkt 000000 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 H:\DOCS\46167.TXT SAG PsN: JOYCE
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plementing incentives such as pay for performance and other approaches that target payments effectively to address workforce 

issues. 

The third goal is to improve working conditions and the quality 

of the jobs themselves. Higher wages and better benefits are not 

likely to be sufficient, because high turnover is a sign of unhappy 

employees. The Federal Government could grant financial incentives and/or regulatory relief to employers and states that achieve 

measurable improvements in working conditions and are able to 

demonstrate reduced turnover and improved job satisfaction while 

maintaining quality of care. 

We could also think about creating one or more centers on longterm care leadership and management innovation to develop, identify and disseminate education and training programs, apprenticeships and best practices. 

The fourth goal is to make larger and smarter investments in 

workforce education and development. In my judgment, one of the 

most important workforce improvement priorities—and Dr. Rowe 

talked about this as well—should be to highlight the need to 

rethink and totally redesign the preparation, credentialing and ongoing training of long-term care administrators, medical directors, 

nurses, allied health professionals and direct care workers. 

Finally, the fifth goal is to moderate the demand for long-term 

care personnel. It is unlikely that the need for new workers can 

ever be completely reconciled with our growing demand because of 

our aging of our population. We need to promote significant investment in developing and testing and disseminating promising technologies designed to improve service delivery efficiency and to reduce the demand for hands-on care. 

In addition, we have to provide better incentives to family caregivers who are already carrying the bulk of this work. This should 

include considering things like giving social security credits to 

those who leave the workforce to perform full-time care giving and 

to really further develop programs, so families know where to turn 

to for help and have more than the crumbs that they are getting 

currently through some of our programs. 

Allowing states to consolidate current grants related to long-term 

care service organization and delivery and education and training—as Dr. Rowe was saying, we need to go beyond demos and actually get some of our promising models to scale, so that they become the norm rather than the exception. 

In closing, what is most important is that any approach be 

broad-based and address the multiple issues that have and will 

drive today’s workforce problems and future trends. Long-term care 

must be viewed as a related but independent sector from health 

care. Workforce improvement initiatives must be targeted specifically to the development of long-term care professionals across the 

full spectrum of settings, and not just included as an afterthought 

in efforts to bolster the hospital and ambulatory care workforce. 

AAHSA and IFAS continue to explore solutions at the policy and 

practice levels and have recently created a national ‘‘Workforce cabinet’’ comprised of a range of stakeholders who are interested in addressing this crisis. We look forward to working with the Senate 

22 

Special Committee on Aging to ensure continued progress in this 

area. Thank you very much. 

[The prepared statement of Ms. Stone follows:] 

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The CHAIRMAN. Thank you, Dr. Stone. 

This time we will turn to members of the Committee for questions and comments. We will start with the Ranking Member, Senator Smith. 

Senator SMITH. Thank you, Mr. Chairman. For the record, I 

would like to put my statement in the hearing record. 

The CHAIRMAN. We will do it. 

[The prepared statement of Senator Smith follows:] 

PREPARED STATEMENT OF SENATOR GORDON H. SMITH

I want to thank Senator Kohl for holding this important hearing today. The work 

of our health care providers and caregivers is crucial to helping of our elderly family 

members age with dignity. Unfortunately, workforce shortages in this vital health 

care and aging support system continue to plague the industry. Identifying the best 

methods to recruit and retain caregivers in the aging network is an issue of particular interest for me, and I thank the panelists for sharing their expertise on this 

topic with us today. 

I particularly want to thank Sally Bowman from Oregon State University for flying across the country to share her knowledge about this field with us. 

I also look forward to testimony from Dr. Rowe. As a member of the Finance Committee, I am charged with ensuring the efficiency of our Medicare and Medicaid systems. While I am a strong supporter of both programs, each faces challenges as our 

nation ages and health care costs continue to explode. I look forward to hearing Dr. 

Rowe’s recommendations for system reform. 

Last year, I had the pleasure of serving as a member of the National Commission 

for Quality Long-Term Care, which was co-chaired by former Senator Bob Kerrey 

and former Speaker Newt Gingrich. The Commission studied in depth the needs and 

constraints placed upon the long-term care workforce. On any given day, the longterm care workforce serves about 10 million Americans, the vast majority of whom 

are elderly. But the workforce suffers from low retention rates and a shortage of 

trained professionals. 

The Commission learned that long-term care professionals feel that they need 

more training, that they have high rates of injury and that many are paid what they 

feel are inadequate wages. These are just some of the many problems that we must 

look at in order to ensure that when help is needed, it can be provided. 

We also know that caregivers, who may be the child or spouse of an elderly or 

disabled person, suffer from the stress of trying to lead their own life while helping 

their loved ones stay in their home. Some caregivers may have disabilities themselves and struggle under the pressure of trying to avoid living in a facility. I am 

a strong proponent of supports, including respite care, for these caregivers including 

the Family Caregiver Support Program in the Older Americans Act. 

I urge support for the work that I have done with Senator Lincoln to encourage 

the Appropriations Committee to increase funding to programs in the Older Americans Act. Again, this year, we led a letter asking appropriators to provide a nine 

percent increase in funding. Although more is needed, we believe this is a good start 

in making our seniors a priority and helping them to remain healthy and in their 

homes, where they want to be, as they age. 

As some of you may know, I am from the small community of Pendleton, OR. I 

want to emphasize the particular difficulties that are faced in maintaining a health 

care and support system in rural areas. Remote locations, small numbers of patients, and difficulties in training and maintaining staff, are just some of the problems that lead to reduced access to help our loved ones in rural communities. 

Like most health care professions, nurses are facing devastating shortages, especially in rural communities. Senator Clinton and I have introduced the Nursing 

Education and Quality of Health Care Act to increase the nurse workforce in rural 

areas, expand nursing school faculty and develop initiatives to integrate patient 

safety practices into nursing education. 

Whether its nurses, physicians or allied health care workers, as the number of 

older Americans grows, the shortage of all health care professionals will be exacerbated. 

In recent years, federal funding for programs to strengthen the health care workforce has taken a direct hit. I have written a letter to my fellow colleagues indicating my strong support to increase this funding, which will improve the geographical distribution, quality and diversity of the health care professions workforce. 

30 

As we discuss the challenges facing elder care at today’s hearing, it is important 

to keep in mind that by 2030, the number of older adults in the United States will 

nearly double as the 78 million members of the baby boom generation begin turning 

age 65 in 2011. Our health and support systems are drastically lagging behind 

where we should be at this point in time to plan for the future. 

I hope that today’s hearing will inspire some new and effective ways that we can 

ensure providers of care are there when our seniors are in need. 

With that, I turn to Chairman Kohl. 

Senator SMITH. I want to give a particular thank you to Sally 

Bowman from Oregon State University for flying across the country. She will be on the next panel. I appreciate these two excellent 

presentations. 

I wonder, Mr. Rowe, is there a State that is doing much of what 

you described? Is there a model out there that we should look to, 

or other states can look to, for achieving some progress in this area 

of preparing for a geriatric generation that is coming? 

Dr. ROWE. I am wishing it was Oregon. But I am not sure. 

Senator SMITH. I was hoping you were going to say so. 

Dr. ROWE. I don’t think so. But I do think that, if you look across 

the states and, you know the states are laboratories of democracy, 

right—there is a lot of different stuff going on. Much of it offers 

good models. You will find some models of Medicaid in some states, 

and some other models in other states focusing on different elements of the health care spectrum that are best practice. I think 

that one can assemble a profile of all the best practice. Some medical schools do a much better job of committing to geriatrics. Some 

nursing schools do a much better job than others. 

There are good best practices, and models out there that do work 

and can be replicated, no question. 

Senator SMITH. Isn’t it a fact that people respond to incentives? 

Don’t we need to look at things at the Federal level to incent physicians and nurses to go into geriatrics? 

Dr. ROWE. Absolutely, and nurses and social workers. Some people have asked me since Monday, when we released the report, how 

can geriatricians make less than internists? How can that be? It is 

because all of their patients are on Medicare; whereas the internist 

is practicing with a population that has some Medicare beneficiaries, and other people paid by private insurers that have paid 

generally higher than Medicare. Internists have a different payer 

mix and a greater possible income. 

So obviously, the fix to that is not too difficult, Senator; because 

there are—if you increase the payment from CMS for individuals 

with geriatric expertise—who have a board certification or a qualification—it is not going to cost that much. There are only 7,100 of 

them in the United States. It would at least provide an incentive, 

or rather, at least it would remove a disincentive for those individuals, with geriatric expertise. 

Senator SMITH. Thank you, Mr. Chairman. 

Dr. ROWE. Thank you. 

The CHAIRMAN. Thank you very much, Senator Smith. 

Senator CARPER. 

Senator CARPER. Thank you. My colleagues that were here before 

me, Mr. Chairman. I just have one question. I am going to ask this 

question tongue-in-cheek. Then I would like to yield to them. 

31 

Dr. Stone, you said in your statement, you mentioned the term 

aging baby boomers? I was wondering how old do you have to be 

to be considered an aging baby boomer? 

Dr. STONE. You have to be 60 this year. 

Senator CARPER. I will just tell you that. Thank you. [Laughter.] 

Dr. STONE. Sorry. 

Dr. ROWE. I think there is some flexibility around that, Senator. 

Senator CARPER. All right. Let me hasten to add, I asked the 

same question of Senator Nelson before he left. He said it is a 

question of mind, not of body. 

Ms. STONE. Of course. 

Dr. ROWE. Of course. 

Dr. STONE. I have been aging for 30 years with the work I have 

been doing. I love every minute of it. 

The CHAIRMAN. Thank you very much. 

Senator SALAZAR. 

Senator SALAZAR. Dr. Rowe and Dr. Stone, thank you for the testimony. The question I would have is on the issue of standards. 

Dr. Rowe, I think you characterized it as this is a place in life 

where there really are no standards for those who work in the profession providing direct care; that we have higher standards for 

probably people who work in shops and lots of other places than 

we do in this area. 

What would you propose that we do in terms of standards? Is 

that a function that we ought to leave to the states to devise standards? Is it something that has to be done at the national level? 

What kind of standards would you propose? 

Dr. ROWE. Well, first of all, I think it is important to recognize 

that the standards the number of federal training hours of that are 

required, which we think should be increased significantly, have 

not changed in 20 years. 

The training now for these individuals—nurse’s aides, home 

health aides—is pretty much procedural training, how to shift a patient from a bedside to a commode, or into a wheelchair, or to help 

change dressings or the clothing of a patient, rather than background information about the aging process and about the characteristics of geriatric medicine and identifying risk factors for falls 

or medication adverse effects. So there is a real curriculum we 

think could be added. 

There are Federal and State standards for some of these providers and just State standards for others. We feel that the Federal 

standards should be increased from 75 to 120 hours; and that the 

State should meet at least those standards, although if they wanted to have more, that would be fine. 

But it is a dual requirement. So there is a Federal role here, 

which is obviously germane to your Committee. 

Senator SALAZAR. Dr. Stone, do you have a comment? 

Dr. STONE. Yes. I would add a couple of things. First of all, I 

think Dr. Rowe was talking about the kinds of training that is provided now and that could be. I will give you an example of a program in Wisconsin that we evaluated a number of years ago called 

Wellspring, which is a quality improvement model in nursing. 

These CNAs were the leaders of clinical research teams. They 

had training together with the nurses and nurse practitioners—offVerDate Aug 31 2005 15:01 Jan 26, 2009 Jkt 000000 PO 00000 Frm 00035 Fmt 6633 Sfmt 6633 H:\DOCS\46167.TXT SAG PsN: JOYCE
32 

site training for several days and around each clinical area; then 

they came back and were really taught, not just through observation, but actually more like an assessment without doing it. I think 

CNAs were not allowed to actually do the assessment. But they are 

the nurses’ eyes and ears. 

Within a year of doing this program, working around incontinence care—and I have a doctorate in public health—and I will tell 

you that these CNAs were amateur epidemiologists. They understood everything that was involved in the care that they were providing. They were no longer just moving somebody to a toilet. They 

were helping them with hydration and preventing decubitus ulcers. 

The empowerment and the knowledge that was imparted to these 

folks was totally different than the kind of training that they get 

today. That is really what we are talking about here. It is not just 

a numbers game. It is really a qualitative difference in the kind of 

training, which then translates in the work that they are going to 

be doing. 

Dr. ROWE. It enhances their self-esteem and their enjoyment and 

retention in the workforce. 

Dr. STONE. I would say that, Senator Smith, on your end, Oregon 

has the best Nurse Delegation Act in country. 

Senator SMITH. That is what I was expecting. 

Dr. ROWE. Yes. Well, she had more time to come up with something. 

Dr. STONE. Because of the Nurse Delegation Act in Oregon, the 

development of this frontline workforce has been phenomenal. 

Many other states have actually looked to Oregon to replicate that, 

to allow more good delegation; which is not just letting people do 

anything, but delegating where they have had significant training 

in dementia care and medication management, which leaves the 

other levels of staff—and Jack actually talked about this at the 

IOM report release a couple of days ago—to do the work that they 

need to do, so that everybody really becomes a team. 

Senator SALAZAR. Thank you, Chairman Kohl. 

The CHAIRMAN. Senator Casey. 

Senator CASEY. Keep it up. Thank you, Mr. Chairman. 

Dr. Stone, Dr. Rowe, thank you for your testimony. But also 

thank you for the scholarship that goes into the testimony itself 

and the experience. 

I am trying to think of it—must have been 10 years ago now that 

the Philadelphia Enquirer did a whole series on, as a lot of newspapers have over the years, on long-term care. One line from one 

of those series, one of those stories, I should say, in the series has 

stayed with me forever. The writer said something along the lines 

of advocates for the frail elderly say that life can have quality and 

meaning, even to the very last breath. Such a simple yet profound 

statement about the end of life and the value of it. 

There is one thing I wanted to ask you about, because you both 

addressed it in different ways and with a lot of scholarship. It is 

the challenge of recruiting and retaining, but especially recruiting 

people to do this work—the back-breaking work, in many cases 

with low wages and inadequate benefits—all of the things that we 

know that are not attractive about this work. 

33 

My sense of it is, spending some time with direct-care workers, 

especially CNAs and people at that level of the workforce, is that 

they really do have a sense of mission about it and a sense of purpose. I just wanted to get your reaction to this—both of you have 

talked about the urgency of recruitment and retention. Both of you 

have talked about the wage and benefits aspects of this. 

But let me ask you this. Somewhere along the way in the last 

8 or 10 years, I read a study done of what these workers bring to 

the table in terms of their own attitudes about their work. At least 

in one survey, I remember that wages and benefits weren’t at the 

top of the list. It was the stake they had in the management of the 

place in a long-term care setting, or their involvement with the 

care. 

Dr. STONE. Right. 

Senator CASEY. They wanted to feel like they were part of the 

decisionmaking and how care was delivered. I just wanted to have 

you speak to the broader question of recruitment, but in addition 

what motivates people to do this work, and how we can incentivize 

motivating it? 

Dr. STONE. I could talk from the direct care worker area. We 

have done a lot of work in this. Clearly, that is true. The organization of the work and the involvement in the actual activities that 

go on every day is what really makes the difference for these folks. 

No. 1 is caring for the people. I mean, there is a tremendous connection. Second is having the empowerment and the support from 

organizations, whether it is a home-care agency or a nursing home 

or assisted living or a hospital, to really do that work as part of 

the team. 

The beauty of the geriatric focus is that everybody across the entire spectrum—whether it is the physician, the nurse, the social 

workers, the allied health professionals, the frontline caregivers— 

all are getting this kind of interdisciplinary training around how to 

really work together. In the best of all worlds, where you have seen 

real models work, everything rises. 

One of the things that I really like about the IOM report and this 

Committee today, that we are not just talking about direct care 

workers, we are not just talking about physicians, nurses, social 

workers. We are talking about it across the spectrum. This has got 

to be a systemic change, because we can help the direct care workers. I mean, they already are committed to what they do. But unless we get the entire system to work together around this, it is not 

going to work. 

So we need everybody in this together at every single level. 

Dr. ROWE. I think that the difficulties that we are having in generating and sustaining the workforce differ at each level. There are 

tremendous drivers with respect to morale and conviction and dedication for the direct care workers. But then the characteristics of 

other parts of the workforce—the shortages of other workers to 

help them get their work done—and their low salary, drives them 

out. 

At the nursing end, the problem is not enough instruction, not 

enough faculty. There aren’t enough geriatric nurse faculty in 

American nursing schools to train individuals to be specialists in 

nursing. 

34 

On the physician side, there are a lot of funded genetic fellowship programs that go vacant every year, because physicians aren’t 

applying for them. About half of the slots in the country go vacant. 

Part of that has to be that the average medical student graduate 

has $100,000 in debt. They are looking at the specialty, which is 

the lowest paid. So that has to be, at least for some of them, an 

important consideration. 

But I think the secret here is a commitment to help the entire 

workforce, not just one piece of it; because our problem is compounded by the deficiencies in each level. If we had deficiencies at 

one level, but we were OK in the others, we could work it out. We 

need a commitment to help the entire workforce by having the sophistication to recognize that the different elements of the workforce have different problems and need different fixes. There is not 

a one-size-fits-all fix here. 

Dr. STONE. I would like to just add one little thing. This is about 

economic development, because these are the sectors that are growing in the 21st century. So it is also an investment in our economy 

to think about how we shift a little bit from where we have been 

putting a lot of our resources and redistribute into where the jobs 

are going to be over the next 20 and 30 years. So it is a challenge. 

But it is also an incredible opportunity. 

Senator CASEY. Thank you. 

Dr. ROWE. Thank you. 

The CHAIRMAN. Well, thank you both very much. You have been 

informative and helpful. We appreciate it. 

Yes, sir, Senator Carper. 

Senator CARPER. I actually did have a serious question too. Could 

I? 

The CHAIRMAN. Sure. 

Senator CARPER. Thanks. I am going to be stuck on that first 

question for a while. 

Somewhere in what I have read coming into the hearing today, 

I noted that we are going to need an additional roughly 3 million, 

3.5 million people to provide health care for us aging baby boomers 

and others in our population just to maintain the current ratio of 

providers to the total population. We do a whole lot in our state, 

our congressional delegation. We try to help Delaware Technical 

Community College, University of Delaware, Lesley College, some 

of our hospitals where they train nurses, to try to make sure that 

they have the resources they need to train the workforce that will 

be needed to take care of the rest of us. 

On the other hand, though, we also look to a couple of our hospitals. We have a VA hospital in northern Delaware that we are 

very proud of. They use information technology. In fact, we do this 

nationwide through the VA in ways that enable us to save costs, 

save lives, make your folks providing the health care more productive. I am sure you are familiar with the work that they have done. 

Another of our larger hospitals is called Christiana Care. They 

have a visiting nurses association—I think they use a telehealth 

system—that they find is a cost-effective, user-friendly way to manage nursing resources and need for services. 

Have you identified any technologies that are being developed or 

used to reduce the demand for hands-on—care using well-trained 

35 

hands to provide the care that we are going to need? Or some technologies that are still being developed? Can you give us some examples that we might find encouraging? 

Dr. ROWE. We have a section of our report that deals with technologies, Senator, specifically. There are various technologies and 

remote monitoring technologies, so that problems are detected 

sooner, and somebody isn’t lying on the floor of their kitchen for 

three days without anyone knowing it; and therefore is much more 

ill when they are discovered than they would have been with earlier intervention. 

Senator CARPER. Give us a couple of others. 

Dr. ROWE. Well, one can have technologies where you can understand what individuals’ vital signs, blood pressure and pulse and 

temperature and monitoring those, so you know the effects of various medications. There are technologies that help move patients, 

that make it much easier for individuals to move patients around 

and position them. 

There are a whole variety of recommendations here that we 

think NIH and other organizations have a real opportunity to conduct additional research on that might be very helpful—and that 

could help to make up for the shortage, Senator, in the workforce; 

because we are just not going to get there. Even if you and your 

colleagues did everything that we recommended and other groups 

would recommend, it is really going to be hard to get there. 

So we are going to have to rely on these new technologies. We 

have to invest in more bioengineering research. 

Senator CARPER. Dr. Stone. 

Dr. STONE. I would just add a couple of things. One is in the area 

of medication management, which is a big one, particularly for people living in the community. There are increasing technologies for 

actually helping patients with more self-management. To the extent that can happen, we can have less need for people to be in people’s homes, and monitoring them. I would also like to put in a 

plug for AAHSA’s Center for Aging Services Technology. 

Senator CARPER. What is it called? 

Dr. STONE. The Center for Aging Services Technology, which is 

one of the centers within the American Association of Homes and 

Services for the Aging, which has brought together researchers, 

providers and companies who are actually interested in exploring 

technologies that are going to mitigate the need for some of this 

labor, but also provide efficiency, to complement the labor that is 

needed as well. So it is not an either/or. It really is complemetarity. 

Dr. ROWE. If we have the technologies, then we have to have the 

standards to train the health care workers in the use of the technology. 

Dr. STONE. Right. 

Dr. ROWE. This is a very, very important consideration. So that 

is going to even further enhance the training requirements. You 

can’t just, you know, wheel the technology into the room. We have 

to have somebody who understands how to apply it and how to understand what it is telling them. 

Senator CARPER. We used to visit my mom when she was living 

down in Florida. She had early dementia. I remember—some of my 

colleagues may recall with relatives of their own, or people in the 

36 

audience—we kept her medicines in what looked like a fishing 

tackle box. There are certain medicines you are supposed to take 

in the morning and at noon, in the afternoon, you know, with 

meals and so forth. We were always concerned that she took the 

right medicine at the right time. 

My sister and I used to say, ‘‘I wonder if anybody has ever actually looked at the medicines she is taking.’’ They were prescribed 

by a range of different physicians who probably never met each 

other, never talked to each other. We were wondering, ‘‘Does anybody ever think about what all these medicines taken together do 

to our mom?’’ So are you suggesting that we have some technology 

that actually does that kind of thing these days? That is good. That 

is a good thing. 

Last question, if I could, Mr. Chairman. 

My youngest son is a senior in high school, graduating. His 

girlfriend has an older brother who is going through med school. 

He is going through his rotations right now. We were talking to 

him not long ago and saying, ‘‘Well, what kind of doctor do you 

want to be?’’ He told us—he obviously hadn’t really made up his 

mind. But I don’t think he is thinking about specializing in geriatrics. 

He told us about some of the things that medical students are 

most interested in becoming—dermatologists, are like, right at the 

top of the list. We said, ‘‘Why?’’ He said it was because it is the 

nature of the work. It is not bad. It is not heavy lifting. They are 

paid pretty good. They are paid pretty good. 

Dr. ROWE. On average, $300,000. 

Senator CARPER. Yes. 

Dr. ROWE. Versus $163,000 for geriatrics. 

Senator CARPER. Versus what? 

Dr. ROWE. Versus $163,000 for geriatrics. 

Senator CARPER. That would give somebody pause, wouldn’t it? 

It is about what we make around here, isn’t it? 

Dr. ROWE. It is not that dermatology isn’t important. It is obviously important. But it is an interesting comparison. 

Senator CARPER. You are suggesting that one of the reasons why 

the pay for those specializing in geriatrics isn’t high is because a 

lot of the compensation comes from Medicare. If you look at what 

we pay for Medicare compared to what people can—— 

Dr. ROWE. I recognize that we have a Medicare trust fund problem. But the fact is that if we paid geriatricians who have qualifications and a way to recognize that, given the scale of the financial problems you folks deal with, there are only 7,100 of them in 

the United States. It is just not going to cost that much. It might 

remove a disincentive, so that half those fellowships will not go 

empty every year. 

Senator CARPER. Very well. Thank you both very much. 

Thanks, Mr. Chairman. 

The CHAIRMAN. Senator Whitehouse, do you have any comment 

or question? 

Senator WHITEHOUSE. I’m trying to get my microphone to work. 

There we go. Thank you, Mr. Chairman, yes. 

37 

This has been a matter of considerable interest in Rhode Island. 

As you probably know, Richard Besdine at the Brown University 

Medical School is probably—— 

Dr. ROWE. I wrote a text book with Richard Besdine. 

Senator WHITEHOUSE. Well, he was probably the first person to 

get specialized geriatric education. He had to go over to Scotland 

to get it at the time. There was no such thing in the United States. 

Since then, as you have pointed out, it continues to be a very 

underrepresented field. The financial incentives aren’t great. 

But it is a highly specialized field. People really need to know 

how the body of a very elderly person is truly different than the 

body of younger people and be able to appreciate that in the way 

they treat them. 

But the cost issue is considerable. I wonder if you could comment 

on whether you find opportunities, or where you find opportunities, 

in improved coordination of care that may ideally lead to cost savings as a result of chronic care being better managed, that could 

then be plowed back into. 

Dr. ROWE. Yes. 

Senator WHITEHOUSE. Increased reimbursement for the geriatric 

community. 

Dr. ROWE. I think it is a very sophisticated question. Dr. Besdine 

at Brown University and I founded the program in geriatrics at 

Harvard Medical School together many years ago, along with Dr. 

Wetle. I know him well. 

We do speak in our report, the IOM report, about models of care 

that have proven to be cost-effective and have improved quality of 

care. There are a number of characteristics of these programs. 

There is a long list of them here. 

Senator WHITEHOUSE. One of them is improved information technology support. 

Dr. ROWE. Some of them relate to that. Some of them are just 

interdisciplinary teams, job delegation. IMPACT is a program the 

Hartford Foundation funded to recognize and treat depression in 

the elderly early, which was very effective and cost-efficient. But 

once the study was over, there was no funding to keep it going, because the kinds of things the people were doing in the team were 

not supported by Medicare. 

So the point we have made in the discussion is that there needs 

to be a consideration of how to sustain new models. We have a 

whole bunch of proven things that we are not implementing into 

our health care system. 

Senator WHITEHOUSE. I would love to follow up with you offline 

on that. 

Dr. ROWE. It would be our pleasure, Senator. 

Senator WHITEHOUSE. I think there has been a lot of work done 

on this. It seems to me that the next step is to find some pilot 

projects where it can be given a little bit more real-world shakeout. 

Then perhaps put in systemwide—— 

Dr. ROWE. You have some integrated health systems in Rhode Island that could implement these in several hospitals at once. 

Senator WHITEHOUSE. Yes, great. 

Dr. Stone. 

38 

Dr. STONE. I would just like to add one thing, however, because 

we have about 25 years of history in this. The problem is that we 

also need to have people trained to do it. The whole new issue 

around the medical home, for example, that is supposed to be the 

new panacea for coordination—unless you have people who are 

trained to understand how to coordinate, the model will not work. 

You have to get back to what people can do in order to actually implement that. 

Senator WHITEHOUSE. Yes. You have an airplane, you have got 

to have pilots who can fly it. 

Dr. ROWE. Yes. It is not a naturally occurring event. 

Dr. STONE. It is not just going to happen. 

Dr. ROWE. We need to get these people together and they will 

start behaving differently. 

Ms. STONE. Yes. 

Dr. ROWE. They need to be trained. 

Senator WHITEHOUSE. Understood. 

I thank the Chairman. 

The CHAIRMAN. Thank you very much, Senator Whitehouse. 

We thank the first panel. We appreciate you being here. 

Moving on to the second panel, our first witness will be Martha 

Stewart, who needs little introduction. In addition to being the 

founder of Martha Stewart Living Omnimedia, which includes her 

expansive multi-media portfolio of award-winning brands, Ms. 

Stewart has experienced life as a family caregiver for her mother, 

Martha Kostyra. 

In 2007, Martha was inspired to open the new Martha Stewart 

Center for Living at the Mt. Sinai Medical Center in New York. 

The center is an outpatient facility for geriatric medicine, which 

provides clinical care and education for patients, offers training for 

physicians and coordinates healthy aging research and practices. 

We will hear from Dr. Todd Semla, who is the president of the 

American Geriatrics Society, where he has been a member of the 

editorial board of Annals of the Long-term Care since 2002. Dr. 

Semla is a clinical pharmacy specialist with the U.S. Department 

of Veterans’ Affairs Pharmacy Benefits Management Service, as 

well as an associate professor at Northwestern University’s 

Feinberg School of Medicine. 

Next, we will hear from Mary McDermott, a member of the board 

of directors for the Wisconsin Quality Home Care Commission. A 

former corporate systems efficiency expert, Ms. McDermott left her 

job in 2000 to become a full-time care provider for her parents. She 

understands long-term care training and quality of care issues, as 

both a service provider and a family caregiver. 

Senator Smith, would you like to introduce your witness? 

Senator SMITH. Thank you, Mr. Chairman. 

Ms. Sally Bowman is a respected professor of human development and family sciences at Oregon State University, where she 

has been a faculty member since 1994. She will share with us her 

experience working with families who have long-term care needs 

and the importance of gerontology specialists. Thank you, Sally. 

The CHAIRMAN. We thank you all for being here. Just one comment. Martha Stewart does need to leave rather soon. So we are 

39 

going to ask her to give her testimony and answer questions. Then 

we will move on to the other three. 

Ms. STEWART. 

STATEMENT OF MARTHA STEWART, FOUNDER, MARTHA 

STEWART LIVING OMNIMEDIA, NEW YORK, NY 

Ms. STEWART. I appreciate the invitation to testify before you 

today and am honored to be here. You have chosen a subject that 

is increasingly critical to our quality of life—not only for older 

Americans but for family members who care for them. I look forward to learning from the work of the Committee as it continues 

to examine this issue. 

The experience of the distinguished professionals on your panel 

today will be important as well. I especially appreciated the remarks of Dr. John Rowe and Dr. Stone. 

I respond to your invitation today as a member of a family whose 

eyes were opened by personal experience and to share what we 

have been learning at the Martha Stewart Center for Living at 

Mount Sinai Medical Center in New York City. 

My professional life has been centered on the home, the wellbeing of the family, and everything that these subjects encompass. 

When I began working in this area more than 25 years ago, the 

subject of homemaking as it relates to families was largely overlooked, though the interest was clearly broad and the desire for information strong. My colleagues and I soon discovered we were satisfying a deeply felt unmet need. 

Today I see a similarly unmet need. Our aging relatives and the 

families who care for them yearn for basic information and resources. We all know that this is a significant sector of our society. 

More than 75 percent of Americans receiving long-term care rely 

solely on family and friends to provide assistance. The majority of 

these caregivers are women, many of whom are also raising children. Often, these women are working outside the home as well. 

I understand the challenges family caregivers face. My mother, 

Martha Kostyra, passed away last year at the age of 93. My siblings and I were fortunate that she was in good health almost until 

she died. But we still came to know first hand the number of issues 

that needed to be managed. 

First, it is difficult, especially in smaller cities and rural locations, to find doctors experienced in the specific needs that arise 

with age. Think of all that this includes: the effect of medications 

on elderly patients; how various medicines interact with one another; warning signs for depression and onsets of other conditions 

increasingly common in the elderly. 

How do we ensure that they take their medications? How do we 

help structure our parents’ lives so that they can live independently for as long as possible? How do we support the generation of 

caregivers who devote so much of themselves to their parents’ 

aging process? 

This only touches on the myriad of issues, of course. Worry is the 

backdrop for everything these families do. What if the parent falls? 

What if she leaves the burners on? What if he takes his medications twice or forgets to take them at all? 

40 

Now I am learning even more about the physical, emotional and 

financial toll that the experience can exact. Caring for an aging 

parent or loved one can be another full-time job. In fact, 43 percent 

of baby boomers have taken time off from work, and 17 percent 

have reduced hours to help care for an aging parent. They do this 

at a time when their expenses are rising. 

One recent study found that half of those caring for a family 

member or friend 50 years or older are spending, on average, more 

than 10 percent of their annual income on caregiving expenses. 

Many dip into savings and cut back on their own health care 

spending to cover the bill. Is it any wonder that family caregivers 

are at increased risk of developing depression, anxiety, insomnia 

and chronic illnesses themselves? 

In our Kostyra family, we were grateful to be there for my mother, who had given so much to us and was a well-loved presence in 

our lives and in the lives of her 13 grandchildren. Our experience 

in her final years, and my resulting awareness of the issues many 

Americans face, is one of the reasons for the creation of the Center 

for Living. The goal of the Center, which is dedicated to my mom, 

is to help people to live longer, healthier, productive lives even as 

they age. 

We have set a goal at the Center to use research and the practice 

of geriatric medicine to try to elevate the level of eldercare and its 

importance in our society. Did you know that there is currently one 

geriatrician to every 8,500 baby boomers? That is clearly not adequate. 

We are also working to develop new tools and resources for caregivers. We are collaborating with a large number of organizations 

and motivated, experienced individuals, many of whom have been 

studying these issues for years. There are numerous devoted and 

knowledgeable people in arena, and we hope we can all learn from 

each other. 

This is a field that eventually impacts most families in emotional 

and encompassing ways. Yet sometimes it is the simple solution 

that holds an answer. Not long ago at the Center, a woman 

brought in her father who had suffered a stroke two years earlier. 

After the stroke, he had been told that he could never eat again 

and was placed on a feeding tube. He was devastated and depressed. He had spent his life as someone with a passion for good 

food, and his future looked very bleak to him. 

At the Center, a doctor experienced in geriatric care asked the 

man to drink a glass of water. He did, without a problem. ‘‘If he 

can do this,’’ the doctor said, ‘‘he can eat.’’ This simple exchange 

improved the man’s quality of life immeasurably. I am sure it improved the quality of his daughter’s life, too, knowing that her father was happier and could eat. 

I want to share with you three things I have learned from our 

work at the Center and that others may find useful. One, we must 

make an effort to coordinate care. Most older Americans have several doctors. It is important for these doctors to cooperate with one 

another and work closely with caregivers. 

Two, it is important that we as a society recognize the stresses 

and challenges that caregivers face and support them as best we 

41 

can. We want to ensure that their health isn’t undermined by the 

demands of eldercare. 

Three, we must encourage families to open up a dialog now. Even 

if your older relatives are in good health, as my mom was, it is important to plan for a day when they might not be. 

I have always been a firm believer in the role of preparation and 

organization in progressing toward a goal. My concern today is 

whether our country and our overstretched medical system can possibly meet the demands of those 76 million baby boomers who will 

start turning 65 in the next two years. We are on the cusp of a 

health and caregiving crisis that has to be addressed now. I know 

you recognize this, and that is why we are here today. 

I thank you for your dedication to this important matter and for 

the opportunity to express my thoughts. 

In fact, I am here with Dr. Brent Ridge, who was a geriatrician 

at Mt. Sinai hospital. Brent is now working with me on the Center 

for Living and on other initiatives involving caregiving. We are 

writing a handbook for caregivers. We have gotten as far as a very 

complete outline. Now we are starting on the actual text. 

It is a very difficult job. There are lots of handbooks, lots of 

guidebooks. But very few of them address all the very serious subjects that a caregiver and the aging population really have to face. 

So thank you very much again for inviting me here. 

[The prepared statement of Ms. Stewart follows:] 

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The CHAIRMAN. Thank you, Ms. Stewart. In what ways do you 

think the Martha Stewart Center for Living at Mt. Sinai Medical 

Center meets the needs of older adults, their families as well as to 

professionals who serve them? 

Ms. STEWART. Well, in many, many ways. We rebuilt the geriatric center at Mt. Sinai to make it a very comfortable and welcoming place. There are more than 3,000 patients that visit the 

Center on a regular basis. Every patient at the Center is assigned 

to a clinical social worker to help patients and families with the 

many social and financial issues that accompany aging. 

In addition to over 20 geriatricians at the Center, there are also 

cardiologists, nephrologists, endocrinologists, nutritionists, psychiatrists, gynecologists and pain specialists, all in one place, which 

really does facilitate the coordination of the care of these patients. 

Electronic medical records rather than paper charts are used 

here, so that all doctors can easily access patient information and 

can check up on the care of these patients. That way, there isn’t 

a medicine that is going to react badly with another medicine, 

which oftentimes does happen with these patients. 

My mom visited, oh, I don’t know how many different doctors. 

She was always—and when I called her up, she was always going 

to another doctor. I said, ‘‘Mom, are you taking all your records?’’ 

She said, ‘‘Oh, I know exactly what I am doing.’’ But not really. I 

mean, because it was very complicated. I couldn’t even understand 

what she was taking. I mean, I saw the drawers of things. So this 

is terribly important, this medical records sharing that is going on 

now. 

We have wellness lectures and yoga and T’ai Chi and meditation 

classes—it’s also very important just to encourage the aging to do 

those very vital exercises. Every medical student who graduates 

from Mt. Sinai rotates through the Martha Stewart Center for Living, so that they graduate having some exposure to managing the 

care of this special patient population. So that is another way to 

encourage the universities, the medical schools, to get students into 

thinking about geriatric medicine. 

We just opened the Center, as I said, late last year. So it is really 

too early to pronounce our model successful. But we are confident 

that it will be and that our complete approach to patient care can 

be integrated into other medical facilities in this county and hopefully elsewhere. 

The CHAIRMAN. Thank you. 

Senator SMITH. 

Senator SMITH. Ms. Stewart, I think we are all grateful that you 

are here. Certainly I admire your Center for Living. What you just 

described is ideal. Your mother was in a rural area. I am from a 

rural part of Oregon. I think about all the things that we need to 

do yet in Government. In fact, we are holding this hearing to try 

to elicit good ideas. 

It seems to me, with the demographic aging of our country, if 

people are counting on Government to fix it all, make it perfect, I 

think our faith in that is probably going to be disappointed. 

But you spoke about your mother. It reminded me of how we lost 

our mother. My mother had 10 children. It was, at the end of a 

46 

wonderful, beautiful life, when she had a very sudden bout of pancreatic cancer. We all took turns at her bedside taking care of her. 

It just does seem to me that one of the missing ingredients here 

that is part of living is that we will all die. Her death was, in fact, 

if it can be described as beautiful, it was that. It was because she 

had her family around. 

I wonder if you have a message for American families as to our 

responsibility to our parents, not just to be there, but perhaps to 

become more educated. Is there a part of your Center that trains 

family members to take care of their moms as they are dying? 

Ms. STEWART. Well, that is what the book will help, the book 

that we are working on, the Care Living Guide, which I hope will 

encourage the children of the aging to take it very seriously that 

mom or dad plans for the future. You know, my mom just didn’t— 

she really didn’t plan. 

She had six kids. We were all well-off. We could all take care of 

her. She was self-sufficient. She never asked us for anything. She 

had been a teacher. She had her pensions. She did all her bookkeeping herself. She did her tax returns herself. She was quite an 

astute and intelligent woman. 

But she never really said, you know, maybe I shouldn’t really be 

in western Connecticut. It wasn’t so rural, but she still needed a 

car to get anywhere. She became her friends’ chauffeur. She was 

chauffeuring friends that were younger than she was, because she 

was still able to drive at 93. 

But she didn’t plan to, you know, go to a warmer climate. She 

didn’t plan to make herself more comfortable as she aged. She really felt that the activity around her was the most important thing. 

We continued to give her that activity. I mean, she did 40 segments 

on my television program. Even her own children didn’t realize 

that. They didn’t realize what a fantastic contributor she had been 

to my life and to the lives of so many other older people in America. She gave them lots of hope that they could age gracefully as 

my mother had. 

But even that aside, the whole aging and the whole dying process 

just made me realize that you have to plan. You have to have help. 

You have to have intelligent resources, not just financial, but from 

everyone to get old gracefully and live well until you die. 

Senator SMITH. Perhaps to Americans living in rural places, a 

word of counsel to become educated and, literate on caring for our 

parents. 

Ms. STEWART. Absolutely. Very important. 

Senator SMITH. Probably good counsel to all of us to be nice to 

our kids and keep family relationships strong, because if you live 

in Pendleton, OR, like I do, you may not have all of the care that 

you might in Connecticut, for example. 

Ms. STEWART. Well, even in Connecticut, some of her friends 

don’t have any care—ones without children and without—I see it 

all the time. They come to me asking for help. I am there to help 

them, because it is a community. 

Senator SMITH. Well, I thank you for what you are doing. It is 

commendable example for all of us. You have added measurably to 

this hearing and to bringing our focus on this emerging problem. 

The CHAIRMAN. Thank you, Senator Smith. 

47 

Senator SALAZAR. Senator SALAZAR. Thank you very much, Chairman Kohl. 

Thank you, Ms. Stewart, for testifying here today and to all the 

panelists as well for being here today. Thank you also for leading 

the way in helping us figure out what we ought to be doing with 

our elderly population and dealing with long-term care issues. 

I have a question of you, because frankly you are a master of 

marketing and communication throughout the country and 

throughout the world. I think when I hear Senator Smith’s question to you about how we get our families involved and educated 

about long-term health care issues, it goes way beyond that. 

I come from a family of eight children. My family has lived on 

the same farm for 150 years, almost 300 miles south of Denver, 

CO. We took care of my father until he passed away from Alzheimer’s at age 85. My mother, who is 86, still lives on the ranch. 

We take turns taking care for her. So I understand the importance 

of the nexus between the children and the parents. 

But I also think that, as a society, we aren’t very good in terms 

of planning for those later stages of life, whether it is financial 

planning, whether it is medical planning, if long-term health care 

is a part of that. So based on your expertise and communications, 

how is it that we can move our society to having a more honest and 

educated view of what we do as we get through the aging process? 

Ms. STEWART. Well, things have changed, I think, tremendously 

in the United States. We have become more youth-centric than 

aging-centric. I think that that has to—we have to have a shift because of this huge number of baby boomers that are reaching 65 

years old. That is still not old. I mean, you are still a vital person 

at 65 years old. 

But as you get older, you realize that you have to rely on others 

many times for transportation, for meals, for just living expenses. 

We have not really done a good job in teaching our children to care 

for the elderly. Our advertising is still focused on the young. We 

should be focusing more on the aging population. 

I think that is all going to happen. I am working on a magazine 

for women over 50 now. I need this magazine. I know all my 

friends need this magazine. One doesn’t exist in this country without trying to encourage and inform, and I am going to spend the 

rest of my time doing this kind of educating. I think that there are 

other people in my position that can also be very, very helpful. But 

that doesn’t mean that we can’t also focus in Government on these 

issues and medicine on these issues to get people focused on the 

care and the well-being of the aging population. 

Senator SALAZAR. I appreciate it very much. Senator Whitehouse 

and I once worked together as attorneys general for a number of 

years and had a number of initiatives with AARP and other organizations trying to deal with it. 

Ms. STEWART. They have done a phenomenal job. But they don’t 

reach everybody. That is a problem. 

Senator SALAZAR. Sometimes I wonder there are a lot of efforts 

out there from lots of organizations and lots of wonderful-meaning 

people. But I wonder how effective we are being in terms of actually reaching the population at a point where they are making decisions for the long-term. Sometimes, my senses is that we have 

48 

made some progress. But if there is 100 miles to go, we have gone 

maybe only the first mile—— 

Ms. STEWART. I think there are 100 miles. I think that we really 

do have to focus. I intend to, as an individual. I hope many other 

people do too. 

Senator SALAZAR. Thank you for being here today. 

Ms. STEWART. Thank you. 

The CHAIRMAN. Thank you very much. 

Senator CASEY. Senator CASEY. Thank you, Mr. Chairman. 

Ms. Stewart, thank you for your testimony and for the insight 

you bring to us from a personal perspective as well, which I think 

informs all of us. 

I was looking at your testimony in the last section, when you 

have I guess—there are three bullet points. The second one, when 

you talk about, ‘‘It is important that we as a society recognize the 

stresses and challenges that caregivers face and support them as 

best we can.’’ 

I was thinking about one initiative in Pennsylvania about 20 

years ago it started. I am pretty sure it is still being funded. It was 

called Aid to the Caregiver. It was an innovative way to have Government help a little bit to provide aid or respite care of one kind 

or another. I think there have been similar models in the Federal 

Government. 

But I just wanted to have you expand upon that point in terms 

of what you have seen, either in the public sector or the private 

sector and non-profit sector, of models or programs that speak to 

the goal of trying to give some aid or relieve some of that stress. 

Ms. STEWART. Well, there is Gail Hunt who heads up the National Alliance for Caregiving. She has been a wonderful resource 

to us at the Center for Living at Mt. Sinai also. Dr. Robert Butler, 

who founded the department at Mt. Sinai. It is the oldest geriatric 

department in America. I don’t know if you know that. Now, he has 

also founded the International Longevity Center. He is actively involved in confronting this caregiving crisis. 

So there are people really working in this area, really trying to 

help solve the problem. It is just a question of focus. It really is— 

and a large focus. 

Senator CASEY. What is it about the way that that kind of respite care is given? In other words, if you have a particularly difficult situation you are caring for, and it is usually women that are 

doing this—caring for an older relative, a parent or something like 

that. What do you think is the—and this is a broad generalization—but what do you think is the most common relief they can be 

provided with? 

Is it taking a day off? Or is it more giving them a break a couple 

hours a day. Or is it a longer break? 

Ms. STEWART. It is very hard to say. I personally work 7 days 

a week. I have many jobs that I do for my company. But I always 

tried to see my mother ever single Sunday. Someone would go to 

pick her up, bring her to my house. The last 6 months or so, she 

wasn’t really driving a distance. She could drive around town, but 

couldn’t really drive a distance any longer. I live about 35 minutes 

from where my mother lived. 

49 

But I would have her over, try to entertain her. On her 93rd 

birthday, I had a dinner party for her. She controlled the conversation. We asked her to just reminisce. I had all my friends there— 

not her friends, but my friends. So they could really get to know 

her. Who knew she was going to die a few months later? 

But it was fascinating, because she really wanted to be independent. But she really wanted to have the interaction. Making 

time to have the time to be interactive with an elderly person in 

your family, or taking the time to just contribute to an organization, so that you could give time to somebody else, it is very important. It is just a way of living. 

That is what we are trying to do in the Center. We are trying 

to be a place where you can go, learn and be cared for, and feel 

wanted. I think that is really one of the major things. 

In New York, there are many older people. I was looking up the 

statistics today about the numbers of elderly. In New York, 13 percent are over 85 years old; in Pennsylvania, 15.15 percent; Maine, 

14.4 percent; Florida is the highest, 16.79 percent. That is a lot of 

people. It is getting to be bigger and bigger and bigger over 65 now. 

So we just have this big challenge. 

Senator CASEY. Thank you very much. 

Ms. STEWART. Wish I could answer all the questions. 

The CHAIRMAN. Thank you very much. 

Senator WHITEHOUSE. Senator WHITEHOUSE. Thank you, Mr. Chairman. 

Thank you for being here, Ms. Stewart. I was struck by the question of the distinguished senator from Oregon, because I did not 

know until this minute that we shared the common experience of 

having our mothers die from pancreatic cancer. 

Ms. STEWART. Painful and horrible. 

Senator WHITEHOUSE.—Senator Salazar mentioned, when we 

were attorneys general, we did a certain amount of work on, in my 

case, particularly end-of-life care, which is sort of a particularly 

sensitive and tender aspect of all of this; but also one that is potentially very ennobling. 

The experience that I have seen and heard of from too many people is that, at that time, there are far too many Rhode Islanders 

and far too many Americans who are experiencing far too much 

pain, who are experiencing far too much either confusion about or 

failure of, their advance directives, and far too many who are experiencing continuing medical intervention that is well-intentioned, 

but is kind of on the ‘‘don’t just stand there, do something’’ theory. 

Frankly, everybody would be better off if the family had the 

chance to stop, settle down and deal with the occasion and experience of that loved one’s passing away. I just think we are terrible 

at that in this country, by and large. 

I was delighted to hear that Senator Smith’s family had the experience of having a beautiful death. We have had a beautiful 

death in my family. We have also had some pretty unpleasant 

ones. The difference seems to follow along these lines. It is something you can prepare for, if it is done right. But there is very little 

support for those decisions. 

In fact, institutions seem to be leaning very strongly in favor of 

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vance directive means, and general disinterest in complying with 

them. Then for God’s sake, let’s not stop doing things until it is all 

over, even if that is highly painful and costly emotionally to the 

family. 

I am just wondering what thoughts you bring to that particular 

issue. 

Ms. STEWART. Well, I am a fighter. I am going to be here forever. 

I am never willingly going to die. I wish I could find the fountain 

of youth that we are all looking for. But you can’t really, I think 

in this Committee, approach it that way. 

You just have to really encourage support of caregiving and support of geriatric medicine to deal with the problems of the elderly. 

I think that that is really what we have to focus on, having places 

like the Mt. Sinai Center, the Martha Stewart Center for Living 

that will really help those patients with many, many, many different problems there and not burden the family with everything. 

The family can’t really take the brunt of it all. 

I don’t think it is just the family. The family will help, but a lot 

of people don’t have large families and lots of kids. What is going 

to happen to those people? 

So it is a huge challenge. It has to be dealt with, as I said, in 

a very systematic and careful way to develop programs and encourage the universities to encourage people to study geriatric medicine 

and provide subsidies for caregivers. I don’t really know anything 

about any of that. All I know is that they need information, education and help. 

Senator WHITEHOUSE. Well, you are a great communicator. You 

are a great person at helping Americans experience the transitions 

and passages of their lives, birthdays and things like that in a 

more favorable way than they might otherwise. I would urge you 

to think about the end-of-life care. Thank you. 

Ms. STEWART. Thank you. 

The CHAIRMAN. Ms. Stewart, thank you so much for being here. 

You have helped us immeasurably and we appreciate your giving 

us your time today. 

Ms. STEWART. Excuse me for having to leave. I have some other 

obligations I have to go to. But I greatly appreciate the invitation. 

The CHAIRMAN. Thank you so much. 

We now turn to the second member of the panel, Dr. Todd Semla. 

STATEMENT OF TODD SEMLA, PHARMD, PRESIDENT, 

AMERICAN GERIATRICS SOCIETY, EVANSTON, IL 

Dr. SEMLA. Good afternoon Chairman Kohl, Ranking Member 

Smith and members of the Committee. Thank you for inviting the 

American Geriatrics Society to address the Committee on preparing 

our nation’s health care workforce for the growing number of older 

Americans. 

The American Geriatrics Society is a non-profit organization of 

7,000 health professionals dedicated to improving the health, independence and quality of life of older Americans. Geriatricians are 

primary care physicians who complete residencies in family practice or internal medicine, and at least one additional year of fellowship training in geriatric medicine. 

51 

Geriatricians specialize in the often complex health condition and 

requirements of older adults. As Dr. Rowe stated, today there are 

fewer than 7,200 certified geriatricians practicing in the United 

States—roughly half the number needed. 

There are similar shortages in other disciplines. In all disciplines, there are insufficient number of geriatrics faculty to train 

upcoming geriatricians and conduct aging research. Today I will 

offer some solutions for your consideration. Many parallel the recommendations of the recently released IOM report on the geriatrics 

workforce. 

We need to establish Federal loan forgiveness programs for geriatric health professionals. Encouraging future physicians burdened 

with school loans to consider a career in geriatrics is a challenge 

because of financial disincentives, as you have heard. In most fields 

of medicine, additional training results in higher income, but not 

so in geriatrics. A national loan forgiveness program would offset 

at least a portion of the financial burden of pursuing a career in 

geriatrics. 

As you heard Senators Boxer and Collins have introduced a geriatrics loan forgiveness bill. We support the principles underlying 

this bill. 

We need Congress to reauthorize expand and fund Title VII 

health professions programs. We have specific recommendations for 

the three programs that are critical to training health care professionals in geriatrics. 

First, AGS recommend expanding the Geriatric Academic Career 

Awards (GACA) to support not only career development for geriatric physicians in academic medicine, but also junior geriatrics 

faculty in other health professions such as nursing, pharmacy and 

social work. We recommend creating a mid-career GACA award 

that would support and retain clinician educators as they advance 

in their careers. 

Second, we recommend expanding the Geriatric Education Center Program to support 14 additional GECs. Currently there are 48 

in 36 states. Ideally, the mandate of the GECs would also be expanded to include training of direct-care paraprofessionals. 

Third, we recommend that Congress consider expanding the geriatric faculty fellowship programs by creating mid-career fellowships that would allow faculty from all disciplines to receive training in caring for older adults. 

We need to support Title VIII nursing workforce development 

programs, the largest source of Federal funding for advanced nursing education supporting almost 50,000 nurses and trainees in 

2008. The Title nursing comprehensive geriatric education program 

supports training for nurses who care for the elderly, curricula relating to geriatrics care and training of faculty in geriatrics. 

We need to expand and enhance support for geriatric research, 

education and clinical centers also known as GRECCs. These are 

centers of geriatric excellence within the VA At the outset, we believe five new GRECCs should be established and funded, which 

would be in keeping with the congressional authorization in 1985. 

We need to address problems with Medicare GME policy. The 

number of Medicare-funded graduate medical education slots has 

not increased since the enactment of the Balance Budget Act of 

52 

1997. We need to expand the number of GME slots, particularly in 

the field of geriatrics, and resist proposed funding cuts to this program. 

We need to provide adequate coverage for necessary and cost-effective services. We must reform Medicare and the nation’s health 

care system to realign reimbursement and incentives. Senators 

Lincoln and Collins have introduced legislation that would fill a 

major gap in Medicare by covering geriatric assessment and care 

coordination services for beneficiaries of multiple chronic conditions, including dementia. Changes like this to Medicare coverage 

are important incentives for geriatricians and other primary care 

providers. 

We need to collaborate to train and prepare the direct care workforce and family caregivers. AGS commends the IOM report for recommending increased standards for all direct care workers. We are 

also developing materials for certified nursing assistants with a 

focus on care of older adults. 

In addition to our AGS Foundation for Health and Aging, we provide support and information to informal caregivers through programs like Eldercare at Home. We would be pleased to collaborate 

with the Committee on any efforts to develop programs for both direct care and informal caregivers. 

To conclude, there are already serious shortages of geriatrics 

health care providers. Given the coming silver tsunami, these 

shortages will reach crisis proportions unless we work together now 

to address them. 

Thank you again for the opportunity to participate in today’s important and timely hearing. 

[The prepared statement of Dr. Semla follows:] 

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The CHAIRMAN. Thank you, Dr. Semla. 

Ms. MCDERMOTT. 

STATEMENT OF MARY MCDERMOTT, PERSONAL CARE WORKER AND BOARD OF DIRECTORS MEMBER, WISCONSIN QUALITY HOME CARE COMMISSION, VERONA, WI 

Ms. MCDERMOTT. I would like to thank Chairman Kohl and 

Ranking Member Smith and other distinguished members of the 

Committee for this opportunity to speak to you today about home 

care. I am here today with SEIU, the largest health care union in 

the country with almost a million members of health care workers. 

In the last 11 years I have had the opportunity to view home 

care from several perspectives. Currently I provide hands-on assistance for my mother and coordinate work of several other caregivers. I am also an officer on the board of directors for the Wisconsin Home Care Commission, a nonprofit organization established in 2006 to assist consumers looking for providers of home 

care and personal care services. 

Before taking on the care of my parents, I worked as an efficiency expert analyzing, designing cost-effective quality standards, 

core competency curriculums, training programs and operational 

processes. My background has enabled me to bring important professional expertise into this very personal arena. 

In 1997, my mother suffered a stroke and, along with my disabled father, moved from Michigan to my home in Wisconsin, so 

that I could assist them in providing the care that they needed. 

We, like many families, wanted to avoid putting my parents in a 

nursing home. 

Families want choices in their long-term care for their loved 

ones. My experience is that caregivers who choose this field often 

lack medical and geriatric skills and knowledge. This is particularly true of people who care for family members and are often isolated and unaware that support is even available. 

Direct care workers, like other workers, need career support that 

includes continuing education, training, career guidance. Such 

training can help individual caregivers in the field create long-term 

caregiving relationships with their clients and reduce the turnover 

that we are now seeing nationally. 

I was fortunate to work with my parents, very high-quality RNs 

and LPNs to obtain the training that I needed to care for my parents and then to train others to care for my parents. I cannot begin 

to express my appreciation to Dr. Barczi and the geriatrics team 

at the VA Hospital in Madison for the training that they gave on 

an as-needed basis. 

They were also very valuable in giving me support, when I needed it, on making health care decisions for my father; and gave me 

valuable suggestions as how to approach care planning as changes 

occurred with my father’s health status. Their partnering with us 

significantly reduced hospitalization, cost and improved the quality 

of the care that was provided in my home. 

I know from personal experience that direct care can be physically demanding and emotionally challenging. We in the field 

struggle to retain the current workforce, given the low wages, the 

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nities for any advancement. Homecare workers’ wages are among 

the lowest in the service sector. One in five health care workers 

lives below the poverty level. 

Under a recent Supreme Court ruling, most home care workers 

are not entitled to even minimum wage or the overtime protection 

of the Fair Labor Standards Act. Congress can rectify this by passing S. 2061, the Fair Home Health Care Act. I urge the members 

of this Committee to sign on to that important legislation. 

Until we treat home care workers with the respect they deserve, 

pay them a living wage, give them health care, we fail as a country 

to provide the professional workforce that is so desperately needed 

with our growing population of seniors and the people with disabilities. A knowledgeable, experienced and responsive worker can significantly improve the quality of life for many clients. 

Some states are offering home care training for aides and personal care workers. But in some places, it has been local unions 

who have been addressing this training gap. After developing a 

registry to enable consumers to choose from among available workers, the Wisconsin Home Care Commission will offer supportive 

services for both home care workers and consumers, including 

training. 

SEIU supports the development of a core competency curriculum, 

which emphasizes consumer choice and preferences and requires 

training in communication, problem solving and relationship skills. 

Such training enables workers to understand and respond to consumer preferences and to provide them with the high quality of 

care that they deserve. 

While training is crucial to the development of a professional 

workforce, it is only one factor. We need to do a better job with 

Federal and State funding for long-term care and improving wages 

and benefits. If we don’t, the training alone will not be enough. 

Again, I thank the Committee for giving me this opportunity to 

speak today. I welcome any questions. 

[The prepared statement of Ms. McDermott follows:] 

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The CHAIRMAN. Thank you, Ms. McDermott. 

Dr. Bowman. 

STATEMENT OF SALLY BOWMAN, PHD, ASSOCIATE PROFESSOR, DEPARTMENT OF HUMAN DEVELOPMENT AND 

FAMILY SCIENCES, OREGON STATE UNIVERSITY, CORVALLIS, OR 

Ms. BOWMAN. Good afternoon, Ranking Member Smith, Mr. 

Chairman and Committee members. I appreciate this opportunity 

to share my remarks today, focusing first on the links among living 

arrangements, health and caregiving; and second on the need for 

educational strategies to train a sustained and capable workforce 

of professionals, paraprofessionals and informal family caregivers. 

In late life, the individual preference to age in place means that 

housing, health care services and personal caregiving are intertwined. Consumers and health care providers have positively responded to the philosophy that older individuals should be able to 

receive services in the least restrictive physical environment possible. 

The challenge and the opportunity is to link services to individual needs, rather than to the type of residential setting in which 

the individual happens to live. The advantage of this approach is 

that declining health status does not require multiple relocations 

for an individual. Moving from place to place is difficult for aging 

persons and their family members and is problematic for health 

care coordination. 

How will the desire to age in place affect baby boomers? They 

will reside in a wide variety of home, community and institutional 

settings, receiving services from a combined workforce of professionals, paraprofessionals and informal caregivers. Projections indicate that the greatest growth in long-term care settings will be in 

assisted living, residential care and home and community-based 

services. 

This will make Senator Smith happy. Oregon was the first State 

to apply for and receive a Medicaid waiver to provide home and 

community-based services in 1981. For over 25 years, Oregon’s financing, reimbursement and licensing policies have favored the 

growth of adult foster care, assisted living, and residential care facilities while reducing nursing home use. These policies resulted in 

savings in public resources. At the same time, they provided living 

arrangements that valued independence and privacy. 

Indeed, many frail older adults, with both physical and cognitive 

disabilities, are living in all these diverse long-term care settings 

and in the community rather than in nursing homes. Because Medicaid daily reimbursement rates for adult foster homes, assisted living and residential care facilities in Oregon are less than half the 

daily rates for nursing facilities, the decrease in Medicaid cases in 

nursing facilities—from 69 percent to 37 percent over 14 years has 

resulted in considerable savings of tax dollars. 

So for example, in 2004, reimbursement of Medicaid long-term 

care recipients who resided in adult foster care, assisted living and 

residential care facilities rather than nursing homes saved Oregon 

taxpayers about $700,000 per day. 

70 

The goal of combining individualized care with a normal life is 

a challenge regardless of the physical setting. It highlights the 

need for a well-trained network of formal and informal caregivers. 

The projected shortfall in formal and informal workers needed to 

care for these aging baby boomers, including myself, requires increased efforts in education and training at every level. 

Geriatric Education Centers, GECs, are and will continue to be 

a key player in this effort. These centers focus on the training of 

professional workers in long-term care—including physicians, 

nurses, social workers, allied health workers. GECs have helped to 

provide aging-related education to these health care workers and 

have also been essential to incorporating geriatric curricula into 

the training of new professionals. 

The Oregon GEC focuses on outreach to rural areas where, in 

comparison to urban areas, a larger percentage of the population 

is older, disabled and suffers from chronic diseases. Yet most rural 

health care providers have not received geriatric training. 

As part of our participation in the Oregon GEC and also part of 

the land-grant mission, the Oregon State University Extension 

Service in the College of Health and Human Sciences has offered 

a regional 2-day gerontology conference for 300 to 400 direct care 

practitioners annually for the past 32 years. This conference 

reaches frontline workers and community service providers who 

serve an aging population. 

Collaborative partnerships involving higher education institutions, community colleges, private foundations, state and local government units on aging, nonprofits and employers can all expand 

opportunities to meet the educational needs of informal family 

caregivers. Educational and training strategies may include publications for late-life decisionmaking; Web-based checklists; interactive board games; community education workshops, both series 

or as single events; and one-on-one consultations. 

The nationally disseminated caregiver training program, Powerful Tools for Caregiving, was produced by a partnership in Oregon 

between a community-based hospital and Oregon State University 

faculty members. Evaluations have shown that family caregivers 

become empowered to practice self-care strategies and develop tools 

that enhance their caregiving efforts. 

Because the vast proportion of long-term care to older adults is 

provided by family members and by paraprofessionals, attention 

should focus on supporting these frontline caregivers. Because longterm care requires one-on-one assistance, labor is the major cost 

and determinant of quality of care. 

Recruitment and retention of direct care workers in all types of 

long-term care organizations continues to be a significant challenge. The Better Jobs Better Care national demonstration projects 

have shown that key dimensions of job satisfaction—such as adequate training, rewards and incentives, career ladders, reducing 

workloads—all affect intentions to stay in or leave the workforce. 

Changes in public policies at the state and local levels and related 

funding will be required to institutionalize management practices 

that can lower the turnover rates of frontline workers. 

Thank you for this opportunity. 

[The prepared statement of Ms. Bowman follows:] 

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The CHAIRMAN. Thank you, Dr. Bowman. 

Questions from the panel? 

Senator SMITH. 

Senator SMITH. You speak of the importance of Oregon’s Geriatric Education Center to rural areas. The conference, you hold it 

every year? Where do you hold it? Different places? What kind of 

attendance do you have? 

Ms. BOWMAN. We hold that event in Corvallis, because that is 

our tradition. We get a vast proportion of participants from the 

rural areas actually not from the metro areas. There are other conferences for family caregivers and for practitioners held around the 

State. You, in fact, hold one yourself. 

Senator SMITH. I do, yes. 

Ms. BOWMAN. You get a fantastic attendance, because you have 

great speakers. I think you also give free lunch. 

Senator SMITH. Yes, we do. You all heard there is no such thing. 

But there is at my aging conference, a free lunch. 

Well, you know, listening to your testimony, a comment about 

Ms. Stewart that, you know, in some urban areas, maybe there are 

more caregivers, there are more professional people. But I wonder 

if, in your judgment, end-of-life care is as good or better in rural 

areas in Oregon. 

Ms. BOWMAN. Well, I think you have to look at the whole continuum of care and compare it, rural to urban areas. I think if we 

are going to talk about end-of-life care, one of the things that I 

didn’t hear mentioned was the role of hospice. So often people bring 

in hospice 3 hours before the patient dies. 

There are resources. But, you know, one of the wonderful things 

about rural areas is the social support system. 

Senator SMITH. That is right. 

Ms. BOWMAN. The friends and neighbors who check on people 

who are living alone. So I think we need to emphasize that importance of the rural support. Through the GEC, we try to do road 

shows and do as much as we can to provide geriatric training to 

the rural health care practitioners in those areas. 

Senator SMITH. Well, I think I appreciate you mentioning hospice. I think they are working alongside the angels as far as I am 

concerned. I have seen the work they do as both wonderful and 

merciful. I would simply add a word of encouragement to families 

to bring hospice in earlier, because they—at least in our family’s 

case—they were helpful in training and making sure we did the 

right things. They are present in rural areas. They certainly are in 

rural Oregon. 

But I appreciate your focus on rural Oregon. Obviously I care 

about all of Oregon. So I wonder if you have any comment about 

how we are doing in our urban centers of Portland and Eugene and 

Corvallis perhaps as well. How are doing? Are we up to speed? Got 

a lot more work to do? 

Ms. BOWMAN. You know, I think the wonderful thing about not 

having enough resources is that you partner to get things done. 

What I have been so proud of and so pleased about are the variety 

of partnerships to meet the needs of families in this State. The 

Family Caregiver Support Program, the Alzheimer’s Association, 

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AARP, the universities, community colleges—everyone partners to 

try to meet that need. 

Senator SMITH. Are they communicating in that partnership? 

Ms. Bowman. They do. I think we can’t underestimate the importance of community education workshops, whether it is the extension service or whoever. You know, I, for example, did a workshop 

in Enterprise, Oregon. I think they closed down the nursing home. 

There were 100 people there. What they said to me was nobody 

ever comes to Enterprise, Oregon. 

So I think the importance of getting training for family members 

as well as all the health care workers we have talked about today 

who need geriatric training—I think we can do it. But we have to 

really work on public-private sector partnerships. 

Senator SMITH. Well, for our CSPAN audience, if you ever go to 

Enterprise, Oregon, you won’t want to leave. It is one of the most 

beautiful parts on Planet Earth. 

Again, Sally, thank you for coming this long way across the Oregon Trail to the nation’s capital, and your testimony; and Mary, 

yours as well. Todd, thank you for your participation today. 

The CHAIRMAN. We thank the panel profusely for being here and 

giving us your wisdom and your experience. This whole area of caring for seniors in our society is daunting in terms of the needs, the 

kind of things that we need to do to attract people to the area, to 

see that they get trained and paid, so that our seniors can get the 

care that they need and deserve and must have in the years ahead. 

We appreciate your being here. We appreciate your testimony. 

You can be sure we will continue to be in touch with you. Thank 

you so much. 

Thank you all for being here. 

[Whereupon, at 4:49 p.m., the Committee was adjourned.] 

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A P P E N D I X 

PREPARED STATEMENT OF SENATOR SUSAN M. COLLINS

MR. CHAIRMAN, thank you for calling this hearing to examine our nation’s future health workforce needs in the face of our rapidly aging population. 

This afternoon’s hearing is particularly significant in light of the report issued by 

the Institute of Medicine (IOM) earlier this week. The IOM report, titled ‘‘Retooling 

for an Aging America,’’ sounds a warning that we are facing a critical shortage of 

doctors, nurses, and other health care professionals who are adequately trained to 

manage the special health care needs of our nation’s growing population of seniors. 

America is growing older. Today, more than 37 million Americans are age 65 and 

over, and these numbers will rise dramatically when the ‘‘baby boom’’ turns into a 

‘‘senior boom.’’ Over the next twenty years, the number of Americans over the age 

of 65 is expected to more than double. In Maine, more than a quarter of our population will be over 65 in 2030. 

Nowhere does the aging of America present more risk and opportunity than in 

the area of health care. It is not just that there will soon be more older Americans. 

It is also that older Americans are living longer. Americans 85 and older—our ‘‘oldest old’’—are the fastest growing segment of our population. This is the very population that is most at risk of the multiple and interacting health problems that can 

lead to disability and the need for long-term care. 

Older Americans consume far more health care resources than any other age 

group. Moreover, their health care needs are very different from those of younger 

persons. While younger people typically come in contact with the health care system 

for treatment of a single, acute health care condition, older people often have multiple, chronic conditions like heart disease, diabetes, arthritis, and Alzheimer’s disease—or any combination of the above. 

Geriatrics is a medical specialty or style of practice that is specifically designed 

to address the complex health care needs of older patients. The essence of geriatrics 

lies in coping rather than curing. Its emphasis is on helping older adults maintain 

their quality of life and ability to function independently, even in the presence of 

chronic age-related diseases and disabilities. 

With its emphasis on maintaining ‘‘functional independence,’’ geriatrics offers 

great promise not only for improved health and quality of life for older persons, but 

it also has the potential to reduce overall medical and long-term care costs. According to a report by the Alliance for Aging Research, the U.S. realizes at least $5 billion in health and long-term care savings for every month that the physical independence of older people is extended. According to the Alliance, this is a conservative estimate. 

Unfortunately, as the IOM report reveals, we are facing a dramatic shortage of 

health care professionals who are adequately prepared to deal with the complex 

health care needs of seniors. 

Despite the obvious need, relatively few physicians, nurses and other health care 

professionals are pursuing careers in geriatrics or gerontology. While experts have 

projected that 36,000 geriatricians will be needed to care for our 70 million seniors 

in 2030, only 7,000—about one per cent of all physicians—are currently certified 

geriatricians. Only about one percent of nurses are certified gerontological nurses 

and only 3 percent of advanced practice nurses specialize in care of the aging. 

Moreover, while most physicians do care for older patients, very few receive formal geriatric training. While almost all medical schools require some ‘‘geriatric exposure,’’ the IOM report notes that this training is often inadequate. Less than 35 

percent of our nursing baccalaureate programs require coursework in geriatric settings. 

In the face of the approaching tidal wave of aging Americans, we simply cannot 

afford to ignore the IOM’s warning. That is why I was pleased to join Senator Boxer 

in sponsoring the Caring for an Aging America Act, which takes some important 

84 

first steps to ensure that our health and long-term care workforces are prepared to 

meet the needs of our aging population. 

Our legislation would provide $130 million in federal funding over five years to 

attract and retain health care professionals and direct-care workers with training 

in geriatrics by providing them with loan forgiveness and career advancement opportunities. It would also create a Health and Long-Term Care Workforce Advisory 

Panel for an Aging America to examine and advise the Secretary of Health and 

Human Services, the Secretary of Labor and Congress on workforce issues related 

to our aging population. 

Again, MR. CHAIRMAN, thank you for calling this hearing, and I look forward 

to working with you on this important issue. 

PREPARED STATEMENT OF SENATOR ROBERT P. CASEY, JR. 

Mr. Chairman, I want to thank you for scheduling this important hearing. It is 

critical that we fully investigate all issues surrounding the direct care workforce and 

the increasingly older population in America. 

This is a critical time for the health care workforce in this country. With the first 

of the baby boom generation on the cusp of retirement, the demand for direct care 

workers will increase exponentially in the coming years and decades. It is estimated 

the number of adults aged 65 and older will almost double from 37 million to over 

70 million between 2005 and 2030. This is an 8 percent increase from 12 percent 

to 20 percent of the United States population. 

In Pennsylvania, the projected increase is slightly larger. People over 65 will comprise 22.6 percent of the population by 2030 going from 1.9 million to over 4 million 

older citizens. 

As the baby boom generation ages, we will need more caregivers and we will also 

need to change our approach to care, emphasizing greater prevention and more coordinated care. Shortages in caregivers for older citizens exist across the spectrum 

of care. The direct care workforce is woefully inadequate to meet the needs of the 

increasing number of older citizens who will require care. By 2030 it is estimated 

we will need an additional 3.5 million health care workers to care for our older citizens, a 35 percent increase from today. 

With respect to physicians, only one percent of all physicians in the United States 

are currently certified as geriatricians. Experts project we will need 36,000 geriatricians by 2030. 

The nation is already experiencing a severe shortage of registered nurses and less 

than 1 percent are certified gerontological nurses. Without increases, the total supply of nurses is projected to fall 29 percent below requirements by the year 2020. 

In Pennsylvania, projections indicate the state will need an additional 24,610 direct care workers. This is an increase of 19 percent and a rate of growth nearly 

three times the state average for all occupations. 

We must begin to address these shortages right now or we will suffer the consequences of our inaction tomorrow. 

Almost every person in this room has a family member or a friend who has required long term care. From my experience with my father, who was hospitalized 

for a significant period of time toward the end of his life, I know what a positive 

impact that knowledgeable and skilled health care professionals can have. 

On Monday, the Institute of Medicine released a study entitled ‘‘Retooling for and 

Aging America: Building the Health Care Workforce’’. This document provides us 

with a detailed roadmap to expanding the direct care workforce, meeting the increasing needs of older citizens, and changing our approach to the models of care 

we provide our citizens in order to emphasize greater prevention, and more effective 

coordination of care. 

This report highlighted three main goals we must achieve: 1) increase the training 

and educational opportunities for all providers of geriatric health care; 2) improve 

upon the recruitment and retention of all providers and specialists in geriatric 

health care by improving wages, benefits and working conditions; and 3) redesign 

models of care so that prevention and coordination of care are prioritized and older 

citizens themselves can participate as much as possible in their own care. 

These are important steps forward that we must take. Our older citizens need and 

deserve quality and coordinated health care as they age. These are our parents and 

our grandparents and they’ve worked hard for us and for our country. Now we owe 

them respect and dignity as they age. It will take time to build up the workforce 

we need, this is not something we can accomplish overnight. This is a daunting 

task, but a task we simply must undertake. 

85 

I look forward to hearing the testimony of all the witnesses today as they share 

their knowledge and experiences with the committee. I look forward to working with 

them, the members of this committee and others to ensure that our older citizens 

will have the care they need—and deserve—in their later years. 

PREPARED STATEMENT OF SENATOR BARBARA BOXER

I would like to thank Senator Kohl, Ranking Member Smith, and members of the 

Senate Special Committee on Aging for having this hearing, and bringing attention 

to this important issue. I also want to commend the Aging Committee for its long 

and influential history of exploring and investigating issues that concern our senior 

citizens and their families. 

California is home to 3.9 million people age 65 and older, more than any other 

state. That population is projected to increase to 8.3 million by 2030, growing from 

11 percent to 18 percent of the state’ population. 

Preparing our workforce for the job of caring for older Americans is an essential 

part of ensuring the future health of our nation. Right now, there is a critical shortage of health care providers with the necessary training and skills to provide our 

seniors with the best possible care. This is a tremendously important issue for 

American families who are concerned about quality of care and quality of life for 

their older relatives and friends. 

Quite simply, the demographic imperative is clear: with the number of adults 

aged 65 and older projected to almost double from 37 million today to nearly 72 million by 2030, we must start now if we are going to adequately train the health care 

workforce to meet the needs of an aging America. We cannot afford to wait any 

longer. 

According to the Institute of Medicine, only about 7,100 U.S. physicians are certified geriatricians today; 36,000 are needed by 2030. Just 4 percent of social workers and only 3 percent of advance practice nurses specialize in geriatrics. Recruitment and retention of direct care workers is also a looming crisis due to low wages 

and few benefits, lack of career advancement, and inadequate training. 

It is clear that there is a need for federal action to address these issues, and that 

is why Senator Collins and I have introduced the Caring for an Aging America Act 

(S. 2708). Senator Collins has been a strong leader on aging issues and I look forward to working with her and this Committee to move this legislation forward. 

The Caring for an Aging America Act would help attract and retain trained health 

care professionals and direct care workers dedicated to providing quality care to the 

growing population of older Americans by providing them with meaningful loan forgiveness and career advancement opportunities. 

Research suggests that geriatricians have the highest job satisfaction ratings 

among all physician specialties, and they find working with older adults to be richly 

rewarding. Yet despite high job satisfaction rates, it remains difficult to recruit adequate numbers of health and social service practitioners to the fields of geriatrics 

and gerontology, which remain among the least well-compensated specialties. This 

is why Senator Collins and I introduced our bill. The Caring for an Aging America 

Act would help to address these financial disincentives. 

Specifically, for health professionals who complete specialty training in geriatrics 

or gerontology—including physicians, physician assistants, advance practice nurses, 

social workers and psychologists—the legislation would link educational loan repayment to a service commitment to the aging population, modeled after the successful 

National Health Services Corps. The bill would also expand loan repayment for registered nurses who complete specialty training in geriatric care and who choose to 

work in long-term care settings, and expand career advancement opportunities for 

direct care workers by offering specialty training in long-term care services. Lastly, 

the legislation would establish a health and long-term care workforce advisory panel 

for an aging America. 

Ensuring we have a well-trained health care workforce with the skills to care for 

our aging population is a critical investment in America’s future. This legislation 

offers a modest but important step toward creating the future health care workforce 

that our nation so urgently needs. 

Our bill has strong support from the health care and senior communities. The report released this week by the Institute of Medicine, Retooling for an Aging America: Building the Health Care Workforce, endorses the financial incentives in our 

bill—including loan forgiveness linked to service—as a key way to recruit geriatric 

providers in the health professions. 

The Caring for an Aging America Act has been endorsed by nearly 30 national 

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ican College of Nurse Practitioners, American Geriatrics Society, American Psychological Association, Coalition of Geriatric Nursing Organizations, and the National 

Association of Social Workers. 

I look forward to working with my colleagues to ensure that we meet our obligations to the seniors of our nation to improve their care. We owe it to our parents, 

grandparents, and ourselves. 

DR. ROBYN STONE’S RESPONSES TO SENATOR SMITH’S QUESTIONS

Question 1—Support and Training for Caregivers 

In the testimony that each of you provided, you state that you believe training 

opportunities should be made available for informal caregivers. I agree and I feel 

that we should work to better support our nation’s caregivers, as they are the backbone of the system to ensure the safety and welfare of our seniors. They also help 

seniors age in their homes, where all of us would prefer to be as we get older. I 

am working with Senator Lincoln to increase funding to the National Family Caregiver Support Program run by the Administration on Aging. I think the help provided by this program, primarily coordinated by the Area Agencies on Aging located 

throughout each state, is so important. But more supports must be made available 

as the number and needs of caregivers increases. 

Question 1. How do you think we can engage the aging network, including Area 

Agencies on Aging, State Agencies on Aging, and other entities to facilitate additional training and help for informal caregivers? 

Answer. The SUAs, the AAAs and other aging network organizations have multiple opportunities to improve upon and expand training for informal caregivers. 

First, they need to recognize that family and other informal caregivers face the 

same challenges as paid direct care workers including how to provide care to their 

loved one (both the clinical and technical aspects of the care delivery), how to communicate with the formal sector (including communication related to cultural competence), how to make decisions in crisis situations and how to take care of themselves. Since community colleges, vocational tech schools, and other educational institutions are developing more comprehensive training programs for direct care 

workers (certified nursing assistants, home health aides, and personal care workers), aging network providers should consider partnering with these entities to offer 

the same curriculum and teaching methods to informal caregivers. Many nursing 

homes also provide both orientation and in-service training to direct care workers 

and could provide a venue for offering training programs to informal caregivers in 

the community. These organizations should also partner with local workforce investment boards in their communities (funded through Department of Labor) who are 

charged with career development for entry level workers in the long-term care sector. Finally, I believe the Family Support Program, administered through the Older 

Americans Act, has been a great symbolic gesture to the millions of informal caregivers across the country. But the resources are limited and the ability of the AAAs 

and other organizations to provide assistance to families varies tremendously. The 

Congress should look at options for expanding the resources to this program through 

the OAA and also ensuring that the organizations are meeting some standard in 

terms of the services offered to caregivers. 

Question 2—Support for Community Health Centers 

Community Health Centers (CHCs) are the foundation of the nation’s health care 

safety net. I believe these centers have an important role in keeping the doors open 

to patients who otherwise might be unable to afford health coverage. In Oregon, 

health centers provide over 130 points of access, where upwards of 180,000 Oregonians receive care each year. 

However, the success of these centers, and indeed, our entire health care system, 

is directly dependent on a well-trained health professions workforce. A March 2006 

study in the Journal of the American Medical Association found that CHCs—especially those in rural areas—are understaffed, including shortages of family physicians, dentists, pharmacists and registered nurses. 

Question 2. Although there are existing health professions programs to encourage 

health care providers to serve in these settings—they still are not receiving the support they need. Do you believe they are effective? What more could be done to encourage medical professionals to practice medicine in rural/underserved areas? 

Answer. The Community Health Centers have targeted primarily families and 

children; relatively few of these organizations have identified the geriatric population as a key user group. This is ironic given the fact that most rural communities 

are aging much more rapidly than their urban counterparts. The first step in ameliorating this situation is to build the capacity of the CHCs to care for the elderly 

87 

population, including hiring staff that are trained in geriatrics and gerontology and 

that know how to meet the needs of rural elders. Special financial incentives need 

to be created to attract physicians, nurse practitioners and physician assistants, 

nurses, social workers, therapists and others who are interested in caring for the 

geriatric population, including debt relief surrounding educational expenses and stipends that allow people to live in these communities. The CHCs also need to expand 

their use of technology to help reach the elderly in remote, frontier areas. Finally, 

they need to understand the aging network resources that are in most rural communities (including the AAAs, senior centers, special transportation programs, rural 

nursing homes and senior housing providers) and partner with these organizations. 

Question 3—Medicare and Medicaid Legislative Relief 

Each of the panelists’ testimony mentioned the important role that Medicare and 

Medicaid play in the topic of ensuring a robust health care workforce. As a member 

of the Finance Committee, I am deeply committed to ensuring that the system 

works for our beneficiaries and responds to our nation’s demographic change. I feel 

that apart from big funding increases to ensure appropriate training and recruitment of professionals, we also need to make sure administration of the Medicare 

and Medicaid programs is running smoothly and we’re reducing burdens on training 

opportunities. A bill that I have introduced with Senator Lincoln, the Long-Term 

Care Quality and Modernization Act, would among other things, allow nursing facilities to resume their nurse aide training program when deficiencies that resulted 

in the prohibition of the training have been corrected and compliance has been demonstrated, instead of the current two-year wait period. 

Question 3. Knowing the great need to educate our nurses with more experiences 

in geriatrics, what support can be given to schools of nursing and long-term care 

facilities to develop strong clinical partnerships? 

Answer. Many nursing homes have developed excellent ‘‘home grown’’ training 

programs for their direct care workers that not only help them to do the their current work but provide career ladders or lattices for these individuals. Given the lack 

of quality training programs in many communities, I commend you for your efforts 

to allow nursing homes to resume training programs as soon as possible. In addition, there are relatively few opportunities for nursing students to have rewarding 

clinical placements in nursing homes and other long-term care settings. When they 

do, however, many become committed to this sector and seek out job opportunities 

there. The Congress needs to consider mechanisms for supporting nursing school 

placements in nursing homes, assisted living and home care that provide meaningful and challenging experiences for students who then will help to expand the labor 

pool in these settings. This might entail developing Centers of Excellence where 

Nursing School/Nursing Home partnerships that meet certain criteria would be eligible for multiple years of funding to support the training program and placements 

costs. I would suggest that similar programs be developed for medical and social 

work schools to prepare medical directors and clinical social workers for this growing field. 

Question 4—National Service Corps vs. Title VII (Health Professions) Programs 

We understand older Americans tend to utilize health services more than younger 

individuals, and by 2030, 20 percent of the U.S. population (71 million Americans) 

will be age 65 or older. Conversely, many health professionals are retiring as this 

population will require greater demand of our public health workforce. As you know, 

the President proposed to zero out many health professions programs in the Fiscal 

Year 2009 budget. Through the years, the Administration has conveyed that funding 

direct primary care through the National Health Service Corps is a better investment than funding HRSA’s Title VII programs, which they believe lack focused objectives. 

Question 4. What are your thoughts on this issue—is the National Health Services 

Corps a better program to improve the placement of providers in underserved areas 

and support training in primary care? 

Follow Up: a. What are your suggestions for improving the efficacy of or expanding Title VII programs as we face the aging of our population and of the healthcare 

workforce? 

Answer. I do not believe that these options are mutually exclusive. I strongly recommend developing a specific track in the National Health Services Corp for people 

who are interested in working in geriatric settings—including nursing homes, assisted living and home care. For this to work, however, funds would need to be dedicated specifically to these settings to attract the ‘‘best and the brightest’’. At the 

same time, it is important to strengthen the Title VII programs that invest in educational opportunities for the professions as well as helping to develop a larger 

cadre of health professionals in the field. In particular, some resources need to be 

redeployed to target the development of the geriatric workforce, including physiVerDate Aug 31 2005 15:01 Jan 26, 2009 Jkt 000000 PO 00000 Frm 00091 Fmt 6601 Sfmt 6601 H:\DOCS\46167.TXT SAG PsN: JOYCE
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cians, nurses and ancillary health professionals who would be interested in geriatric/long-term care settings if financial incentives were available. I would, furthermore, recommend strengthening the Geriatric Education Centers across the country 

that have helped to train many health professionals in the field. 

Question 5—Recruiting a More Diverse Workforce 

In your testimony, you mention the need for long-term care employers to focus 

on new sources of labor that previously have been poorly utilized in the health care 

workforce, such as minorities and retirees. 

Question 5. How do you think long-term care employers can best be encouraged 

to do this and are there models for ways that employers can effectively reach out 

to better recruit from these under-utilized groups? 

Answer. With respect to older adults and retirees as prospective caregivers in the 

long-term care sector, one of our BJBC studies found that elderly individuals and 

employers are interested in expanding these opportunities. This may be a viable option for many older adults who cannot afford to retire as well as those who are interested in pursuing a caring career. Title V of the Older Americans Act currently 

focuses on job development for older adults. I recommend that a special program 

be developed to create partnerships between the Title V providers and long-term 

care employers (nursing homes, assisted living and home care) to explore the potential of using this program to expand the labor pool. The National Health Services 

Corps could also experiment with a Retiree Corps that could be recruited to work 

in these settings. Both of these options, of course, would require sufficient training 

resources to prepare and support this workforce. In addition, a study would be required to explore challenges to the recruitment of older workers including issues related to access to Medicare and Social Security benefits and physical barriers (e.g., 

the need to lift residents/clients) that would deter the hiring of elderly workers. 

With respect to a more diverse workforce, the direct care workforce in long-term 

care settings is already incredibly ethnically, racially and culturally diverse. The 

real issue here is to develop culturally competent workplaces that respect all caregivers and that provide training in the overt and more subtle cultural differences 

that can cause communication problems and poorer quality care delivery. Employers 

also need to explore mechanisms for hiring a more diverse supervisory and clinical 

staff including nurses, social workers, therapists, medical directors, primary care 

physicians and administrators. This could start with the development of partnerships between these employers and historically black colleges and universities and 

their counterparts in the Hispanic community. Resources could also be provided to 

employers with a diverse direct care workforce to help them develop career ladders 

for CNAs, home care aides and personal care workers who are interested in becoming nurses, social workers and administrators in this sector. Finally, some providers 

have developed strategies for recruiting foreign professionals (particularly nurses) 

into this sector (although most of this recruitment has been for hospitals). A targeted strategy needs to be developed that recognizes a code of ethics as it relates 

to both the countries or origin and the needs of the workers who come to work in 

the U.S. through these routes. 

MARTHA STEWART’S RESPONSE TO SENATOR SMITH’S QUESTION

Question 1—Geriatric Education & Training at Mount Sinai 

I understand the Martha Stewart Center for Living supports the education of both 

practicing and future physicians, as well as patients, caregivers and the community. 

Further, physicians at the Center also support education through community talks, 

screenings and health fairs. 

Question 1. Would you describe how this model of care was created and how it 

has benefited the patients who receive care at the Center for Living? 

Answer. The Martha Stewart Center for Living, now with 4,000 patients, is one 

of the largest outpatient practices in the country catering specifically to the health 

care needs of older adults. The models of care have been developed over time at the 

Department of Geriatrics and Adult Development at Mount Sinai School of Medicine, which was founded by Dr. Robert Butler and is the oldest such department 

in the country. Doctors, nurses, and social workers at the Center continue to innovate their approach. Patients see the Center as their medical home, and its interactive programming allows them to become active participants in managing their 

well-being. 

89 

TODD SEMLA’S RESPONSES TO SENATOR’S SMITH QUESTIONS

Question 1—Lack of Nurse Educators 

Currently, less than one percent of the nation’s 2.4 million practicing nurses are 

certified as gerontological nurses or geriatric advanced practice nurses. This statistic 

underscores the importance of educating students in gerontology. In 2007, the American Association of Colleges of Nursing reported that 40,285 qualified applicants 

were turned away from baccalaureate and graduate nursing programs. The top reason cited by schools of nursing was a lack of expert faculty. The bill I introduced 

with Senator Clinton, The Nursing Education and Quality of Health Care Act of 

2007, would help to address the faculty shortage by creating a Nurse Faculty Development program focused on offering scholarships and fellowships for nurses who 

wish to become faculty. 

Question 1. Knowing the demand for educators is high, what other support can 

be given to nurses who wish to become geriatric nurse faculty? 

Answer. AGS recognizes that the shortage of faculty in schools of nursing with 

baccalaureate and graduate programs is a continuing and expanding problem. AGS 

requests that Congress supports providing $200 million in fiscal year 2009 appropriations funding for Title VIII Nursing Workforce Development Programs, the largest source of funding for advanced nursing education. As stated in our testimony, 

before the Senate Special Committee on Aging, Title VIII nursing comprehensive 

geriatrics education program supports training for nurses who care for elderly, curricula on geriatric care, and training of faculty in geriatrics. In addition, the programs are the largest source of federal funding for advanced education nursing; 

workforce diversity; nursing faculty loan programs; nurse education, practice and retention; comprehensive geriatric education; loan repayment; and scholarship. 

AGS also requests that Congress support all Title VII Health Professions Programs at FY 2005 levels of $300 million. Specifically, we ask that Congress fund 

Geriatrics Health Professions Programs under Title VII at least at the FY 2007 levels of $31.5 million. Title VII Geriatrics Health Professions Programs supports three 

initiatives: Geriatric Education Centers (GECs) Program, geriatric faculty fellowships, and Geriatric Academic Career Awards (GACAs) all which are critical to improving recruitment and retention of Geriatrics Health Professionals. The AGS supports efforts to develop and enhance the GACA program to support junior geriatrics 

faculty and expand its availability to other health care professionals, including 

nurses. We also support establishing a mid-career GACA award that would support 

and retain clinician educators as they advance in their careers. In addition, we recommend creating a GACA-like award for advance practice nurses. 

In addition to the suggestions outlined in our testimony, we ask Congress to 

consider the recommendations contained in the June 2005 American Association of 

Colleges of Nursing (AACN) white paper entitled, Faculty Shortages in 

Baccalaureate and Graduate Nursing Programs. The paper addresses the scope of 

the problem and strategies for expanding the supply of nursing faculty (See http:// 

www.aacn.nche.edu/publications/whitepapers/facultyshortages.htm for more information). 

Among the strategies to alleviate the shortage and expand the supply of nursing 

faculty are: 

• Identify any existing regulatory requirements that limit nurses with non-nursing graduate degrees from teaching in nursing programs, so that efforts to remove 

these barriers can be planned. 

• Utilize the expertise of junior faculty by partnering them with senior, fully 

qualified faculty who can provide course oversight and faculty support without requiring the more labor-intensive team teaching. 

• Remove impediments to graduate study for working nurses, such as offering 

more convenient times for courses, encouraging partnering institutions to offer students more flexible work schedules to accommodate class schedules, and offering 

courses specifically for partnering health care facilities, possibly at their site(s). 

• Examine college/university retirement policies and work to eliminate unnecessary restrictions to continued faculty service, particularly mandatory retirement 

ages and financial penalties for retired faculty who return to work part-time. 

In collaboration with the Hartford Institute for Geriatric Nursing, the AACN also 

administers a Geriatric Nursing Education Project (GNEP), which is funded by the 

John A. Hartford Foundation. The GNEP incorporates several complementary programs to ultimately improve nursing care for older adults through curriculum enhancement, faculty development and scholarship opportunities. (See http:// 

www.aacn.nche.edu/education/Hartford/index.htm for more information). 

The programs include: 

90 

• Awards for Excellence in Gerontological Nursing Education 

• A Faculty Development Institute Offered through the Geriatric Nursing Education Consortium 

• New Series of Web-Based Interactive Case Studies Available 

The AACN also administers The John A. Hartford Foundation funded Enhancing 

Geriatric Nursing Education for Baccalaureate and Advances Practice Nursing Programs, an initiative that supports gerontology curriculum development and new 

clinical experiences in 30 selected baccalaureate and graduate nursing programs. 

(See http://www.aacn.nche.edu/education/Hartford/ShowcasingInnovations.htm for 

more information). 

According to projections from the Bureau of Labor Statistics (BLS), there will be 

more than one million vacant positions for registered nurses (RN) by 2010 due to 

growth in demand for nursing care and net replacements due to retirement. It is 

critical that we ask Congress to implement the recommendations from AACN and 

continue to encourage our nursing workforce to participate in the program opportunities outlined above to ensure we have an adequate and well-trained nursing workforce to care for the aging population. 

Question 2—Public Health Emergencies 

In the event of a public health emergency, public health providers at the local 

level will be among the first responders. 

Question 2. Does HRSA train individuals so they are able to respond to the needs 

of vulnerable populations, such as seniors? 

Answer. AGS Recommendations: Currently, HRSA does not train individuals so 

they are able to respond to the needs of vulnerable populations such as seniors, in 

the event of a public health emergency.However, it would seem like a natural extension of their training as it is estimated that some 3.4 million, or 34 percent, of all 

calls for emergency medical services involve older patients. Our rapidly aging population will only increase the pressure on our emergency medical system. This population has specific and often complex medical needs. To ensure that older adults receive quality care prior to arriving at the hospital, first responders must acquire the 

additional knowledge, skills, and attitudes that encompass the basic concepts of 

geriatric medicine. 

In 2003, AGS and the National Council of State Emergency Medical Services 

Training Coordinators (NCSEMSTC), along with Jones and Bartlett Publishers 

(J&B) partnered to develop a program that will train prehospital professionals (first 

responders, EMTs, and paramedics) to deliver state-of-the-art care to older adults. 

The continuing education curriculum called GEMS (Geriatric Education for Emergency Medical Services) emphasizes the unique conditions and needs of older patients. (See http://www.gemssite.com/ for more information). 

As America’s 77 million baby-boomers age, the number of emergency calls involving older patients will likely rise significantly. People are living longer and therefore 

are often sicker and present more complicated conditions. Emergency responders are 

going to have to be well-trained at recognizing serious medical problems in the elderly. 

The AGS believes that first responders must be aware of the complexities of treating older people or they may not take correct action. Communications are particularly important and EMS providers will need to recognize symptoms of drug interaction, dementia, elder abuse, and heart disease, all common problems among older 

people. 

Unfortunately, there is no identified source of funding that would support states 

offering such training to EMS providers. Congress could look at creating an 

Emergency Medical Services Geriatrics program that is modeled on the Federal 

Emergency Medical Services for Children (EMSC) Program. This program was 

developed in 1984 and since that time, Federal grant money has helped all 50 

States, plus the District of Columbia, the Commonwealth of the Northern Mariana 

Islands, American Samoa, US Virgin Islands, Guam, and Puerto Rico. (See http:// 

bolivia.hrsa.gov/emsc/ for more information). 

The EMSC program has improved the availability of child-appropriate equipment 

in ambulances and emergency departments. Federal grants to States and territories 

have supported hundreds of programs to prevent injuries, and has provided thousands of hours of training to EMTs, paramedics and other emergency medical care 

providers. The success of the program has led to legislation mandating EMSC programs in several states, and to educational materials covering every aspect of pediatric emergency care. 

The EMSC Program is saving children’s lives. A similar program focused on geriatric patients is needed as well as these populations both present unique health care 

needs that require additional training. Such a program would support the state 

91 

training coordinators in ensuring that EMS providers receive training in the unique 

health care needs of older adults. 

Question 3—Importance of Social Workers 

In your written testimony you mentioned the importance of loan forgiveness and 

specifically mention social workers. As you may know, yesterday was World Social 

Work Day, and I was honored to introduce a bill with Senator Mikulski to work to 

increase the number of social workers and ensure federal assistance exists to help 

them remain in their field, including loan forgiveness. As you also mention in your 

testimony, care coordination is important for so many of our vulnerable elderly with 

chronic health conditions, and while we may not think of them in this capacity, social workers do a great deal to ensure care is coordinated for so many of our vulnerable citizens. 

Question 3. What do you think are the best ways to support social workers who 

focus on our elderly vulnerable populations and how can we perhaps better train 

them in care coordination models that you’ve discussed today? 

Answer. AGS Recommendations: The AGS believes that social workers trained in 

the field of geriatrics are imperative and therefore, strongly supports incentives for 

social work students who train to care for our aging population. Incentives, such as 

federal loan forgiveness legislation, are among the remedies needed to make careers 

caring for older adults more appealing and to address recruitment and retention 

problems. 

The National Institute of Aging estimates the nation will require 70,000 trained, 

‘‘aging savvy’’professional social workers by 2020. Currently, only 5% of social workers are trained in aging issues. 

As stated in our testimony, the AGS strongly supports the ‘Caring for an Aging 

America Act’ introduced by Senator Barbara Boxer (D-CA), which would, among 

other things, establish the Geriatric and Gerontology Loan Repayment Program for 

social workers, along with physicians, physician assistants, advance practice nurses 

and psychologists who complete specialty training in geriatrics or gerontology and 

who agree to provide full-time clinical practice and service to older adults for a minimum of two years. While loan forgiveness is a very good start, it is also important 

to find a method to support specific training programs—as all schools do not equally 

prepare students for practicing with older adults and for care coordination. 

The Hartford Partnership Program for Aging Education (HPPAE) was created to 

meet the workforce demand for geriatric social workers by training and educating 

more than 1,000 social workers in older adult care and to establish a specialized 

aging curriculum in Masters of Social Work programs across the country. The 

HPPAE is an eight-year initiative coordinated by the Social Work Leadership Institute (SWLI) at the New York Academy of Medicine and is funded by the John A. 

Hartford Foundation. In 1999, 80 percent of the HPPAE graduates who participated 

in the program’s pilot study went on to pursue careers in the field of aging. Currently, 72 schools in 32 states have adopted the Hartford Partnership Program for 

Aging Program. Graduates of these programs are highly sought after by employers 

in the field. (See http://www.socialworkleadership.org/nsw/ppp/about.php for more 

information) 

In addition, current practitioners and those who enter the aging field do not always stay in the field because of challenging working conditions. Continuing education focused on care coordination and payment for care management are important methods to increase retention. 

The AGS also supports creating a GACA-like award for social workers. The Geriatric Academic Career Awards (GACA) funded under Title VII Health Professions 

Programs of the Public Health Service Act supports the career development of newly 

trained geriatric physicians in academic medicine. 

The field of geriatrics promotes preventive care, with an emphasis on care management and care coordination that aims to help older patients maintain functional 

independence in performing daily activities and improve their overall quality of life. 

Social workers are an important part of the geriatric team. Now is the time to address social work recruitment into the field of aging and build on programs that 

train social workers to provide care coordination and case management. 

92 

MARY MCDERMOTT’S RESPONSES TO SENATOR SMITH’S QUESTIONS

Question 1—Nursing Shortage in Rural Areas 

In Oregon, our nursing shortage is most acute in rural areas, as I can imagine 

is the case in Wisconsin. Our schools are turning away potential nursing students 

that could be serving in these areas. Since the 2002 academic year, the number of 

qualified applicants turned away by Oregon nursing schools has increased by more 

than 300 percent, with more than 1,500 qualified applicants being turned away in 

2007. 

Question 1. I am curious if Wisconsin is experiencing similar challenges, and as 

a personal care worker, could you share with us what effects older Americans are 

experiencing from the health care workforce shortage, including nurses and other 

health care professionals, in rural areas? 

Answer. The problems with nursing schools which you site for Oregon are identical in Wisconsin. This happened to my daughter who was a four point student and 

wanted to be a nurse. When she reached the point in her education to enter the 

nursing program she was told there was a two year wait before she could continue 

her education. Long story short, she changed directions. My sister-in-law, a surgical 

RN in California complains that the nurses coming out of nursing school now are 

inadequately trained as they attempt to rush as many through as possible. This is 

a complaint I have heard from RNs in WI, MI, NJ, NC, and FL. The problem appears to be on two levels, limited training availability and inadequate training. The 

impact to the elderly is they have less availability to nursing professionals and people who are available lack some basic training and most generic training. 

The farther you get from communities with populations of ten thousand the worse 

the problem becomes and the elderly are forced to rely on friends, family, and neighbors. While I personally feel the old fashioned community support model is beneficial to all parties involved, it should not be the sole avenue of home care support. 

It does not provide the consistent preventive professional service that older people 

need. It can also diminish their feelings of independence, dignity, and can cause 

feelings of being a burden which leads to depression with its corresponding health 

care issues. They are also open to criminal predators who target the elderly. 

I have worked in a consulting capacity with a few home health care agencies over 

the last ten years to improve their hiring and training practices as well as the quality of their care. Actually I think they got tired of my stealing their employees. An 

agency will receive $25.00-40.00 dollars per hour and pay their workers between 

$5.00-9.00 per hour. The agencies are in a population base of 400,000 and my community has a population of 9,000, but I advertised in the larger population. When 

the agencies placed ads in good economic times, they average between three to five 

responses from uneducated people or students. They are lucky if they get one qualified person and will need to run ads repeatedly to get that one person. During bad 

economic times they may get eight to twelve responses with the same results of a 

possible one qualified person. 

There is a perception, which for the most part is true, that privately advertised 

home care pays more. Consequently the ads get more attention as well as a greater 

number of highly trained overly qualified people. Generally these are people who are 

looking to supplement their income, flexible hours that will work with their family’s 

needs. Also included are those who work better outside of an institutional environment and professional home care workers. I set up a system of three team members 

with myself as back-up between 1997 and 1999. The team included one RN ($27.00 

per hour), one LPN ($17.00 per hour), and one CNA ($9.00 per hour). In 1998 I was 

told both my parents were in critical condition and would most likely not live six 

months. I utilized each team members’s talent/training level to the tasks best suited 

with the mandate to spoil my parents rotten. It must have worked well since my 

father lived until October 2005 and my mother is still alive. 

Once we passed this critical and financially burdensome stage, we switched the 

team profile to two CNAs daily and one RN for weekly visits. By this time I had 

become able to train aides in my parent’s care, including the generic skills that most 

were lacking. In 1998 the ads we ran generated eight responses of which three were 

qualified. In 2000 we had ten responses of which two were qualified. In 2003 we 

had 150 responses. Twelve people over qualified foreign licensed RNs and LPNs (one 

of which was a doctor) highly trained medical personnel which had to be retrained 

and re-licensed in this country, from Ireland, Russia, and Palestine, and Romania. 

Their employment needs were too temporary to suit our situation and their monetary expectations were no longer feasible for us. Three respondents were students 

in medical fields and two were professional home care workers. The majority of respondents were not fit for a phone conversation. Several did not speak English. 

Even when English was their native language they took the term unintelligible to 

93 

whole new level. Imagine the dire health consequences of miscommunications with 

people who maybe hard of hearing or suffering from dementia when being cared for 

by such workers. We hired one student willing to make a one year commitment who 

is now a medical assist specializing with the disabled and elderly and one professional home care who still works here 4 hours a week. 

While the numbers may look like an upturn is occurring with people in the home 

health field it is not. Economic conditions and population growth through immigration have an increasingly greater impact on the number of those who are responding 

to ads for home care work. Workers who are in the field because of economic reasons 

are not always the best because they leave as soon as their financial issue is resolved or are not consistent on the job. It is impossible not to notice that for private 

care ads, as well as agency ads, qualified applicants have flat lined or even declined, 

though the number of responses has increased. 

Many people who have found themselves in the position of suddenly making care 

decision for their parents have sought direction from me over the years. It is always 

the case that solving their problems is much more difficult when their parents live 

in small towns. I can’t tell you how many times I hear ‘‘Thank God for that lady 

next door’’. Programs targeting rural areas are most certainly warranted and will 

only increase in necessity with the experiential growth that our population of seniors is experiencing. 

Question 2—Caregiver supports 

In your testimony, you mention that you are a caregiver for your mother and that 

you also were for your father. You also mention that you did extensive work to ensure an appropriate and trained team was hired to help you care for them. I know 

that the purpose of funding through the Older Americans Act is to help provide supportive services and referrals for the elderly and their family members to help seniors stay in their home, and out of facilities, as they age. 

Question 2. Did you receive any information, referrals or caregiver help through 

your local Area Agency on Aging and how do you think we can better ensure that 

caregivers, like you, receive the support you need? 

Answer. From 1997 to 1999, I was exposed to many doctors, hospital social workers, nursing care facilities. With all the health care professionals I dealt with not 

one provided the information or resources that would have saved me over 

$300,000.00. I did aggressively go after information in the first year. The only option 

anyone wanted to speak to me about was putting my parents in a nursing home. 

It was a learning experience without direction. Thankfully that fit my career specialty, so developing processes and analyzing needs allowed me to put together the 

perfect team profile and care plan for my parents. In 2000, I left my career to pick 

up some of the time with my parents and reduce cost of care. While I made many 

inquiries, most agencies were only interested in their special area that related to 

some funding table, while others only wanted to talk about nursing homes. Finally 

in 2003, while at the mall getting a battery for my father’s watch, a woman working 

at the kiosk and I started talking about health care costs. I said I didn’t know how 

much longer I could afford my health insurance because I was taking care of my 

parents and it cost me $480.00 per month which, along with everything else, was 

breaking me financially. She said her sister took care of their parents and got 

health insurance and was paid to do so. She gave me the number to call for the 

state agency and from that point on we received help and information. Yes, I had 

called the county and state agency previously, but was only given misdirection and 

useless information. 

Subsequently, I discovered that too many agencies had small qualifying focuses 

and an inability to understand where to direct people who may not fit their particular profile. Everyone is protecting their small piece of the pie and failing to provide cost effective solutions. Each agency has a set of rules which may conflict with 

others, causing more confusion as well as increased cost to those providing care and 

those getting care. This situation enables those prone to fraud, a lucrative playing 

field, which in turn reduces the availability of services. The conflicting regulations 

are a nightmare for both care recipients and administrators of the various programs. One example occurred in my home when a doctor ordered a blood draw after 

a hospitalization. The private agency’s RN we hired could not do the blood draw because of Medicare restrictions from another agency whose RNs could not perform 

the task due to liability and some other restriction. It had to be done and the two 

agencies actually got into a fight over the rules and regulations they each work 

under with my mother caught in the middle. Not one tolerant of silliness when a 

person’s health is at risk. I just hired a private nurse to come in and get the blood 

the doctor needed. Other options, proposed by the two agencies would have had adverse consequences for my parents, which both agencies agreed they did not want 

to see. 

94 

Addressing this issue is currently underway in Wisconsin, and is also one of the 

proposed goals for the Wisconsin Quality Home Care Commission. To this end, there 

have been many positive efforts in Wisconsin. Persuading any agency to work efficiently and cooperatively with other agencies (governmental, qusi governmental, or 

private) is a very difficult task to accomplish. If someone told you that merging the 

states of Oregon and Washington would save 10 million dollars a year and would 

improve the services to both states, but you would have to fine another job and 

could no longer control the money to the state, how fast would you jump on that 

band wagon? And how do you convince the law makers of Oregon that they should 

now use the laws of Washington? 

I discovered several ways the county and state could cut cost and improve services. However, with the current protect your turf attitude, the majority of initiatives 

will continue to be layered costly fix after costly fix instead of real solutions. This 

will continue until the financial back is broken and the baby gets thrown out with 

the bath water in cut backs. I am very proud of the initiatives that have taken place 

in Wisconsin since I found myself in this life altering circumstance in 1997. People 

in this state now have better access to information. But there is so much more work 

to be done. The first paragraph of Charles Dickens’ A Tale of Two Cities runs 

though my mind regularly when I reflect upon this unexpected phase in my life. 

While one of the most rewarding of my accomplishments, it has also been one of 

the most difficult. It is the conditions in which I found the elderly and the care 

givers which drive my conscience to help make things a little better. This world that 

I have adventured into is so far from who I am that I do stand in awe of those who 

have chosen this as a career path. I also pray they will at some point in time receive 

the recognition and assistance they so justly need and deserve. 

When my job is finished here, I have the option to avoid the homecare field if I 

so choose, but I can’t avoid getting old any more than you can. What caliber of person do you want in your home making decisions that could mean the difference between life and death? 

SALLY BOWMAN’S RESPONSES TO SENATOR SMITH’S QUESTIONS

Question 1—Geriatric Education Centers and the Aging Network 

In your written testimony you mention the great publications and information 

that OSU has worked on related to ensuring elderly consumers and their caregivers 

are aware of the options available to them. 

Question 1. How do you ensure that seniors and their caregivers have access to 

this information, and do you work with the aging network, such as the State Unit 

on Aging and Area Agencies on Aging to ensure that the products are offered where 

seniors and their caregivers will have access to the information? 

Answer. OSU Extension Service publications on aging are available for free on the 

OSU web site. They can also be ordered for a small charge. They are included in 

the next eXtension national Family Caregiving website located at 

www.extension.org. Because we are part of the national network of University Extension Services, other Universities also utilize our educational materials with their 

audiences. 

In addition, our partners in the state, including the State Unit on Aging, AARP, 

Area Agencies on Aging, and our Oregon Geriatric Education Center partners, 

OHSU and PSU, distribute our publications at health fairs and trainings. We share 

our educational materials in these venues, and disseminate up-to-date lists of educational resources at events and conferences. We also actively co-teach with partners 

from other agencies, thus expanding our outreach. For example, we collaborated 

with AARP on a statewide Prepare to Care project, in which one of our activities 

was viewing the recent PBS special, Caring for your Parents, at selected locations 

around the state, followed by a panel of local and state experts. 

Our OSU Extension faculty members with county assignments partner with the 

State Unit on Aging, regional Area Agencies on Aging, nonprofit agencies, and businesses to provide trainings in chronic disease self-management, tai chi, strong 

women, and family caregiving to older adults and their family members. Other 

workshops and events include medication management, optimal aging, aging in 

place, financial planning in later life, etc. These offerings are available in both 

urban and rural areas, although not in every county due to funding limitations for 

staffing. 

Question 2—Federal Geriatric Programs 

For Fiscal Year 2008 (FY08), Congress provided $31 million for geriatric programs. In FY07, Oregon received $390,000. Unfortunately, the President’s FY09 

budget zeroed out geriatrics programs, including the Geriatric Education Centers 

95 

Program, Geriatric Training for Physicians, Dentists, and Behavioral and Mental 

Health Professionals and Geriatric Academic Career Awards Program. 

Question 2. In your testimony, you speak to the importance of Oregon’s Geriatric 

Education Center to rural areas—how would you evaluate its success? 

The Oregon Geriatric Education Center has fostered a collaborative relationship 

between OHSU, PSU, and OSU in the area of geriatrics and gerontology. One of 

the results of that collaboration is that we work together on developing train ing 

opportunities around the state. We provide a resource center of educational materials that are lent to professionals and to long-term care facilities. We develop curricula, if there is a gap in educational resources. The OHSU geriatrics physician 

who serves on the GEC is very active in providing geriatric training to other physicians around the state. In addition, we partner with geriatricians through their professional association. We report our activities and our outreach in the federal reports, and we are also working together this year to improve our evaluation of outcomes. In short, the Oregon GEC helps focus the energy of the three Oregon universities on working together on health programs and aging. It provides leverage that 

helps us respond to private foundation grant-related opportunities. 

Follow Up: What other incentives could help induce physicians to pursue careers 

in geriatrics? 

Answer. Financial incentives, such as scholarships and loan repayment programs, 

have been shown to be effective in recruiting health care providers, such as physicians and nurses, to practice in specific fields, such as geriatrics. Research also provides evidence that if you want to recruit health care providers to practice in rural 

areas, the greatest likelihood of success is if you recruit amongst students who grew 

up in rural areas. If you want to recruit health care providers to serve older adults 

from minority groups, the greatest likelihood of success is if you recruit amongst 

students from minority groups. If you want to recruit health care providers to work 

with older adults, the greatest likelihood of at some point in their life. These findings should inform the design of recruitment programs because they will contribute 

to their overall success. 

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Æ 


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