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Health Care Workforce

Who Cares For Older Adults? Workforce Implications Of An Aging Society

PROLOGUE: At the turn of the twenty-first century, American society has begun debating in earnest whether or not demography is destiny. Experts have been forecasting the effects—good and bad—of an aging society for decades, and the United States is fast approaching the "zero hour" at which the baby-boom generation begins to retire. This is coupled with a supply of health care workers, especially nurses, that some say is not adequate to meet current needs, let alone the needs of a society with twice as many elderly citizens. In this paper Christine Kovner and her colleagues join the two threads of debate to explore the implications of an aging America for the nation’s already stressed health care workforce.

Institutions that train health care workers responded to twentieth-century demographics and embraced the need to prepare workers in pediatrics—for example, the authors assert, "all programs in nursing and medicine...have required pediatric rotations, but a similar commitment to geriatrics has yet to emerge." To quantify the difference, today there is approximately one pediatrician for every 1,000 children, but only one geriatrician for every 2,000 elderly persons will be available by 2030. The authors recommend that every health care professional be trained in geriatrics, to ensure the proper treatment of the elderly.

Kovner is a professor in the Division of Nursing, Steinhardt School of Education, at New York University (NYU); a clinical associate in nursing at the NYU Medical Center; and a senior fellow at the John A. Hartford Foundation Institute for Geriatric Nursing at NYU. She holds advanced degrees in nursing from NYU and the University of Pennsylvania. Mathy Mezey, Independence Foundation Professor of Nursing Education at NYU, directs the Hartford Institute and is codirector of the Certificate Program in Bioethics and the Medical Humanities, Montefiore Medical Center Division of Bioethics and NYU Division of Nursing, and also holds advanced degrees in nursing from Columbia University. Charlene Harrington is a professor of sociology and nursing in the Department of Social and Behavioral Sciences at the University of California, San Francisco, School of Nursing. She holds advanced degrees in public health nursing, sociology, and higher education from the University of Washington and the University of California, Berkeley.

Abstract

 
There is a critical shortage of geriatrics-prepared health care professionals. In 2002 more than thirty-five million people were age sixty-five and older, and 23 percent of them reported poor or fair health. Older adults use 23 percent of ambulatory care visits and 48 percent of hospital days, and they represent 83 percent of nursing facility residents. Yet 58 percent of baccalaureate nursing programs have no full-time faculty certified in geriatric nursing. Only three of the nation’s 145 medical schools have geriatrics departments, and less than 10 percent of these require a geriatrics course. We argue that every health care worker must have some education in geriatrics and access to geriatrics care experts.

There is some evidence that care of older adults by health care professionals prepared in geriatrics yields improvements in outcomes, such as better physical, functional, and psychosocial status without an increase in costs.² A recent study found that although frail older patients treated in both inpatient and outpatient geriatric units had the same mortality rates as did those treated with usual care, the patients who received specialized geriatric care had sizable reductions in functional decline and improvements in mental health at no additional cost.³ Older patients cared for by nurses prepared in geriatrics are less likely to be physically restrained, have fewer readmissions to the hospital, and are less likely to be transferred inappropriately from nursing facilities to the hospital.⁴

Despite the need for and proven efficacy of geriatric care, there remains a critical shortage of geriatrics-prepared health care professionals.⁵ Although some modest progress has been made, with some disciplines making more than others, the number of nurses, doctors, pharmacists, and social workers specializing in geriatrics falls far short of demand. Geriatrics content is woefully lacking in medical schools and nursing programs, and primary care and specialty health care professionals, who are likely to care for large numbers of older patients, continue to receive inadequate training in geriatrics.

This paper briefly reviews the characteristics of older adults and their use of health care services, identifies the number and types of professionals caring for older adults, and discusses the gap in the preparation and skills of health workers to provide care to older adults.⁶ We discuss the policy implications of health care needs of older adults and the health workers who care for them.

Background On Older Adults

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As do most developed countries, the United States has a large and growing elderly population. Every day 6,000 Americans reach their sixty-fifth birthday. This number is expected to increase to 10,000 a day by 2012.⁷ The U.S. Census Bureau estimates that in 2002 there were more than thirty-five million persons age sixty-five and older—close to 13 percent of the U.S. population—and that by 2015 there will be almost forty-six million persons (15 percent of the estimated population) in this age group.⁸

Health problems of older adults. Older adults have many more health problems than younger adults do, with 26 percent of persons age sixty-five and older reporting poor or fair health in 1999, compared with 11.5–18.5 percent of persons ages 45–64.⁹ People age seventy-five and older report an average of three chronic health problems at any time and use more than 4.5 prescription drugs.¹⁰ Among the chronic conditions reported by noninstitutionalized older adults are arthritis (56 percent), hypertension (55 percent), heart disease (32 percent), and urinary incontinence (17 percent). The incidence of many other illnesses, such as many cancers, osteoarthritis, and hip fractures, also rises with age.¹¹ Of special concern is the number of people with Alzheimer’s disease, which affects 5–15 percent of persons over age sixty-four and 40 percent of those over age eighty; its prevalence is expected to double from approximately four million in 2002 to eight million by 2020.¹²

Older adults’ use of services. Older adults had more than 192 million visits to physicians’ offices in 1999, or 25 percent of all office visits.¹³ The average older person had 10.5 ambulatory care visits that year, compared with 6.4 visits for those under age sixty-five.¹⁴ As the largest age group of patients who obtain care from nonfederal short-stay hospitals, in 1999 older adults used 2,256.8 days per 1,000 population; the next-closest age group, persons ages 55–64, used only 795.1 per 1,000. At the same time, persons age seventy-five and older used almost twice as many days as did those in the 65–74 age group.¹⁵ In 1998 persons age sixty-five and older used 77,211,000 days of care in short-stay hospitals.¹⁶

Of the 7.6 million persons who received formal home-care services in 1998, 69 percent were age sixty-five and older, and almost 16 percent were age eighty-five and older.¹⁷ There are dramatic differences in the number of home-care patients among the cohort of persons age sixty-five and older: There were 202.0 patients per 10,000 in the 65–74 age group; 470.3 patients per 10,000 in the 75–84 age group; and 885.4 patients in the group age eighty-five and older.¹⁸ Forty-five percent of the direct care that registered nurses (RNs) provide in community and public health settings is to persons ages 65–85.¹⁹

Finally, almost 90 percent of residents (about 1.5 million persons) in the 18,000 U.S. nursing homes are age sixty-five and older.²⁰ Residents of nursing facilities represent a vulnerable and frail subpopulation of older adults. The average age of residents is eighty-five. The majority are women (74 percent) and are poor.²¹ Only 17 percent of residents have a spouse, and many have no living children, family, or friends.²² Many residents have multiple chronic illnesses, and most are unable to feed, bathe, dress, transfer, and use the toilet (known as activities of daily living, or ADLs) without at least some assistance. Eighty-three percent of residents need assistance with three to six basic ADLs.²³ Many residents are cognitively impaired, and half are believed to have dementia.²⁴

Workforce Preparation In Geriatrics

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Workforce capacity to deliver care to older adults can be analyzed by examining the capacity of nursing and medical schools and other programs to train students in geriatrics at both the undergraduate and graduate (or specialized) levels, and the capacity of the current supply of health care workers to care for older adults. The current supply consists of physicians; nurse practitioners, clinical nurse specialists, and other health care professionals who are certified in geriatrics; and nongeriatric practitioners who have gained some degree of geriatric competence either during their specialty educational preparation or through continuing education.

Nurses. Registered nurses (RNs) are educated in baccalaureate, associate degree, and diploma nursing programs. In 2000, 31 percent of new RN graduates and 30 percent of the nation’s practicing nurses were baccalaureate prepared.²⁵ In 1999 only 4 percent of more than 670 baccalaureate nursing programs (thirty programs) met all criteria for exemplary geriatrics education, such as a stand-alone geriatrics course, two or more clinical placement sites in geriatrics, and at least one full-time faculty member nationally certified in geriatrics. Only 23 percent of baccalaureate nursing programs required and 14 percent had as an elective a stand-alone geriatric course. The remainder integrated geriatrics content into one or more courses. At the same time, 58 percent of the programs reported no full-time faculty certified in geriatric nursing, and 80 percent reported no part-time certified faculty members.²⁶ Fifty-four master’s programs and forty post-master’s programs prepare advanced practice geriatric nurses in the United States.²⁷ The average program has about five students, and together the programs graduate about 300 students a year.²⁸

Overall, less than 1 percent (21,500) of the nation’s 2.2 million practicing RNs are certified in geriatrics.²⁹ Certified geriatric nurse practitioners and clinical nurse specialists have met state board of nursing specifications or passed an examination offered by the American Nurses Credentialing Center (ANCC). In 2002 approximately 5,700 nurses were thus certified, representing 0.2 percent of the nation’s practicing nurses and 4 percent of all certified nurse practitioners and clinical nurse specialists.³⁰

Educational programs preparing advanced practice nurses, who are likely to care for large numbers of older patients (for example, programs preparing adult nurse practitioners, women’s health practitioners, and family practitioners), do not have specified requirements in geriatrics. While most programs address patients with chronic illness, content and clinical experiences are not specific to older adults, who typically have multiple chronic conditions and comorbidities.

An Internet search revealed only five schools of nursing that offer master’s degree programs to prepare gero-psychiatric nurses.³¹ The annual graduations from these programs are unknown. No master’s program to prepare gero-psychiatric nurse practitioners or clinical nurse specialists receives funding from the Health Resources and Services Administration (HRSA) Division of Nursing.³² There is no examination to certify nurses in this specialty.

Physicians. Only three of the nation’s 145 allopathic and osteopathic medical schools have a geriatrics department. Fourteen medical schools (less than 10 percent) require a geriatrics course. An additional eighty-six schools offer an elective in geriatrics, but only 3 percent of medical students register for these courses.³³ Only slightly more than 0.5 percent of medical school faculty (about 600) indicate that they are geriatrics specialists (not necessarily board certified).

Physicians receive advanced training in geriatrics within the accredited specialty of internal medicine. In 2002 there were ninety-seven programs in geriatric medicine out of a total of 7,765 accredited specialty programs. These geriatric medicine programs had a total of 333 resident slots, representing less than 0.3 percent of the 97,362 resident slots reported by the Accreditation Council for Graduate Medical Education (ACGME).³⁴ Of the 650,000 licensed physicians practicing in the United States, fewer than 9,000 have met qualifying criteria in geriatrics, a ratio of 2.5 geriatricians to every 10,000 older adults.³⁵

Residency training programs in both family practice and internal medicine specify a geriatrics requirement. In family practice, the ACGME specifies that residency education must include an educational experience in the "common and complex clinical problems of the older patient" and that there must be experience with older adult patients in hospitals, family practice clinics, long-term care facilities, and homes. The length of the geriatrics rotation is not specified.³⁶ In internal medicine residency education, the ACGME specifies that residents have "formal instruction and regular, supervised clinical experience in geriatric medicine" and that geriatric clinical experiences, although required, may take place in one or more specifically designated geriatrics settings.³⁷ The ACGME does not specify required geriatrics training in other residency programs preparing medical specialists who are likely to care for large numbers of older patients, such as physical medicine and rehabilitation, emergency medicine, cardiology, and oncology.

There are sixty-two programs in geriatric psychiatry within the specialty of psychiatry.³⁸ From 1995 to 2001, 456 fellows completed gero-psychiatric training. Currently, 2,696 psychiatrists have passed boards in geriatric psychiatry.³⁹ An additional 6,000 psychiatrists indicate that 25 percent or more of their practice is in geriatrics. If only 5 percent of the older adult population has a cognitive impairment, that is almost 1.75 million persons, many of whom may need at least a consultation with a gero-psychiatrist.

Other workers. Less is known about the geriatrics training of other health care workers, and space limitations preclude a review of all health professions here, although we offer a few examples. The Alliance for Aging Research reports that of the approximately 200,000 U.S. pharmacists, only 720 have geriatrics certification.⁴⁰ Less than 0.3 percent of physical therapists are board certified in geriatrics. Similarly, the Council on Social Work Education reported that 3 percent of graduate social work students (1,071) who reported majors in 1996 chose aging or gerontological social work.⁴¹ At the same time, 62 percent of members of the National Association of Social Work said that gerontology is necessary in their position.⁴²

What Does The Future Hold?

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Existing levels of geriatric physicians and nurses are clearly insufficient to meet current and future demands. The Alliance for Aging Research estimates that in contrast to the existing 9,000 geriatricians, 20,000 geriatricians are needed to meet current demand and at least 36,000 will be needed to treat older adults by 2030, although it provides no calculation to support this estimate.⁴³ This would be 0.55 geriatricians per 1,000 population. For a comparison, there are about fifty-nine million children up to age fourteen cared for by about 57,000 pediatricians, or 0.97 pediatricians per 1,000 population.

Although there are no similar projections in nursing, health care settings that serve older adults appear to be more negatively affected by the nursing shortage than other work settings are. For example, in 2000, 152,894 RNs (6.9 percent of practicing RNs) were employed in nursing facilities.⁴⁴ The percentage of RNs employed in these facilities decreased sharply between 1996 and 2000, a time of nursing shortage, as compared with a substantial increase between 1992 and 1996, a time of nursing oversupply.⁴⁵ The shortage of RNs in nursing facilities is a serious concern. As the sole professional provider in these facilities, RNs are responsible for overseeing the work of other licensed and nonlicensed nursing staff. The average U.S. nursing facility provides 3.5 hours per resident day of RN, licensed vocational nurse/licensed practical nurse (LVN/LPN), nursing assistant (NA), and director of nursing (DON) time.⁴⁶ Of the total time, 60 percent (2.1 hours) is provided by NAs (who have only seventy-five hours of training).

Several reports have shown the need for much higher RN staffing levels. Several studies have also recommended greater use of geriatric nurse practitioners in nursing facilities.⁴⁷ An expert panel recommended a minimum of 4.55 hours per resident day of total nursing time, including administrative nurses and direct and indirect care time.⁴⁸ Studies have also recommended a substantial increase in the number of nurses instead of the current reliance on nursing assistants.⁴⁹ Staffing levels below 2.0 NA hours per resident day and 0.75 hours of licensed staff (RN/LVNs) result in a higher probability of serious quality-of-care problems, and staffing levels for long-stay residents below 4.1 hours per resident day could result in negative consequences for residents. Ninety-seven percent of nursing facilities do not meet this level of staffing.⁵⁰

Issues And Policy Implications

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While discussions of health care workforce issues take into account the projected increase in the number of older adults needing services, these discussions do not adequately reflect the need for a workforce prepared in geriatrics, nor do they address the complexity of organizing, delivering, and financing care for the very old, who typically have multiple illnesses and conditions. As the older population increases, there are likely to be fewer Americans per capita prepared to care for them. A shortage of nurses, physicians, and other workforce personnel prepared in geriatrics, although it affects all settings, especially affects settings such as nursing facilities that serve large numbers of frail older adults and that chronically experience workforce shortages.

How many is enough? Among the critical health workforce issues is, How many people trained in geriatrics do we need? We clearly don’t have enough now, and we will need more in the future. But the available evidence does not provide enough information about how many more we need. Does every older adult need a geriatric nurse practitioner, geriatrician, or pharmacist certified in geriatrics? No. Does every older adult need a provider who has some education and training in geriatrics? Yes. Do these providers need access in person, by phone, or via electronic communication to a geriatric nurse practitioner, geriatrician, pharmacist certified in geriatrics, or other health care worker with advanced education in geriatrics? Yes.

What training should be provided? Unfortunately, we are still a long way from achieving consensus within the health care professions that every training program needs to produce practitioners who have some level of competence in geriatrics. All programs in nursing and medicine, for example, have required pediatrics rotations, but a similar commitment to geriatrics has yet to emerge.

Addressing the dual goals of every health care worker’s having some education in geriatrics and every provider’s having access to geriatrics experts can be achieved by meeting four objectives: (1) getting more people educated as experts in geriatrics, (2) getting more health professional programs to increase their content on geriatrics, (3) getting more health care providers to employ practitioners with training in geriatrics, and (4) getting more health care settings to provide geriatric-specific care. Achieving these objectives is dependent on creating effective coalitions among professionals and professional organizations, state and federal agencies, and other interested parties such as the AARP, the Department of Veterans Affairs (VA), the Medicare Payment Advisory Commission (MedPAC), and trade unions to stimulate discussion and action.⁵¹

A crucial step in designing effective geriatrics education programs is to obtain accurate data about current and projected geriatric workforce needs, including recommendations about what would be an appropriate balance of numbers and geographic distribution between geriatric specialists and generalist providers. Among the questions to be answered are: How much time do people who are trained in geriatrics spend taking care of older adults? What is the appropriate ratio of such providers to the older population? What types of patients need access to geriatric specialists rather than generalists with some geriatrics training?

Even without an estimate of the precise number of specialists needed, a reasonable goal is that students in health professional education programs should have required content in and experience caring for older adults. At a minimum, all medical schools, university-based nursing programs, and schools of social work must have faculty who have specialty training in geriatrics and either departments, divisions, or sections of geriatrics. There should be similar goals for other health disciplines’ training programs. Based on a goal of ten to twenty full-time equivalents (FTEs) at each medical school, a committee convened by the International Longevity Center recommended the need for at least 2,400 academic geriatrics faculty by 2020.⁵² If university-based nursing schools were to have a more modest goal (in part because many nursing schools have fewer students than medical schools have), these schools would require almost 4,000 geriatrics faculty members to assure a pipeline of appropriately prepared geriatric nurse researchers.

Sources of support. Many current advances in geriatrics education and workforce preparation are attributable to support from the John A. Hartford Foundation; to the Geriatric Research, Education, and Clinical Centers (GRECC) program of the VA; and to support from the Donald W. Reynolds Foundation. With support from the Hartford Foundation, and in nursing from the Hearst Foundation, schools of medicine, nursing, and social work have taken substantial steps to attract additional students to careers in geriatrics. The Reynolds Foundation funded departments of geriatrics at two medical schools.⁵³ Several initiatives are under way, again with support from the Hartford Foundation, to ensure the geriatrics competence of all practicing health care professionals. Nursing education programs have initiated efforts to encourage the addition of geriatrics content into the undergraduate curriculum. As in medicine, nursing programs are moving to introduce geriatrics content into the preparation of adult and family nurse practitioners and clinical nurse specialists. The 12,500 nurses certified by the ANCC as adult nurse practitioners and the 24,400 certified as family nurse practitioners represent an untapped pool of health care workers whose practice encompasses many older adults but whose educational preparation contains minimal geriatrics content.⁵⁴

Programs under way. Both nursing and medicine have begun programs to ensure geriatrics competence among practicing nurses and physicians. In nursing, a program is under way to improve the geriatrics competence of the 20 percent (400,000) of practicing RNs who belong to specialty nursing associations whose members take care of large numbers of older adults, such as oncology, neurology, rehabilitation, and critical care. The program focuses on encouraging these nurses to become certified gerontological nurses, a credential of the ANCC that is open to RNs regardless of educational preparation.⁵⁵ Approximately 17,000 nurses now hold this certification. There are similar programs to assure geriatrics competence among physicians in specialty practices, such as oncology, where older patients predominate. Ongoing initiatives include specialized and comprehensive geriatrics education modules that can be completed either during specialty preparation or through continuing education, and the development of Web sites that specifically address the needs of specialty physicians for geriatrics content.⁵⁶ These programs in all likelihood will increase the number of health care workers trained in geriatrics, although the impact on patient care remains unknown.

As the organization responsible for accreditation of hospitals and an increasing number of home health and nursing facilities, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates that facilities demonstrate their staffs’ age-specific competence. By strengthening this portion of the survey, the JCAHO could encourage more stringent standards for geriatrics competence and create a climate that is conducive to the development of national standards for staff competence in geriatric care.

Efforts in the states and federal government. All states should be encouraged to follow the example of the six states (Arkansas, California, Delaware, Florida, Indiana, and South Dakota) that specifically mandate theoretical content and clinical experiences in geriatrics for nursing education. States with mandatory requirements for continuing education for health professional relicensure, such as exists in twenty-one states for RNs, could mandate a specified number of continuing education credits in geriatrics as a condition of relicensure. As surveyors of home-care agencies and nursing facilities, state health departments should include evidence of staff training in geriatrics as part of their mandatory survey process. Such state regulations would require additional expenditures by nursing facilities and home health agencies and would likely meet resistance from those organizations.

The federal government has several options for strengthening the geriatric workforce. Several reports have called for a national commission to investigate publicly and philanthropic-funded economic incentives to clarify the nation’s agenda and to increase health professional participation in geriatrics.⁵⁷ Susan Reinhard and colleagues recommend congressional support for increased allocation of funds to the geriatric workforce and targeted allocation of funds for geriatric-workforce initiatives in policy proposals such as the Nurse Reinvestment Act, the Nurse Employment and Education Act, and the National Nurse Corps.⁵⁸ HRSA support of training programs and scholarships in the health professions should be directed to promote training in geriatrics. Similarly, HRSA should direct additional funds to support the thirty-three geriatrics education centers (GECs) it funds, which are mandated to provide geriatrics training to interdisciplinary health professional faculty. Such increased funding is likely to meet some resistance from Congress and special-interest groups, because these recommendations will require overall increased spending or decreased spending in another area to provide funding for geriatrics.

Through its mandated oversight function, the Centers for Medicare and Medicaid Services (CMS) should include evidence of staff training in geriatrics in its survey process. The CMS also should create incentives to encourage nursing facilities to use geriatric nurse practitioners. Several reports support review of Medicare funding of graduate medical education (GME), possibly allocating this funding for patient care rather than medical education.⁵⁹

Unfortunately, these initiatives are set against a landscape in which the United States is likely to fall further behind in caring for older adults. Federal and state governments are distracted by the need to focus on national security. The president’s proposed fiscal year 2003 budget includes a decrease in funding for GECs as well as an $11 million cut in Title IV research and training, under the Older Americans Act.⁶⁰

Clinical settings. Although educational changes are important, there must also be changes in clinical settings. Two objectives are getting more provider organizations to employ practitioners with training in geriatrics and getting more of them to provide geriatrics-specific care. Payment issues and financial incentives to organizations that employ or could employ people with expertise in geriatrics affect employment decisions and individual choice of specialty. For example, a hospital may choose to employ adult or family nurse practitioners rather than geriatric nurse practitioners, because it may view generalist nurse practitioners as more flexible than geriatric nurse practitioners would be. In the same way, nursing homes may choose to hire associate-degree RNs rather than baccalaureate-prepared RNs who are more likely to have had geriatrics content in their academic programs, because the associate-degree RNs may be more available or less expensive to hire. Also, payers such as Medicare and managed care organizations could provide financial incentives, such as higher reimbursement for facilities that employ geriatric specialists.

Need for further research. As in many areas of health care, there is a continued need for research about the geriatric health care workforce and the organizations in which they work. This research includes factors associated with specialty and work setting chosen, as well as the association between geriatrics training and patient outcomes. Particularly important is research comparing the outcomes of patients cared for by geriatric specialists with those cared for by generalists. It also includes research on organizations and systems and why they choose to employ workers with certain kinds of training and experience. Similarly, there is a need for more health services research to assess the effectiveness of different models of training, staffing, and organization of care and their relationship to health outcomes and quality of care.

Twenty years from now, will health professions students look back on the early twenty-first century with wonder about how things have changed? As they study in departments of geriatrics, take required courses in geriatrics, and learn to care for older adults, they may look back on 2002 with a bit of arrogance—as well they should.

Editor's Notes

 
Preparation of this manuscript was partially supported by the John A. Hartford Foundation Institute for Geriatric Nursing. The authors acknowledge the assistance of Grace Londono, Abraham Brody, and Sandi Hui in preparing the manuscript.

NOTES

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1. J.R. Kirby, S.R. Machlin, and J.M. Thorpe, Patterns of Ambulatory Care Use: Changes from 1987 to 1996, Pub. no. 01-0026 (Rockville, Md.: Agency for Healthcare Research and Quality, 2001); National Center for Health Statistics, "National Hospital Discharge and Ambulatory Surgery Data," 16 June 2001, www.cdc.gov/nchs/bout/major/hdasd/nhdstab.htm (18 March 2002); National Association for Home Care, "Basic Statistics about Home Care," November 2001, www.nahc.org/Consumer/hcstats.html (20 March 2002); and NCHS, Health, United States, 2001, with Urban and Rural Health Chartbook, Pub. no. (PHS) 01-1232 (Hyattsville, Md.: U.S. Department of Health and Human Services, 2001).
2. Geriatrics is used throughout this paper to denote both geriatrics and gerontology.
3. H.J. Cohen et al., "A Controlled Trial of Inpatient and Outpatient Geriatric Evaluation and Management," New England Journal of Medicine 346, no. 12 (2002): 906–912.
4. L.K. Evans et al., "A Clinical Trial to Reduce Restraints in Nursing Homes," Journal of the American Geriatrics Society 45, no. 6 (1997): 675–681[Medline]; M.D. Naylor et al., "Comprehensive Discharge Planning and Home Follow-Up of Hospitalized Elders: A Randomized Clinical Trial," Journal of the American Medical Association 281, no. 7 (1999): 613–620[Abstract/Free Full Text]; and P. Shaughnessy et al., "Quality of Care in Teaching Nursing Homes: Findings and Implications," Health Care Financing Review 16, no. 4 (1995): 55–83.[Medline]
5. R. Butler et al., A National Crisis: The Need for Geriatrics Faculty Training and Development (Washington: Alliance for Aging Research, 2002); and AAR, Medical Never-Never Land: Ten Reasons Why America Is Not Ready for the Coming Age Boom (Washington: AAR, 2002).
6. A discussion of the nonprofessional workforce is beyond the scope of this paper.
7. AAR, Medical Never-Never Land.
8. U.S. Census Bureau, Projections of the Total Resident Population by Five-Year Age Groups (Washington: Census Bureau, Population Projections Program, Population Division, 2000).
9. NCHS, Health, United States, 2001.
10. AAR, Medical Never-Never Land.
11. M.E. Gluck and K.W. Hanson, Medicare Chart Book, 2d ed., Pub. no. 1622 (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, Fall 2001).
12. AAR, Medical Never-Never Land.
13. NCHS, Health, United States, 2001.
14. Kirby et al., Patterns of Ambulatory Care Use.
15. NCHS, Health, United States, 2001.
16. NCHS, "National Hospital Discharge and Ambulatory Surgery Data."
17. NAHC, "Basic Statistics about Home Care."
18. NCHS, Health, United States, 2001.
19. National Council of State Boards of Nursing, "Data Collection Completed for 1998 Role Delineation Study," Issues 20, no. 1 (1999): 1.
20. CDC, "Nursing Home Residents, Number, Percent Distribution, and Rate per 10,000, by Age at Interview, According to Sex, Race, and Region: United States, 1999," ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Datasets/NNHS/nnhs99/table3nhtemp.xls (17 July 2002).
21. C. Harrington et al., Nursing Facilities, Staffing, Residents and Facility Deficiencies, 1991–1999 (San Francisco: University of California, San Francisco, 2000).
22. G.S. Wunderlich and P. Kohler, eds., Improving the Quality of Long-Term Care (Washington: National Academy Press, 2001).
23. Ibid.
24. N.A. Krauss et al., Nursing Home Update—1996, Pub. no. 97-0036 (Rockville, Md.: AHRQ, July 1997).
25. E. Spratley et al., The Registered Nurse Population, March 2000: Findings from the National Sample Survey of Registered Nurses (Rockville, Md.: DHHS, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, 2002).
26. P. Rosenfeld et al., "Gerontological Nursing Content in Baccalaureate Nursing Programs: Findings from a National Survey," Journal of Professional Nursing 15, no. 2 (1999): 84–94.[Medline]
27. Emily Schmid, education policy and program assistant, American Association of Colleges of Nursing, personal communication, 20 March 2002.
28. Linda Berlin, director of research and data services, AACN, personal communication, 3 April 2002.
29. Spratley et al., The Registered Nurse Population, March 2000; and Elaine Scherer, assistant director of certification services, American Nurses Credentialing Center, personal communication, 18 March 2002.
30. Ibid.
31. Berlin, personal communication.
32. Patricia Calico, program officer, HRSA Division of Nursing, personal communication, 13 March 2002.
33. Butler et al., A National Crisis.
34. Accreditation Council for Graduate Medical Education, Annual Report (Chicago: ACGME, 2000).
35. Butler et al., A National Crisis; and AAR, Medical Never-Never Land.
36. ACGME, "Program Requirements for Residency Education in Family Practice," 26 September 2000, www.acgme.org/req/120pr701.asp (29 May 2002).
37. ACGME, "Program Requirements for Residency Education in Internal Medicine," July 2001, www.acgme.org/req/140pr701.asp (29 May 2002).
38. ACGME, List of Programs within a Particular Specialty for Current Academic Year and Those Newly Accredited Programs with Future Effective Dates (Year ending June 30, 2002) (Chicago: ACGME, 2002).
39. Gary J. Kennedy, professor of psychiatry and behavioral science and director, Division of Geriatric Psychiatry, Albert Einstein College of Medicine, personal communication, 14 March 2002.
40. AAR, Medical Never-Never Land.
41. A. Scharlach et al, Optimizing Gerontological Social Work Education (Berkeley: University of California, 1997).
42. Ibid.
43. AAR, Medical Never-Never Land.
44. Spratley et al., The Registered Nurse Population.
45. Ibid.
46. C. Harrington et al., "Nursing Facility Staffing in the States in the 1991–1995 Period," Medical Care Research and Review 55, no. 3 (1998): 334–363[Abstract/Free Full Text]; and Harrington et al., Nursing Facilities, Staffing, Residents, and Facility Deficiencies.
47. C. Harrington et al., "Experts Recommend Minimum Nurse Staffing Standards for Nursing Facilities in the U.S.," Gerontologist 40, no. 1 (2000): 5–16[Abstract]; and S. Reinhard and R. Stone, Promoting Quality in Nursing Homes: The Wellspring Model (Washington: Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, 2001).
48. Harrington et al., "Experts Recommend Minimum Nurse Staffing Standards."
49. Wunderlich and Kohler, eds., Improving the Quality of Long-Term Care.
50. Centers for Medicare and Medicaid Services, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress: Phase II Final, vol. 1–2 (Baltimore: CMS, 2002).
51. Reinhard and Stone, Promoting Quality in Nursing Homes.
52. Butler et al., A National Crisis.
53. Ibid.
54. Mary Smolenski, director of certification, American Nurses Credentialing Center, personal communication, 13 March 2002.
55. Jessica Scholder, director, Specialty Nurses Activities Partnership Program, John A. Hartford Institute for Geriatric Nursing, New York University, personal communication, 13 March 2002.
56. D.H. Solomon and J.R. Burton, Increasing Geriatrics Expertise in Surgical and Medical Specialties (New York: American Geriatrics Society, 2001).
57. Reinhard and Stone, Promoting Quality in Nursing Homes; and Butler et al., A National Crisis.
58. S. Reinhard et al., Initiatives to Promote the Nursing Workforce in Geriatrics (Washington: Institute for the Future of Aging Services, 2002).
59. Ibid.; and Butler et al., A National Crisis.
60. "NIA Seeks $57 Million Increase; AoA Title IV Loses $10 Million," Aging Research and Training News 25, no. 2 (2002): 11.

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