INTERVIEW: Generations Guest Editors Steven Dawson and Christopher Langston

Demand for eldercare has never been higher, but the growth of the direct-care workforce is stagnating. The newly released Spring 2016 issue of Generations, the journal of the American Society on Aging, explores this emerging eldercare crisis and offers solutions from many different angles. Recently the issue’s guest editors, PHI founding president Steven L. Dawson and former John A. Hartford Foundation program director Christopher A. Langston, spoke with PHI about why there seems to be such little urgency to address this crisis — and what can be done to fix that.

PHI: A lot of the papers in the issue refer to the 2008 Institute of Medicine (IOM) report Retooling for an Aging America: Building the Health Care Workforce, which Christopher played a role in putting together. Could you describe the report and explain why it as so important?

Christopher Langston: In setting up that IOM report, the John A. Hartford Foundation and other lead foundations gave the committee a pretty broad mandate: “the eldercare workforce.” And one of the things that was most impressive and thoughtful was that the IOM committee added to the usual health-profession suspects consideration of the direct-care workforce and also family caregivers. What family members do, what the direct-care workforce does — that is the base upon which everything else rests. And yet neither had received very much formal consideration at this level before the 2008 report.

Steven Dawson: The experts in the field who put together the IOM report really emphasized action. It wasn’t just a more conventional call for more research. That’s what we play upon in the introductory article: Eight years ago the IOM, which everyone respects, said: a) this is a crisis, and b) we’ve got to do something about it, not just study it. And yet.

“We Don’t Want to Think About Aging Unless We Have To”

PHI: And yet, comparatively little has been done since. That’s basically what you were arguing in that introductory article. Can you think of reasons for that? Why has there been such a lack of political will to go down that road?

CL: These are really complicated problems with lots of stakeholders, and there’s relatively little public pressure. I ascribe that mostly to people not understanding the connections between workforce and workforce training and problems in the quality of care that they experience. Lots of people aren’t happy with how their parents’ or grandparents’ care is going, and yet they don’t connect it to, say, what the federal government or state governments do in terms of training requirements, much less how those long-term care players and professionals are paid. There is dissatisfaction, but it doesn’t add up to pressure to do something; and in a system where real heavy hitters — hospitals, doctors, nursing unions, the long-term care industry — all have a very wide range of very pressing issues right now, there just isn’t enough energy in the system to make anybody focus on the workforce part. There’s a lot of focus and a lot of stress, but it’s all on other things right now.

SD: It’s also connected to how much we don’t pay attention to, or don’t even want to think about, aging. We certainly don’t want to think about aging unless we have to. And when we have to, it’s much more immediate, tactical: “Whom do I call now that my mother just fell?” Which is understandable, but it’s embedded in a culture that sees “the elderly” more as a problem then as people.

Additionally, in the long-term care system — like all the rest of our social-service systems and education system — nothing really fundamentally changes unless the economic incentives are aligned. I’ve seen studies that have repeatedly shown that even if you prove that a certain procedure improves health care outcomes, it still does not disseminate unless the system financially rewards it.

Everyone pretty much ends up acting rationally on their own economic self-interest, and that economic self-interest does not reward investing in the workforce. Unless those economic interest dynamics shift, then no amount of appeal to assist elders, no amount of appeal to help “poor” direct-care workers, will create fundamental change. So the role of public policy should be to try to align those incentives and make it so that good stuff gets rewarded and bad stuff gets punished. And we don’t seem to have figured that out in any real fundamental way.

CL: I certainly agree with that. At least until very recently, quality didn’t have a good economic case for itself. Better-trained workers doing a better job didn’t necessarily translate into a better bottom line for anybody, and under those kinds of adverse circumstances, why would anybody change their practices?

The “Triple Threat”

PHI: Steven, in your paper “The Direct Care Workforce — Raising the Floor of Job Quality,” you write about an emerging “triple threat” of three shifting economic factors: The growing demand for care, the shrinking pool of potential caregivers, and an improving job market. What implication does the “triple threat” have on the direct-care workforce and its potential to meet the demand for eldercare?

SD: We’re already seeing that this combination of factors is causing increased rates of staff vacancies. And that type of pain for employers, providers, and consumers is a different, more profound level of pain than the pain of just high turnover and churn — which, as Chris said, everyone complains about, but nobody has the economic incentive to fix it. If you own a home care agency and are unable to grow your business because you can’t find anybody to fill staff vacancies, that’s really a significant business problem. It will eventually force policymakers to recognize that this is not sustainable; something different must be done.

The Massachusetts Senior Care Association is a really important example. They’ve documented that nursing home CNA vacancy rates over the last four or five years have doubled from 5 percent to 10 percent — even worse in some rural areas. That’s forced the trade association to create an unprecedented agreement with SEIU to ask the legislature for enough money to provide “a livable wage,” train nurse aide supervisors, and to provide scholarship support for new CNAs. I believe this will be just the first of many trade associations and employers who will see they must try something different.

Now, will the “triple threat” last forever? Demand for care will continue to increase; in fact, the curve of the demand will actually sharpen. And the supply of caregivers is going to be pretty flat for quite a while. Will the unemployment rate — which is really the spark of the “triple threat” — continue to fall? I don’t know. We are now experiencing the longest economic recovery in history, so maybe we have two or three more years of growth left? But that’s all the more reason to act now.

In the paper, I argue that the pressure is there; it’s going to build for at least the immediate term; and there will be a reaction. The strategic point is to help shape that reaction. Because otherwise, the solution will just be patchwork of short-term measures — wage bonuses, hiring bonuses, whatever — to try to get warm bodies in the door. That’s not going to help in the long term. The strategic opportunity here is to help the provider community and policymakers understand why this is happening, and why a systemic response is better than a bunch of short-term, kneejerk reactions.

CL: I think the staff-shortage crisis certainly can motivate some more fundamental reform. I’m not really such a big optimist, but one of things that I think is an interesting and potentially very useful direction is trying to use our scarce human resources in much more efficient ways. In the long-term care sector, one of the things that PHI has championed for a long time is the advanced aide concept. Isn’t there some way that better training would enable that direct-care worker to be more impactful? Isn’t there a way that that person, with a little bit more training and a little bit better connection to the rest of the health care team, can prevent hospitalization? God didn’t say that there should be direct-care workers, and there should be doctors, nurses, and social workers, and these categories are unchanging and shouldn’t be mixed up a bit.

“We Have Lots of Answers”

SD: The good news is we have lots of answers. There’s been enough experimentation to know what types of training we need, what types of workers, how to blend technology into it, how to make things more cost-efficient. The bad news is, we don’t have the urgency to follow through. Everyone’s willing to offer a trenchant critique of the system, but there isn’t the urgency to say, “We have to actually do something.”

Strategically, maybe there’s an opportunity here, because the “triple threat” dynamics will help shift people’s sense of urgency and calculations of economic self-interest. Figuring out how to increase the urgency, how to increase people’s understanding of what these problems are — that, in fact, we do have solutions available — should be the main effort. Without that urgency, we just are not going to be able to compete with the hundred other equally valid social issues that the country is facing: poverty and inequality, climate, housing issues, you name it.

We need to figure out a way to sharpen the debate so that people understand the risk, and then use that sense of urgency to shift the financial alignments. That’s how the urgency has to be translated into action. The average nursing home director or home care agency owner needs to understand that if they don’t do something to improve the quality of direct-care jobs, their business will not thrive and may not even survive. Until those financial incentives are aligned in terms of public policy and consumer demand, nothing else is going to change.

— by Matthew Ozga