Christopher A. Langston, PhD Program Director The John A. Hartford Foundation

Christopher A. Langston, PhD
Aging Population Intensifies Provider Shortage

By Sandy Graham

EDITOR'S NOTE: Christopher A. Langston, PhD, is program director at The John A. Hartford Foundation of New York. He is responsible for the foundation's grantmaking in support of its mission to enhance the nation's capacity to care for its older citizens. Earlier, Langston worked for The Atlantic Philanthropies on aging issues and taught at Purdue University. He holds a doctorate from the University of Michigan.

In your work, you focus on improving geriatrics – by helping train physicians, nurses and other practitioners in the care of older people – and training professors to teach geriatrics. Why is this important?

Obviously, the way we treat our bodies and the health practices we engage in – or don't engage in – are very important to our health. Health care really has very little to do with how healthy people are. The important determinants are social and economic status, education, luck and the health risks we've chosen. But as we get older, health care becomes more and more an important determinant of health, helping us to stay on the narrowing path of independence and functioning. In older age, it's more important to have someone who is trained to address the little health issues that can arise before they result in disability or death.

The Hartford Foundation points out that older Americans are not well-served by our health care system, which is "fragmented, expensive and low quality." But that's true for all age groups. Is there something in particular missing for older people?

Fragmentation matters more for older people than it does for younger people because, again, health care becomes more important in older age. People 65 years and older account for only about 14 or 15 percent of the population but 50 percent of hospital occupancy and 35 percent of primary care visits. They're 70 percent of home health cases, 90 percent of nursing home residents and 95 percent of hospice beneficiaries. So they're bigger users of the system – and they are less resilient in the case of health care misadventures.

What is the least understood part of the health picture for older Americans?

I think quality is low – and people don't understand that. A Hartford Foundation poll released in April bears this out: We asked older people if they had a primary care doctor and if they were satisfied with their care. Of the 1,028 people we polled over age 65, about 97 percent had a provider, and 93 percent were satisfied or very satisfied with their care. But when we asked them if they had their medications reviewed annually, discussed preventing falls with their provider, had been asked about mental health issues – all those kinds of really important preventive services – 76 percent of those surveyed had had half or fewer of the services we asked about. In short, they're not getting [good care] and they don't know they're not getting it.

Is The Hartford Foundation a pioneer in supporting better geriatric care and training?

We made our first grant in aging and health in 1982. It was to retrain physician-faculty in medical schools in geriatrics to really boost the number of faculty in the field of geriatrics. There are other important players today. The Veterans Administration has played an enormous role – today, about 50 percent of veterans are 60 years or older. The Atlantic Philanthropies and, more recently, Donald W. Reynolds Foundation are partnering with us, too.

How aware are people generally of the need for better geriatric care and training?

The awareness is growing. A study we commissioned from the Institute of Medicine in 2008 entitled "Retooling for an Aging America: Building the Health Care Workforce" brought a lot of information into one place and brought the credibility of IOM to bear. Reynolds and Hartford have funded studies of the geriatric workforce as well. We have one geriatrician for every 2,620 Americans over age 75 (the "old old"), and some of those are in education. For geriatric psychiatry, there is one practitioner for every 10,865 people over age 75.

The bad thing is that the gap is going to grow. It's very frustrating. We are just not able to keep up.

Is that why Hartford, in its grants, is stressing geriatric training for other providers such as nongeriatrician physicians, nurses and social workers?

It's all practitioners really. Fundamentally, geriatrics is team care. The breadth of people's needs and the complexity of people's needs mean there is no way to count on one provider to meet them all. The skills of physicians, nurses, social workers – we need all those skills to maintain independence and function of older people as long as possible. Do they need another pill or do they need help in getting their apartment cleaned up?

While much of our work is in medical training, there are parallels in nursing, pharmacy and about every field you can think of. We're funding several tactics: the development of clear competencies in training – what can they do in their professions to care for older people and what do they need to know to do it?

POGOe – the Portal of Geriatric Online Education – is a way to share what we're learning. It contains interactive cases, educational videos and slide sets all tagged to different geriatrics competencies. It's free – the Reynolds Foundation funded it, and Hartford and others are sponsors. Anyone can use it.

We also work on faculty development. Any of us would be a little daunted if we weren't really experts in what we were teaching and needed help and consultation. We've funded GNEC – the Geriatric Nursing Education Consortium at the American Association of Colleges of Nursing. GNEC has put together regional meetings of faculty who want to learn to use the educational tools we have for geriatrics. And we've done a similar thing within physician and social work training.

Are you familiar with Colorado and the challenges it faces in geriatrics?

The University of Colorado has been one of The Hartford Foundation's 28 Centers of Excellence in Geriatric Medicine and Training nationally since 1997. We're tremendously proud of the service delivery model that Eric Coleman has developed on care transitions with our support. [For more about Coleman's work helping older people cope with changing care settings such as moving from hospital to care facility, see story, Winds of Change in the Winter 2011 issue of Health Elevations.]

CU Denver also has been one of our training sites since the 1990s and brought together medicine, nursing and social work as effective geriatrics teams. This type of interprofessional training was unusual then, but now is quite the thing.

When you pass 65 years of age, do you plan to seek care from a geriatrician?

It would depend on the complexity of my health issues at that point. If I'm lucky and I don't have more than my current load of chronic health conditions and a well-functioning team of health professionals, I might stick with them another five or 10 years.

But when I really begin to struggle, I'd want to switch over to somebody who specializes in my needs and concerns. The developmental progression of later years is something geriatricians are really good at. Good participatory decision-making goes into geriatric care – helping people figure out what's good for them. That's what I'd want.