LeadingAge Magazine · July/August 2015 • Volume 05 • Number 04
“Better care, better health outcomes, and lower costs. If we all can work on the triple aim, that’s where we want to be—the right care in the right place of service for the right cost and value.”

Those are the goals of Terry Fulmer, Ph.D., R.N., for the long-term services and supports (LTSS) workforce.

Fulmer is president of the John A. Hartford Foundation, which focuses on improving the health of older adults, and she has seen nursing and caregiving from every angle. Before coming to the John A. Hartford Foundation, she was university distinguished professor and dean of the Bouvé College of Health Sciences at Northeastern University, where she was also professor of public policy and urban affairs in the College of Social Sciences and Humanities. She was the founding dean of the New York University (NYU) College of Nursing, and is an elected member of the Institute of Medicine. Fulmer is recognized as a leading expert in geriatrics, and is best-known for her research on elder abuse and neglect.

LeadingAge interviewed Fulmer for her thoughts on the LTSS workforce and what will be needed to make it better prepared to handle the challenges to come.

LeadingAge: First, can you tell us about the research you’ve done in your career concerning the long-term services and supports (LTSS) workforce?

Terry Fulmer: My area of research is elder abuse and neglect. Anyone who studies this subject immediately understands the essential nature of LTSS. I collaborate with adult protective service (APS) workers, who are a vital part of the LTSS system. APS workers are out in the community with some of our sickest, frailest and most vulnerable older adults who often have very substantial problems. [Those older adults] might have substance abuse and mental health problems—and so might the people taking care of them. Or they might have well-intended aging spouses who really can’t keep up the needed care so the result is neglect. It is a very complex challenge.

Obviously there is an additional set of people comprising the long-term services and support system—the family caregivers and friends trying to take care of the older adults in their lives. When I’m doing screening for elder abuse and neglect, I sometimes see horrific examples of maltreatment, but other times I see well-intended care providers who really haven’t had adequate support or training to do the complex work that’s so necessary for older people who are quite advanced in age with multiple chronic diseases.

I have not done studies on elder abuse and neglect in nursing homes per se. I see older adults as they cycle from hospitals to nursing homes to rehabilitation facilities and back. The NICHE program (Nurses Improving Care for Healthsystem Elders), originally funded by the John A. Hartford Foundation in 1992, is a model of care for older adults that looks at the way nurses can provide a systematic approach to care delivery across settings in partnership with family members and volunteers. NICHE is now in over 700 hospitals in the U.S. and has an evidence base that reflects better care outcomes for older people.

I’m sure you’re aware of the 2008 Retooling for an Aging America report from the Institute of Medicine. This report led to the formation of the Eldercare Workforce Alliance to advocate for its recommendations, and LeadingAge is a key member of this alliance. I was on that committee and we used the opportunity to better understand the direct care workforce and [to] think about how nursing aides, home health attendants and home care aides—who are the linchpins for the care system—can be further supported in their work. They have rewarding but extremely difficult jobs [with] poor pay, poor training and poor benefits. That report has really shaped my thinking about how to improve the LTSS workforce support system.

LeadingAge: What more do we need to do for the LTSS workforce in terms of training, as well as increasing the dignity and career opportunities these workers deserve?

Terry Fulmer: State laws usually require more hours of training for a manicurist than for a home attendant caring for a frail older adult. We have to continue to keep the pressure on related to improving the content, quality and quantity of education that’s so important to this workforce, and do it in a way that doesn’t swamp the system or the individual and deter them from entering this workforce in the first place. Geriatric Education Centers (GECs), funded by the Health Services and Resources Administration (HRSA) since 1983, have done an enormous amount to train our direct care workforce. Initially, GECs were only for physicians, nurses and social workers, but very quickly everyone understood that the home attendants, home health aides and family members need that education equally, if not more. This collective training is also in better alignment with the concept of health care teams. This idea is emphasized even more in HRSA’s new version of the program, the Geriatrics Workforce Enhancement Program.

The John A. Hartford Foundation also funded the Geriatric Interdisciplinary Team Training Program between 1995 and 2002, and that program examined what is needed for interdisciplinary team training across professionals and direct care workers so we can have better preparation for the care of older adults. Since then, interdisciplinary team training has gained important momentum, and there is general agreement that team-based care is better for older adults who often have multiple chronic diseases and disorders that warrant multiple medications and a carefully orchestrated approach to avoid any untoward (iatrogenic) outcomes.

Status for the LTSS workforce continues to be a problem with very little prestige for those in the role. There is also a dramatic gender imbalance in this workforce; with the vast majority female, one wonders about gender inequality and what that means for compensation. These jobs are often entry-level positions for people moving to this country for the first time who choose to join this workforce as a way of gaining employment, improving their lives, and hoping to move forward to higher paid professions such as nurses, physicians or social workers.

We must continue to work on respect for the LTSS workforce in specific and dramatic ways. We’re in the middle of a very serious conversation in the U.S. about what’s going on with racial bias and discrimination, and we have to be very mindful as we think about this workforce. We have to elevate the conversation and keep the pressure on to make this work distinctive and honorable with salaries that constitute a living wage.

LeadingAge: In keeping with the Foundation’s stated interest in new models of care, what sorts of promising innovations do you see developing today, and how are those innovations impacting the workforce?

Terry Fulmer: One exciting new program we’re supporting is with the Partners in Care Foundation in Los Angeles, which is partnering with the Administration for Community Living (ACL). The ACL has as its mission “to maximize the independence, well-being, and health of older adults, people with disabilities, and their families and caregivers.” The goal for the Partners in Care program is to look at the way we can enhance care and provide status and stature to community-based organizations so they can be better connected to traditional clinical care. They are leading a consortium of grassroots organizations which include home and community-based providers and evidence-based health promotion programs. These LTSS agencies in our communities have a sound understanding of the nuances of those communities. They understand the culture, the needs, norms and mores [of their neighborhoods and cities].

LeadingAge: What is on your “wish list” re models of care? What would you like to see in the future?

Terry Fulmer: As a former board member for the Institute for Healthcare Improvement, I have been deeply influenced by the “Triple Aim” mission: Better care, better health outcomes, and lower costs. If we all can work on the Triple Aim, that’s where we want to be—the right care in the right place of service for the right cost and value.

We need a fundamental “reboot” in this country related to the way we’re delivering care. Obviously there is the Affordable Care Act, ACOs, and all the ways we’re asking who should deliver the care, what kind of care, and how people can participate with us in person-centered care. Person-centered, appropriate care, within the frame of the triple aim: That’s my wish.

LeadingAge: How can we prepare the workforce to handle the vast increase in the number of people they’ll be serving?

Terry Fulmer: I’m optimistic about the progress in the fields of engineering, computer science, and health informatics, and the resultant avatars, apps and robotics that are being developed which will help with remote care and self-management. Technology that can help older people access care in the way they want it, in the time frame they want it, is truly person-centered. There are very positive and important breakthroughs in technology that can help assist, for example, in medication delivery, help people improve their function and help individuals stay connected. We know how much social support matters with healthy aging.

We also have a lot of promising opportunities with the advent of social media, social networking, and the very rapidly developing use of media as a way of addressing complex problems. Not only will older adults be able to access and use these new strategies, but the LTSS workforce will too. For example, you can use iPads in the home to keep older adults connected with family, and use iPhones to take pictures of skin rashes for earlier diagnosis and treatment. Technology will never replace the human touch and personal assessment, but it will certainly expand access to needed services.

LeadingAge: Where does increasing the size of the workforce fit into that vision?

Terry Fulmer: All of us would agree we need to stay vigilant about the size and quality of the LTSS workforce. We have to increase the number of people and create a career that has status, livable wages and benefits. Further, we need to keep our representatives in Congress aware of the issues related to the demands and the needs of an aging population We also have to ask ourselves, how we can we provide more incentives and retain individuals in this workforce to avoid turnover and burnout? It is extremely challenging work.

LeadingAge: In the last few years the John A. Hartford Foundation has shifted its strategic priorities “downstream” to focus more on the practice of serving seniors, and less on infrastructure. Can you elaborate on that and how it affects your work on behalf of older people?

Terry Fulmer: For 30 years … our principal strategy has been to try to improve the competence in care of older adults on the part of health care professionals through grants designed to expand academic geriatric capacity in medicine, social work and nursing. Our grants have supported over 1,000 scholars in these fields to be more effective researchers, educators, and leaders in their fields. We also supported the development and testing of improved models of care in which the health care workforce might someday practice. Where these models have demonstrated their benefits, we worked to support their spread.

Our new strategy, shifting downstream, as you note, is focused in five areas or portfolios. The first takes advantage of the individuals we’ve trained as leaders and experts in the field. All of the leaders we’ve developed are “change agents,” and we are encouraging them to use the skills they have attained and lead change. We want them to spread the ideas and best practices they have developed and continue to refine models of care that are showing promise.

Our second area is centered on linkages, promoting new ways to bridge educational programs in geriatrics with the practice arena. Our Models of Care portfolio supports the development, testing and spread of proven innovations that improve older adult health outcomes while lowering costs.

The fourth portfolio is concentrated on improving the tools and measures that constitute the infrastructure supporting the delivery of quality care for older adults. Quality measurement and information technology tools can directly drive improvements in clinical practice and patient outcomes by enabling clinicians to benchmark themselves against peers, to identify poor-performing areas, to prioritize interventions and to track the progress of quality improvement initiatives. And finally, we continue to be passionate about communication strategies that can advance the Foundation’s non-partisan mission to improve the health of older adults through grants that support engagement with the policy making process.


LeadingAge: In our field there has been concern for a long time about the lack of students going into geriatric nursing. Based on your experience in nursing education, how much does that concern you?

Terry Fulmer: Geriatrics continues to be a challenging area for student recruitment. We have a strong culture of youth, and when one looks at the number of beauty products and the amount of dollars spent on anti-aging strategies, it almost seems inevitable that few students want to join our specialty. Having said that, I believe the public is going to be engaged in an entirely different way over the next several decades. Boomers are aging differently; they have less chronicity, different health habits and different demands. This may help accelerate interest in the LTSS workforce. Geriatric nurses and geriatricians continue to be limited workforces. We have to get our incentives aligned for all who choose to work in care of older adults and ensure that the payment models are appropriate.

This is not a short-term fix, and we have to take a long view. We need to remember that since 1900 we’ve almost doubled longevity. In 1900 the average life expectancy was about 43 years and now it’s about 80; that’s very impressive. People are living longer and healthier lives, and what we have to do is continue to accentuate the positive and work on creating a quality of life for those older individuals who ultimately will have chronic diseases and need our help.