University of Southern California Dissertations and Theses

Health care personnel needs for long-term care in California: Projections through the year 2020

(USC Thesis Other)

Health care personnel needs for long-term care in California: Projections through the year 2020

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content HEALTH CARE PERSONNEL NEEDS FOR LONG-TERM CARE IN CALIFORNIA: PROJECTIONS THROUGH THE YEAR 2 02 0 by Kathleen McMahon Gentile A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY r UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE IN GERONTOLOGY August 1990 UMI Number: EP58965 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. DissertattGn PVMisWng UMI EP58965 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106 - 1346 uNivERsny or southern C a l if o r n ia LEONARD VAVIS SCHOOL OF GERONTOLOGY G & r a n UNIVERSITY PARK % LOS ANGELES, CALIFORNIA 9ÛÛÛ7 (<^7 This w/LÙùten. by Kathleen McMahon Gentile und2A th z dJji2,cXon. o {^ h er The6Z6 CommiXtzz, and appn.o\Jzd by aZZ J itii me.mbeA^, ho6 been pAe- 6en ted to and accepted by th z Vzan Tkc LtonoAd Vav>u> SckooZ o (^ G2A.ontoZogy, Zn poAdUaZ {^at(^ÂJUbn2 .n t 0^ tk z A.e.quÂAme,nt6 tk z degree THESIS COm TTEE 11 ACKNOWLEDGMENTS I am grateful to David A. Peterson, Ph.D. for his consummate guidance and leadership as both professor and thesis advisor while I was a graduate student at the Leonard Davis School of Gerontology. I am also grateful to James E. Birren, Ph.D., D.Sc. for his guidance and for the many opportunities he extended to further my career. To all my professors and instructors at the Leonard Davis School of Gerontology, I thank you. To my husband and three daughters, my eternal gratitude and love for your steadfastness and patience. Ill TABLE OF CONTENTS Page ACKNOWLEDGMENTS..........................................ii LIST OF TABLES............................................v CHAPTER 1. INTRODUCTION......................................... 1 Statement of the Problem...........................,1 2. SETTING THE STAGE; WHAT IS LONG-TERM CARE AND WHO ARE THE RECIPIENTS...................................... 4 3. LITERATURE REVIEW....................................9 4. DETERMINATION OF THE AT-RISK POPULATION: CANDIDATES FOR LONG-TERM CARE SERVICES...........................24 Demographic Profile of the Elderly Population...................................... 24 The Service Delivery Environment................ 37 Who Are the Service Providers?................. 3 9 5. THE SUBJECTS OF THIS RESEARCH, THEIR SERVICES AND THE SERVICE ENVIRONMENT............ ...........................4 6 Physician Supply...................................4 6 Productivity.................................54 Health Maintenance Organizations.......... 55 Preferred Provider Organizations.......... 56 Supply of Nurses...................................56 Registered Nurses...........................57 IV Allied Health Professionals.......................67 Physical Therapist..........................71 Occupational Therapy........................73 Speech-Language-Hearing Personnel......... 75 6. PROJECTIONS OF LONG-TERM CARE PERSONNEL...........77 Methods and Calculations...........................77 Long-Term Care Population................... 7 8 Health Care Personnel Serving the Elderly........................84 Projections of Long-Term Care Personnel in 2020 ..................................88 Physicians.................................... 90 Nurses.........................................92 Allied Health Professionals..................95 7. SUMMARY AND RECOMMENDATIONS...................... 100 REFERENCES.............................................. 104 V LIST OF TABLES 1. Projected Growth of California Population 1980 to 2020 ........................... 25 2. Growth of 65+ Population in California 1980 to 2020 ...................................... 26 3. Gender Distribution in 65+ Population in California..........................28 4. Gender Differences in the Oldest-Old Population............................. 30 5. Projected Percentage Increase in the Number of Needed Personnel from 1985 to 1994 ...................................... .42 6. Projected Percentage in the Number of Needed Health Service Occupations.............43 7. Projected Percentage Increase in the Number of Needed Health Service Groups.......... 44 8. Physicians Per 100, 000 Persons....................50 9. Registered Nurses Per 100,000 Persons Statewide and by Health Services Areas (1985) (Ratio of Registered Nurses Per 100, 000 Persons)................................... 60 10. Projected Long-Term Care Population and Its Components.................................7 9 11. Calculation of Long-Term Care Population.........83 12. Standards of Adequacy for Selected Health Care Professionals (Numbers Required per 100,000 Persons)............................................89 13. Projections of Health Care Professionals for California in 2020 ........................... 91 CHAPTER 1 INTRODUCTION Statement of the Problem The vision of a high quality long-term care delivery system within California requires adequate numbers of professionally trained personnel to respond to the multiple health care and social service needs of the growing elderly population. There is currently discussion within the health services industry that critical shortages and maldistribution of personnel exist within specific health service occupations providing long-term care services to the elderly population in California. It is apparent to some that the numbers of personnel needed to provide long-term care services for the growing numbers of elderly in the future will greatly exceed the current supply of practitioners or be disproportionately geographically distributed within California. This paper presents the supply of selected health care professionals currently in California and projects the numbers of health care professionals who will be needed through the year 2020 to provide long-term care services to the 65+ population in California. The paper begins with a definition and discussion of long-term care, its components and its population. A national perspective on personnel supply and demand in the long-term care industry provides the background for a literature review including an update on national and statewide reports on health care personnel needs. Critical to this discussion is the demographics of the potential at-risk elderly population to be served and consideration of their health and functional status which predicts the types and amounts of required health services. A description of the personnel who are the subject of this study is presented in terms of services provided, the environment in which their services are performed and the educational preparation required for licensing. Health and health-related services are a major component in the long-term care delivery system. This study focuses on health care service providers. The health care occupational categories studied here include physicians, nurses (registered, licensed vocational and nursing aides), and allied health personnel (physical and occupational therapists and language-speech-hearing therapists). These occupational categories will be referred to interchangeably as long-term care personnel or health care personnel. These occupations were selected on the assumption that they are the "first-line" of health care professionals utilized by the at-risk elderly population. Selection of these health care personnel for study does not discount the role played by other health care professionals and paraprofessionals and by social service providers in the long-term care delivery system. Supply and demand projections for these other related occupations and service providers lends itself to similar study by others. Projections of the number of health care personnel needed by the year 2020 will be made based on the numbers of the selected health care professionals currently practicing in California, the frequency of services demanded by the 65+ long-term care population, and the percentage of time the health care personnel devote to care for the elderly. Determining future personnel needs will afford the long-term care industry an opportunity to match industry-wide occupational trends with specific personnel needs within their own environment and for educational institutions to develop appropriate training programs. CHAPTER 2 SETTING THE STAGE: WHAT IS LONG-TERM CARE AND WHO ARE THE RECIPIENTS? What is long-term care? Long-term care is generally defined as the assistance that is needed to manage as independently and as decently as possible when disabilities undermine capacities (Kane and Kane, 1987) . The need for long-term care most often arises among the older population as a result of diminished abilities. Some adults who are under age 65 often need assistance due to a physical or mental limitation brought on by a traumatic brain injury, chronic mental illness, a developmentally disabling condition, or, in more recent years, a patient with AIDS. The very old (85+) are most particularly in need of long-term care services because of their proven high incidence of disabling, chronic diseases. Long-term care is part health care and part social services. Some of the health care needed to prevent, minimize or manage chronic functional disability requires the services of physicians and nurses, and other health professionals including physician assistants, pharmacists, dentists, podiatrists, physical therapists, occupational therapists, and language-speech-hearing therapists. Components of long-term care also fall under the purview of social services, such as housekeeping chores, meal-delivery, housing, transportation, counseling, and information and referral service, which require the services of trained geriatric social workers, administrators, gerontologists, or case managers. One of the major determinants of who needs long term care is based on the level of functioning measured by compiling components of independent activities such as toileting, eating, dressing, bathing and locomotion. Other activities which are essential to daily living and are used as measurements of functioning include money management, household maintenance, transportation and basic household tasks such as cooking and cleaning. Long-term care thus refers to a range of services needed to compensate for functional disabilities or impairments. Discussion of long-term care in this paper is based on a concept which essentially says that long-term care is a set of health, personal care, and social services delivered over a sustained period of time to persons 6 who have lost or never acquired some degree of functional capacity (Kane and Kane, 1987). In putting the spotlight on the long-term care service providers in California, the reader might be misled to think that any problems of personnel supply and demand within the health services industry is particular to this state. On the contrary, a review of the national health service industry shows that changing demographics, economics and public policy have combined to transform the national health care delivery system since the 1970s and current projections anticipate further alterations. Studying the national health care system will hopefully shed some light on personnel supply and demand problems within the long-term care delivery system in California and perhaps lead to some solutions which would be applicable to California. The growth in the national health care workforce during the 1980s is occurring simultaneously with the changes in the entire health care delivery system. These changes are influenced by several factors and in turn influence the present and future status of health care providers. Major factors involved in the transformation occurring in the health care delivery system include the competition among the growing numbers of practitioners in many fields and the growing emphasis (both public and private) on cost containment. Movement away from fee for service and cost reimbursement systems to prospective payment systems are being examined while its impact continues to accumulate. Health care services are being delivered in traditional settings, such as private offices and hospitals, while alternative settings are growing as financial incentives are changing. Emphasis on cost- effective health care has resulted in shifts to freestanding clinics, emergency centers and hospital outpatient centers. Growth in the numbers of people enrolled in Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) accounts for some of the shifts in the delivery of health care services. The aging of the population has significantly affected the health care delivery system, and more specifically the long-term care system, and the health care personnel within that system. The number of people aged 65 and over and the percent of the population they represent have grown and will continue to grow in the coming decades. By the year 2000 it is expected that the number of persons in this age group will have increased to 35 million or 13% of the population, up from 29 million or 12% of the population in 1985 (U.S. Department of Health and Human Services, 1988). More than 51 million persons or about 17% of the population will be 65 years or older by the year 2020. Moreover, the portion of the population aged 85 years and over is expected to continue to grow faster than any other subgroup of the elderly population. Approximately 7 million persons will be at least 85 years old in 2020 compared with nearly 3 million in 1985. In addition to demographic changes such as the aging of the population, changes in the delivery of care as a result of factors such as technological advances and the current emphasis on health promotion and prevention of illness before it occurs affect the types of skills and training needed by health personnel to adequately deliver care. CHAPTER 3 LITERATURE REVIEW There are basic questions relating to the study of the supply of personnel in the long-term care service industry. They include, among others: What are the occupations involved in serving the older population and how many persons are in these occupations? What numbers will be required to meet the growth requirements as the older population increases and new facilities and services appear? What numbers will be required to offset ordinary attrition and high turnover rates characteristic of some health care occupations? Answering these questions is critical to the operation of the health care delivery system in California, and also to the funding of agencies, professional organizations, and private enterprise. Educational institutions are also affected. What appears to be fairly straightforward and relatively simple becomes difficult when closely studied. There are many underlying complexities, questions and considerations encountered by those who 10 have previously addressed this issue. A systematic method of study, analysis and evaluation has not been developed to answer these questions. The first attempt at a national comprehensive study was conducted by the Surveys and Research Corporation for the Administration on Aging in 1967-1968 (cited in Tibbitts, 1980, p. 20). A time constraint restricted the study largely to persons knowledgeable within the industrial and occupational areas addressed. The investigators concluded that probably 330,000 persons were employed in facilities and programs for older people, some 290,000 of them in long-term nursing facilities. It was forecast that by 1980-1985 employment would reach one million, a forecast that still stands. Because of various forms of attrition, numbers required to be trained may well exceed this estimate by a third or even more. The Office of Employment Structure and Trends in the Bureau of Labor Statistics (cited Tibbits, 1980, p. 20) released a report. Manpower Needs in the Field of Aging; The Nursing Home Industry (1975) which covered current employment and projections. The Fall 1976 issue of the Bureau's Occupational Outlook Quarterly was devoted to a somewhat in-depth discussion of 40 or more occupations serving older 11 people in the housing, social service, senior center, nursing home, nutrition, and home care industries. The report discusses such matters as job tasks and responsibilities, training and experience requirements, work conditions, salary levels, and prospectives for employment. In 1977 the Bureau prepared a report of a hearing conducted in 197 6 by the Commissioner on Aging entitled Human Resource Issues in the Delivery of Services to the Elderly. Principal issues discussed by 70 individuals and organizations who testified included recruitment, turnover, education and train ing, salaries, barriers to effective staff utiliza tion, and issues peculiar to rural areas, minorities, and volunteers. Witnesses at the hearings also testi fied that development of multi-disciplinary centers of gerontology to provide career and short-term including in-service training was important to prepare those persons who would be serving the older population. The Homeworker-Home Health Services study by the Bureau of Labor Statistics in 1973 (cited in Tibbits, 1980, pp. 20-21) dealt with manpower-relevant matters such as staffing patterns, levels of care vis-a-vis institutional care, personal and training experience qualifications, and working conditions. A principal 12 focus of the study is the projection of personnel needs over the 1980 decade. Using variables such as employment requirements and available personnel, philosophy and acceptance of home services for the long-term ill, legislative authorization and appropriations, and older population growth, the Bureau presented four projections of manpower needs. One projection estimated that by 1990, 198,000 homemaker-home health aids would be needed. It is significant to note that the number of openings for attrition replacements would exceed the number of openings for growth positions over the ten year period. In 197 6 the Federal Council on the Aging completed a survey of available information regarding health manpower needs. Among the conclusions reported were the following; There is very limited coordination and unification of health manpower needs and services provided by the Federal government and other private, state and local and county organizations. Little attempt is made to organize and integrate the research findings of the various agencies. Many of the personnel providing health services for the elderly are not properly trained for their positions. They perform their jobs without the skills necessary to meet the special needs of this clientele. 13 While a considerable amount of data and other information currently exist on health manpower needs and resources, little effort has been made to relate the existing data to future planning activities and programs. (Tibbits, Friedsam, Kerschner, Maddox and McClusky, 1980, p. 21) In 1981, Kane and associates carried out a study of the supply and demand for geriatric physicians. They concluded that there was a need for 1,500 academic geriatric physicians at present and 11,000 to 16,000 practicing geriatricians. By the year 2030, they anticipate the need for 47,000 practicing geriatricians (Kane, Solomon, Beck, Keeler, and Kane, 1981). A report issued by the National Institute on Aging titled Personnel for Health Needs of the Elderly Through the Year 2020 offered a number of conclusions and recommendations that are relevant to the state of California. They include: A wide range of well-educated health personnel . . . will be required to respond to the diverse needs of older people. Under any conditions, requirements for personnel specifically prepared to serve older people will greatly exceed the current supply. Health care practitioners will routinely serve older persons in the future as part of their regular practices. The care of older persons may typically comprise one- third to two-thirds of the future workload of most physicians and other types of 14 health personnel. (National Institute on Aging, 1987, p. 88) The current shortage of health care professionals, primarily in nursing and the rehabilitative personnel will become more critical in the 21st century according to two studies released in June 1988. The Institute of Medicine's (lOM) Allied Health Services: Avoiding Crisis and the U.S. Department of Health and Human Services' Sixth Report to the President and Congress on the Status of Health Personnel in the United States (U.S. Department of Health and Human Services, 1988) agree that the increasing size of the elderly population will severely tax, if not overwhelm, the caregiving professions, The most visible example of current and future shortages is in the field of nursing. A random sample of one-third of United States hospitals found that 79% of the reporting hospitals indicated a shortage of registered nurses with 53% of the reporting hospitals indicating that the shortage was moderate or severe (American Hospital Association, 1987). Registered nurse (RN) vacancy rates in hospitals have more than doubled between 1983 and 1987 (from 4.4% to 11.3%). A survey conducted by the American Health Care Association revealed that 34% of nursing homes 15 reported severe RN shortages; and because of the survey's low response rate (17%) the result may not be applicable to the national population of nursing homes (U.S. Department of Health and Human Services, 1988). The National Association of Home Care reports that the nursing shortage has reached the home care setting. The results of one survey conducted by the National Association of Home Care reported that 56% of all home care agencies responding to the survey expressed difficulties in recruiting and/or retaining RNs. Another 48% reported problems in recruiting and retaining home-maker home health aides. Of the hospital-based home care agencies, 42% indicated experiencing difficulty in recruiting and retaining nurses. Although the Commission on Nursing reports that adequate data regarding the nursing shortage in the ambulatory and community health setting are not available, they acknowledge that anecdotal evidence suggests that HMOs are finding it increasingly difficult to hire enough RNs to meet the demand (U.S. Department of Health and Human Services, 1988). The 1980 Graduate Medical Education National Advisory Committee predicted a surplus of 144,700 physicians by the year 2000. This would translate to 247 doctors for every 100,000 persons in the United 16 States. In 1986 there were 224.9 physicians for every 100,000 persons, an increase of 18.2% over the 1980 population, compared to a general population increase of only 5.1% (U.S. Department of Health and Human Services, 1988). By the year 2000, the rate will grow to 276.7. The Institute of Medicine report (Institute of Medicine, 1988) provides valuable guidance for federal, state and local government, professional, and private efforts to increase the supply and improve the quality of the many types of allied health personnel required to meet the health care needs of the U.S. The report notes that the growing elderly population is among the factors contributing to the importance of making careful assessments of needs for health personnel and arriving at sound decisions about education, regulation, and utilization of such personnel. The report emphasizes the variety of individuals and groups that must play a part in resolving these issues and also addresses the continuing need for better data on personnel supply and utilization. The Sixth Report to the President (U.S. Department of Health and Human Services, 1988) is the latest in a series of biennial reports required by the 17 Public Health Service Act and prepared by the Health Resources and Services Administration. The report finds that, despite a drop in the number of persons entering health professions schools, the number of health personnel continues to increase and to exceed the growth rate of the U.S. population. But, the report also points out that certain specialty and geographic imbalances remain. For example, about 13 million people remain underserved in the nation's primary care health manpower shortage areas. Population and economic factors may remain unfavorable for the establishment of health care practices in many rural and urban poverty areas. There is an increased demand for registered nurses in hospitals, along with problems of recruitment and retention. Data indicate chronic deficits of skilled nursing personnel in nursing homes. In some allied health fields such as physical therapy, occupational therapy, radiologic technology, and medical records service, there are indications of current or impending shortages. The Sixth Report (cited in U.S. Department of Health and Human Services, 1988) discusses current numbers of health personnel and how they affect, are affected by, and are adjusting to changes in the health care delivery system and other developments. 1 It also provides projections of future supply and requirements for health personnel. Both the Sixth Report (cited in U.S. Department of Health and Human Services, 1988) and the Institute of Medicine Report (Institute of Medicine, 1988) emphasize that population growth and aging will result in increased spending for health services in future years. Additional jobs are being created in several areas, and adjustments are taking place. The Institute of Medicine report on allied health personnel does a good job of describing this process for a number of occupations. Students' education choices, particularly of those students who select allied health and nursing careers, are very sensitive to the availability of jobs. Moreover, educational institutions have been quick to adjust either by expanding enrollment capacity or by offering new programs. Although most nursing and allied health education takes place in colleges and universities, hospital and other programs provide a considerable amount of training in certain occupations and regions of the country. After reviewing the national data available on personnel supply and demand, it would now be appropriate to review the data on the status of health 19 care personnel in the state of California. In the 1987 State Health Plan, a report issued by the Office of Statewide Health Planning and Development (1988), it was reported that while there appeared to be an adequate supply of primary care physicians, there were large variations in the number of primary care physicians per population among the counties of the state. The State Health Plan was issued in compliance with recent legislation which required consolidation of three distinct reports into one annual report. This particular report, in addition to other mandated reports on competition and deregulation on special populations, focused on trends in the supply and distribution of health manpower, facilities, services, and capital. Overall the report concluded that the number of physicians, dentists, pharmacists and optometrists in California is adequate to meet the health care needs of the population. However, some gaps in the distribution of these professionals continue to exist. Rural counties in Northern California, North San Joaquin, Central Valley and the Inland Counties health service areas have the fewest health professionals per population (Office of 20 Statewide Health Planning and Development in California, 1988). The California Association of Hospitals and Health Systems (CAHHS) conducted the 198 8 Nursing/Personnel Survey which detailed turnover and vacancy rates for 15 personnel categories. Infor mation was requested on recruitment and retention of staff; reductions and increases in staff, services and beds; and special elements regarding relationships between hospitals, physicians and the nursing staff. The survey concluded that California hospitals are responding to the changing health care environment. Vacancy rates in all personnel categories continue to be substantially less than the national figures. The overall vacancy rate for California in 1988 was 5.7%. Turnover rates decreased from 19.2% in 1987 to 18.7% in 1988. California hospitals appear to be responding to changes in staffing and scheduling which provide flexibility and adjustment to the current nursing shortage. Hospitals continue to diversify into health care delivery alternatives outside of the acute setting. Ambulatory surgery centers, outpatient clinics and home health services and skilled nursing services appear to be the most popular (Beghin, 1989). 21 Determination of the supply of statewide health care personnel has generally been ascertained through the survey of college and university instructional programs to determine the extent to which emphasis is placed on aging, life span development, or later adulthood. Over 40 studies have been reported. Again, many of these studies have been conducted on a national basis, but a few studies have concentrated on geographic regions. For instance, institutions of higher education in California were surveyed in 1975 and of 127 respondents, 50 (39%) offered courses in aging (Swanson, 1975). A 1981 survey which reached 263 colleges and universities reported 108 which offered courses in aging (41%) (California Council on Gerontology and Geriatrics, 1981). Only a few studies of long-term care instruction in California institutions of higher education have been conducted. Birren and Hirschfield (1977) surveyed professional schools and departments in many institutions of higher education, reportedly finding few programs including content on long-term care and aging. In 1988, Gilford surveyed the 19 campuses of the California State University system and reported 32 different credentials in aging being 22 offered at the undergraduate level and five at the graduate level (Gilford, 1989). Overall, national and state studies indicate generally adequate numbers of health care professionals to meet the needs of the population, but gaps continue to exist in some specialties of medicine and in the distribution of these professionals. Some studies indicate continued increase in the physician- to-population ratio, but there has been little change in the geographic distribution of physicians since 1970. There is some evidence though that the disproportionate distribution between urban and rural areas may begin to narrow with changes in population growth and various economic factors, but some areas will always remain unfavorable for physicians to establish a practice. There continues to be an increase in the demand for nurses in hospitals along with the growing demand for nurses in alternative health care settings, such as home health care and long-term care settings. Perpetuation of low morale and low wages continue to discourage enrollment in educational programs for all levels of nursing students. There are also indications of shortages of certain allied health personnel, including occupational therapists and physical therapists. 23 Training schools are also experiencing difficulty in recruiting students, as well as faculty and researchers. 24 CHAPTER 4 DETERMINATION OF THE AT-RISK POPULATION: CANDIDATES FOR LONG-TERM CARE SERVICES Demographic Profile of the Elderly Population California’s total population is projected to increase to 39.6 million in 2020, a two-thirds rise from 23.8 million in 1980 (Table 1). Reductions in mortality rates and improvements in life expectancy are projected to continue, resulting in significant changes in the age structure of California's population. In 1980 there were 2.4 million elderly people, 10.2% of the total population. By 2020, the elderly population is projected to rise to 6.2 million and will comprise 15.6% of the population (Table 2). The dramatic rise in the numbers of elderly in California is further illustrated by the fact that the increase is almost three times faster than the under 65 age groups. This large increase is due in part to the aging of the baby boom children, the generation born between 194 6 and 1964 (Department of Finance, 1988). i I The distribution by age and gender is of special ! interest and importance in determining the population 25 Table 1 Projected Growth of California Population 1980 to 2020 Millions 1980 Calif. Dept, of Finance 1988 1990 2000 2020 26 Table 2 Growth of 65+ Population in California 1980 to 2020 2500 2000 1500 1000 500 Thousands 1980 65 - 69 2020 Calif. Dept, of Finance 1988 27 which is most at-risk for utilizing long-term care services. Within 30 years, 1990 to 2020, there will be a dramatic doubling of the number of persons 65 and older. The older population will be almost 16% of the state's total population by 2020. This represents 6,159,981 persons 65+ in 2020, up from 3,271,606 in 1990. Of persons age 65 and over, the number and proportion of the very old will increase fastest. In 1980, about 219,000 persons were 85 years and over, comprising 9.0% of the elderly. By 2020, this age group is projected to almost triple to 621,000 persons, or 10.1% of the elderly (Table 2). The gender distribution of the elderly population presents a different picture. Life expectancy is significantly greater for women than for men. For the state as a whole, the total number of elderly women is slightly greater. In 1980, there were almost 1 million men and 1.4 million women over 65. By 2020 this differential is expected to increase to 2.6 million men to 3.5 million women (Table 3). National data show that in 198 6 life expectancy for men at age 65 is 14.8 years compared with 18.6 years for women (U.S. Department of Health and Human Services, 1988). California's aged population generally reflects that of the nation. There were 69 elderly men for every 28 Table 3 Gender Distribution in 65+ Population in California Thousands 400 0 300 0 2000 1000 1980 2020 Male Female Calif. Dept, of Finance 1988 29 100 women in 1980. Although this differential is projected to decline, there will still be 75 elderly men for every 100 women by 2020. For the oldest old in California, the gender difference is even greater. As can be seen in Table 4, in 1980 there were 65,000 men and 154,000 women aged 85 and older. This population subgroup is expected to rise faster than any other age group. By 2020, California's oldest old will comprise 177,000 men and 430,000 women, representing increases of 174% and 187%, respectively. Research shows that very old persons are at significantly higher risks for chronic and disabling conditions. The increase in absolute numbers of the 65 and older population, and most especially the 85 and older age group, will dramatically expand the need for long term care services. The predominance of elderly women who are widowed, poor and live alone offer a special challenge to the long-term care delivery system to offer services which can maintain and support their functional independence to avoid institutionalization (The Commonwealth Fund Commission on Elderly People Living Alone, 1987) . There will be some important changes in the racial and ethnic composition of California's Table 4 30 Gender Differences in the Oldest-Old Population Thousands 500 400 300 200 100 2020 1980 1990 2000 Male Female Calif. Dept, of Finance 1988 31 population which will significantly change during this time period. The white population is projected to rise from 15.8 million persons in 1980 to a high of 17.0 million in 2000 and decline in 2020 to 16.1 million. During this same time period, the Hispanic and Asian total populations will more than triple, and Blacks will increase by two-thirds. By 2020, Hispanics will comprise nearly the same number as Whites, 14.9 million compared with 16.1 million, respectively (California Health and Welfare Agency, 1988). The non-white elderly will rise at much faster rates than the whites. From 2010 to 2020, elderly Hispanics will increase 80%, Black elderly 44%, and Asians and others 72%. The aging of California's population has significant implications with regard to the need for and provision of long-term care services. The increased demand for long-term care services may be moderated by the fact that Californians today are healthier than in the past and may remain healthier as they grow older. To the degree that the rapidly growing numbers of very old persons are at risk for chronic and disabling illness, then the demand for long-term care services can be expected to grow 32 proportionately. The growing number of nonwhite elderly persons are of special importance with respect to long-term care services. Elderly Hispanics and Asians generally have lower utilization rates of nursing homes services. A study of utilization by Mexican-American elderly in the southwest concluded, for example, that the nursing home is a "culturally defined alternative of last resort" (Bribes and Bradley-Rawls, 1982). Another factor that needs to be considered in estimating the population at risk for long-term care is the need and demand of younger age groups. Medical progress has improved survival rates and life expectancy of babies with birth defects. People of all ages who experience disabling chronic illnesses and injuries, particularly as the result of accidents, live longer now. Disabled people report more chronic conditions than in the past. There has also been an increase in the rate of limitations of activity due to chronic conditions, especially among disabled middle- aged persons 45 to 64 years old (Rice and LaPlante, 1988). About 40% of persons needing help with activities of daily living or instrumental activities of daily living are under 65. The developmentally disabled population is also aging and there is a 33 growing awareness of their potential long-term care needs. The potential recipients of long-term care include individuals of all ages with functional impairments, the developmentally disabled, physically disabled, mentally ill, as well as the elderly dependent and disabled population. For purposes of this paper, the population which forms the basis of this study includes all persons 65 and older. This is not to say that recipients of long-term care who do not fall within this age group do not warrant study and concern, but due to restrictions of time, space and economics, this report is constrained to limit the population which is served by the specified long-term care personnel. Health and Functional Status of the Future Elderly Population The potential needs for long-term care personnel to serve older persons will depend in large part on the health and functional status of the growing elderly population. The majority of older individuals in the future are likely to be healthy and able to function independently. In 1984 more than 90% of persons 65 and over were living in the community, and about two-thirds of that group perceived their health 34 to be good to excellent. It is that relatively small percentage of the elderly population who need long term care services, either in an institution or at home, that this paper addresses. The small percentage translates to potentially hundreds of thousands of people by the year 2020. The functional status of these elderly individuals will determine the kinds of health services delivered, the environment in which the services are rendered, and the types of personnel who will be needed. Determining health and functional status, types and amounts of health services, and predicting the frequency of service utilization by the at-risk population involve uncertainties about the future. For example, the extent of chronic disabilities among the older population and the impact of possible changes in various societal and health conditions are among the unknowns. Estimating utilization rates of health services by older persons using physician visits, short-stay hospital days, nursing home residency, or home health services as measurements have inherent difficulties. There are other uncertainties in making projections. They include, among others, unknown discoveries or advances in treating or preventing chronic diseases, changes in 35 mortality, morbidity and disability, attitudes towards use of health care services, and the changing structure of the health services industry itself. It is probable that chronic diseases arising from physical or emotional causes will be the more important of disabilities in the future. Chronic diseases have now superseded acute diseases as the major threats to the continuance of health and are responsible for more deaths and cases of total disability than acute illnesses. Chronic diseases, such as arteriosclerosis, arthritis, adult-onset diabetes, and cancer, which tend to be managed and controlled rather than cured, often require the continuing attention of physicians and other personnel and may impair abilities to live independently. Although most older adults develop one or more chronic health problems, these conditions vary from relatively minor difficulties to severe disabilities. In many cases only relatively modest changes in lifestyle ensue, requiring little or no assistance from others. In other cases increasing amounts of care and professional health services are required. Because chronic conditions tend to accumulate, many elderly persons, especially the oldest old, often experience multiple health problems at the same time. 36 Persons with multiple problems tend to utilize a substantial share of available services. Evidence shows that there has been a "mild worsening of health among the older population during a recent period of declining mortality" (Crimmins, 1987). A greater proportion of the young old in 1980 are suffering from chronic conditions than in 197 0. Also, in 1980 people over the age of 65 spent more days in restricted activity than in 1970. There is also some evidence which points to the fact that chronic conditions restricting activity are starting at earlier ages and thus lasting a longer time during a person's life span (Crimmins, 1987). Such information has tremendous impact on the delivery of health care and medical treatment now and in the future. The lengthening of life and the continuation of chronic, disabling disease combine to increase the need and demand for health care services. While some speculate that the incidence of disabling chronic diseases might be lowered in the future, current data does not support the idea of postponement of the age at onset of chronic illness and a reduction in the average period of diminished physical vigor, and thus a reduction in the need for health care services (Fries, 1981; Schneider and Guralnik, 1987). 37 The Service Delivery Environment Recent developments in the health care industry have affected the settings in which health care services are delivered. They include: (a) emphasis on health care cost containment; (b) increases in the number of practitioners; (c) changes in the methods of financing health care; (d) entrepreneurial initiatives in service delivery; (e) increased need for care and rehabilitation of the elderly; and (f) technological advances along with growing use of highly sophisticated diagnostic and therapeutic equipment. For these reasons the characteristics of practice and the service delivery environment have been redefined. Hospitals are still the major employers of nurses and many allied health personnel. The continuing struggle to control the spiraling costs of health care has led to changes in the approaches to the delivery of health care services and the settings in which health care personnel provide these services. Typical changes include centralization of services such as laboratory and radiology, as well as decreased delivery of these services in settings outside of hospitals, increased automation and use of computers and contracting for services. Also, greater emphasis on providing care in the most cost-effective setting 38 along with emerging technologies that allow for an increasing number of procedures on an outpatient basis are substantially reducing hospital inpatient stay requirements. There has also been a corresponding increase in ambulatory care services. New types of care delivery sites such as ambulatory surgery centers and freestanding emergency and diagnostic centers have altered the traditional sites of service delivery. With early discharges from acute care hospitals there has been an increased need for home health care ser vices. There has also been an expansion in the use of health maintenance organizations and preferred physi cian organizations as means for obtaining health care. Data from the Bureau of Labor Statistics shows that during the 1980s job growth in health services settings other than hospitals has significantly exceeded that in hospitals. Surveys conducted by the American Hospital Association show a 3% decline in hospital full-time equivalent employment from 1982- 1985 (cited in U.S. Department of Health and Human Services, 1988). Some observers predict that alternate care delivery systems will continue to constitute a larger share of the health care delivery system in the coming years. If so, it is likely that employment in these 39 settings will account for larger proportions of the practice settings for health care personnel. Who Are the Service Providers? At a national level, the numbers of health care personnel have increased considerably since 1980, continuing the trend begun in the late 1960s and early 1970s. Increases in the number of physicians, dentists, podiatrists, optometrists and registered nurses have been substantial from 1980 to 1986. Similar increases in numbers of allied health occupations averaged about 21% during this same period. Although these fields are still growing, they have been doing so at a reduced rate since the mid 1970s. The growth rate of health care providers has far outpaced the growth rate of the U.S. population during this period. The resident population grew by only 6%, substantially less than the increases in health personnel. Because the percentage increases in health care providers have continued to exceed the percentage increase in the population, the ratios of the number of practitioners-to-population have continued to rise as well. Nationally, the widespread rise in health services employment has been driven by the 40 increasingly aging population requiring more health care, the expansion of outpatient care services, and the growing willingness of health insurance programs to cover home health care. As in the past, the largest number of job gains occurred in hospitals, where almost half of all health services workers are employed. The largest rates of employment growth, both in 1988 and in the last six years, occurred in outpatient care facilities, where employment has risen by more than 80% over the expansion and, to a lesser extent, in medical and dental labs and offices of physicians. Occupational data from California mirror to a great extent the data coming from national sources. In California, health specialty occupations within the professional, paraprofessional, and technical workers group are expected to grow at a rapid rate between 1985 and 1995 (California Employment Development Department, 1988). The number of business and health service workers is projected to continue to grow faster than total employment, rising by 35%. Over 564,000 new jobs will be added to this group. Among the occupations expected to show the most rapid growth are medical assistants (52.7%), home health aides and social welfare aides (51% each), 41 housekeepers and physical therapy assistants. The numbers of home health aides are expected to grow due to the increasing numbers of elderly and a continuing trend to provide medical care outside of the hospital setting. Current information indicates that the health services industry will be experiencing a significant percentage increase in the number of needed personnel from 1985 actual numbers to projections for 1995 of over 39% (California Employment Development Department, 1988; Table 5) . Of the 50 occupations in California with the largest absolute growth from 1985 to 1995, three health service occupations are included--registered nurses, nurses aides, orderlies, and licensed practical nurses (Table 6). Of the 50 fastest growing occupations in California from 1985 and projected to 1995, nine are included in the health service group--podiatrists, physical therapists, medical assistants, social welfare aides, home health aides, occupational therapists, physical therapy, and registered nurses (Table 7). The data presented in Tables 5, 6, and 7 indicate the number of personnel employed in the listed 42 Table 5 Projected Percentage Increase Personnel from 1985 to 1994 in the Number of Needed 1985 1995 % Change Health Services, total 646,290 900,020 39.3 Offices of Physicians 113,160 146,170 29.2 Offices of Dentists 60,670 86,190 42.1 Offices of Osteopathies 480 890 85 . 4 Offices of Others 24,950 42,240 69.3 Nursing & Personal Care 101,230 139,240 37.5 Hospitals 69,280 365,080 35.6 Med & Dental Labs 20,050 23,680 18.1 Outpatient Care Fac 47,220 80,430 70.3 Health & Allied Services 9,250 16,100 74.1 43 Table 6. Projected Percentage Increase in the Number of Needed Health Service Occupations 1985 Registered Nurses 140,170 Nurses Aides, Orderlies 76,820 Licensed Practical Nurses 49,700 1995 207,280 102,230 64,380 % Change 47 . 9 33.1 29.5 44 Table 7 Projected Percentage Increase in the Number of Needed Health Service Groups 1985 1995 % Change Podiatrists 700 1, 130 61.4 Physical Therapists 6,130 9, 470 54.5 Medical Assistants 17,790 27,170 52.7 Social Welfare Aides 3, 890 5, 940 52.7 Home Health Aides 4,260 6,430 50 . 9 Occupational Therapists 2,220 3,320 49.5 Physical Therapy 3, 810 5, 680 49 .1 Registered Nurses 140,170 207,280 47 . 9 45 occupation in 1985 and the number of personnel who will be needed in 1995 to fill the projected occupational vacancies. As used in the report cited above, demand (job opportunities) is an estimate of job openings resulting only from the creation of new jobs (expansion demand) or from the need to replace workers leaving the labor force (separation demand). It must be noted, however, that these numbers do not accurately depict the employment picture in California for mental health service workers and mental health professionals. Their numbers are integrated with the employment figures for health service workers and miscellaneous categories rather than delineated separately. Mental health professionals are clearly involved in the delivery of long-term care services to the elderly population and must, in the future, not be overlooked when projecting employment within the various health service areas. 46 CHAPTER 5 THE SUBJECTS OF THIS RESEARCH, THEIR SERVICES AND THE SERVICE ENVIRONMENT This chapter presents recent developments in the supply and distribution of physicians, nurses, and allied health professionals, including a description of the kinds of services delivered and the service environment. The most current data available are used to place the recent developments in the health care delivery system in context with historical trends. References to national issues, trends, and data are made when applicable to California particularly. Physician Supply Nationally since 1970 the number of physicians has grown faster than the general population, shifting the focus of concern from adequacy of supply to balances in distribution. The environment for the delivery of services has changed appreciably and health care costs have escalated, drawing attention to 47 the physicians' contribution to those costs. There have been changes in characteristics of the practice setting, including financing and utilization of services, productivity and access to care. The increasing supply and distribution of physicians has impacted the delivery of long-term care services described earlier. The supply of physicians continued to grow at a rate of 3.4% per year between 1980 and 1985, about the same pace as observed in the 197 0s. Data from the American Medical Association showed that as of December 31, 1985, there were 522,716 total physicians in the U.S., over half of whom were board-certified. The physician to population ratio increased from 202 to 228 per 100,000 between 1980 and 1985 (National Institute on Aging, 1987). The number of active physicians is expected to grow about 2% a year between 1985 and 2020. This rate is slightly greater than the anticipated increase in the population 65 years and older. The number of active medical doctors and doctors of osteopath is expected to increase to more than 700,000 in 2000 (National Institute of Health, 1988), The increase in the number of physicians in 2020 is projected to be 48 approximately 850,000, which is slightly less than the comparable growth rate of the elderly population during that same period. Data on the supply of health professionals in California is derived principally from the state's licensing boards. Separate licensing boards are empowered in California to regulate the practice of medicine, dentistry, optometry, pharmacy and nursing. The Office of Statewide Health Planning and Development in California (OSHPD) receives reports from each of these boards in order to facilitate the preparation of a legislatively mandated report, the Health Manpower Plan, focusing on the trends in the supply and distribution of health manpower, facilities, services, and capital. The first Health Manpower Plan in 197 6 established standards for determining the adequacy of the present and future supplies of health professionals. The Health Manpower Plan made findings about the adequacy of supply for each profession and developed ratios of health professionals to population to express the standards of adequacy for each health profession. The standards are expressed as ratios of the number of health professionals needed per 100,000 49 persons residing in the same area in determining the supply of health personnel appropriate to the population. A range was established by which numbers of health professionals were compared to population figures to allow some flexibility due to differences in geography, economics and demography. Other manpower reporting agencies rely on these ratios (and ranges) in determining adequacy of the supply of health professionals. The OSHPD (1988) reported that the statewide ratio of physicians per 100,000 persons is 240. The West Bay, East Bay, Santa Clara, Los Angeles and Orange health service areas have ratios greater than the statewide ratio. The West Bay area which includes Marin, San Francisco and San Mateo counties has a ratio of physicians per population almost twice that of the state. The Northern California, North San Joaquin and Central Valley health service areas have ratios less than two-thirds the statewide ratio (Table 8) . The state's medical schools and postgraduate medical training programs are predominantly located in the health services areas which have more physicians to population. The areas of the state with the fewest 50 Table 8. Physicians Per 100,000 Persons Statewide and by Health Service Areas Statewide 240 Northern California 159 Golden Empire 210 North Bay 194 West Bay 466 East Bay 247 North San Joaquin 149 Santa Clara 250 Midcoast 177 Central Valley 147 S.Barbara-Ventura 204 Los Angeles 265 Inland Counties 172 Orange 250 San Diego-Imperial 233 Source: Board of Medical Quality Assurance Office of Statewide Health Planning and Development, 1988, pp..8-10. 51 physicians per 100,000 persons do not have any medical schools. In these areas there are several teaching hospitals which have residency training programs and serve as clinical training sites for medical students. Specialty The practice of medicine has become very specialized. Movement towards specialization begins in medical school and continues through postgraduate training and practice. The vast majority of physicians now enter residency training in a particular specialty of medicine. A system for categorizing specialties was adopted by the American Medical Association in 1963. The most recent data available to the Office of Statewide Health Planning and Development from the American Medical Association on the distribution of physicians by specialty in California is for December 31, 1983. Primary care physicians are defined to include family practice, general practice, internal medicine, pediatrics and obstetrics-gynecology. The standards of adequacy developed in the first Health Manpower Plan for primary care physicians range from a high of 117 primary care physicians per 100,000 persons to a 52 low of 83 primary care physicians per 100,000 persons. The mid-point ratio is 100 primary care physicians per 100,000 persons. The 1983 statewide ratio is 99 primary care physicians per 100,000 persons. Although the statewide supply of primary care physicians is adequate there are large variations in the number of primary care physicians per population among the counties of the state. Of the 58 counties in the state 36 have fewer primary care physicians per population than the low standard of adequacy. Nationally, the rankings of specialties has remained stable since 1980. In both 1980 and 1985, internal medicine had the largest number of practitioners, followed by general/family practice, general surgery, pediatrics, psychiatry, obstetrics gynecology, anesthesiology, orthopedic surgery and pathology. There has been a continuing decline in the percentage of general/family practitioners among all medical doctors, most recently falling from a share of 12.5% in 1981 to 12.1% in 1985. This decline, coupled with the growth in the share of internal medicine and pediatrics, has produced a relatively constant percentage of all physicians across the three primary care specialties of family practice, general internal 53 medicine and general pediatrics, at 30.9% in 1985. General and family practice declined notably during the 1970s and continues to show a downward trend, although more slowly. By contrast, the share of internal medicine increased significantly during the 197 0s and has continued at a moderated pace during the 1980s. The share of primary care medical doctors has remained relatively constant, changing from 30.7% of the total in 1981 to 30.9% in 1985. Physicians are increasingly becoming employed rather than self-employed as alternative health delivery systems have taken on greater importance. The percentage of employed non-federal physicians in patient care grew from 23.4% to 25.7% form 1983-1985. There is evidence that young physicians may be preferentially selecting corporate or group practice for more stable income and predictable hours (U.S. Department of Health and Human Services, 1988). In 1985, 47.0% of young physicians (under 36 years of age) were employees, compared to 41.7% in 1983. Interestingly, approximately 23.5% of male physicians are employed while 45.4 of female physicians are employed physicians. This preference for employed status may, however, be only a transitional state for 54 many younger physicians (U.S. Department of Health and Human Services, 1988) . Productivity According to the most recently published data, the mean number of visits per week per physician in 1985 was 118.4, virtually unchanged from the previous year, but a decline of 15% from 1975. The decline relates to changes that have occurred in practice settings of visits for patients. In the one year period 1984 to 1985, the proportion of visits in the hospitals declined, while those serving outpatients either decreased or were unchanged (American Medical Association, 1986). Older adults are likely to be utilizing considerably more ambulatory care from physicians in the future. Between 1981 and 1985 the number of ambulatory visits to physicians by persons 65 and older increased about 20% (about 4% a year). Between 1978 and 1985, the total number of visits increased about 40%, or more than 5% a year. If this 5% increase continues through the turn of the century, the number of ambulatory visits would increase by 75%. 55 Persons over the age of 65 in 1985 accounted for more than 20% of all ambulatory care visits to physicians. Many of the medical specialties have reported increases in the number of visits by older adults since 1981. If these patterns continue, almost all medical specialties will be devoting substantial shares of their efforts to providing services to older adults. Health Maintenance Organizations Health maintenance organizations’ (HMOs) enrollment has increased substantially each year since 1970. For the five year periods since 1970, the average annual growth rates ranged from 14.7%, to 9.9%, and 15.1%. Currently it is reported by the Office of Health Maintenance Organizations that HMOs serve approximately 20 million people, more than triple the enrollment a decade ago. A study by Arthur D. Little, Inc., (cited in U.S. Department of Health and Human Services, 1988, pp. 3-10 to 3-11) predicts that up to 160 million Americans will subscribe to HMOs by the early 1990s and that by 1995, 60% of the U.S. population will be enrolled in HMOs. 56 Preferred Provider Organizations Preferred provider organizations (PPOs) continue to be a major developing alternative in health delivery and financing with implications for Medicare and Medicaid. In 1985, the American Association of Preferred Provider Organizations reported 264 operational PPOs with 1.3 million Americans in a health insurance plan with the option of using a PPO. A more recent study cites the number of persons in PPO-type plans increasing to 2.5 million. Even though PPOs have drawn considerable attention as a health care cost-containment strategy, questions remain concerning quality assurance, utilization controls, reimbursement methods, provider selection, consumer satisfaction and long-term cost benefits. Supply of Nurses Nursing practice and the settings in which it is carried out are undergoing change as the population of the country and the delivery system are requiring different care emphases and different practice modes. While it is beyond the scope of this paper to present an in-depth analysis of these changes, it is important to present a summary of these changes and have an 57 understanding of the character and location of the nursing work force. Nursing personnel consists of three types of occupational groups: registered nurses, licensed practical/vocational nurses, and nursing aides. Formal educational programs preparing individuals for examination for licensure exist for the first two of these groups. Although some formal preparation may exist for segments of the nursing aide group, for the most part, they are on-the-job trained and are not licensed personnel. Registered Nurses In November 1984 the registered nurse population in the United States consisted of an estimated 1,887,697 individuals with current licenses to practice located in the United States (Moses, 1986). The national sample survey, conducted by Westat, Inc. (cited in U.S. Department of Health and Human Services, 1988, p. 10-11) for the Division of Nursing, Bureau of Health Professions, obtained the latest comprehensive data on the registered nurse population in the country. 58 The report issued in 1984 is the third in a series of sample surveys made of registered nurses. Among the 1.9 million registered nurses in the population in November 1984, 3%, or an estimated 57,200, were men. The number of men in the population has more than doubled since 1977. An estimated 155,390, or about 8%, of the 1.9 million registered nurses were from racial/ethnic minority backgrounds. While the proportion of nurses with minority backgrounds among the total population showed only slight change since 1980, the number of such nurses increased 30%. Since 1977, the number increased about 78%. The median age of the registered nurse population in November 1984 was 39.0, not much different than the median of 38.4 found in the November 1980 study. About 38% of the 1984 population had completed their basic nursing education in the 10- year period beginning in 1975 and almost a third had been graduated within the previous 15 years. An estimated 1,485,725 of the 1.9 million registered nurse population in November 1984 were employed in registered nurse positions in nursing. Since early 1977, the number employed has increased about 50%. Between 1980 and 1984, the increase was 59 16.7%. Thus, the relative increase in the number employed during the 1977-1984 time frame was greater than the relative increase in the total Registered Nurse (RN) population. According to the study of the nurse population in November 1984 (cited in U.S. Department of Health and Human Resources, 1988, p. 10- 11 to 10-12), 78.7% of the registered nurse population was employed in nursing, as compared with about 7 0% in 1977, and an estimated 77% in 1980. The ratio of nurses to the population is used to examine the distribution pattern of nurses in various areas of the country because of the large differences in population sizes. Although these ratios are used for comparison purposes, they are not a true measure of the nursing services provided to the population. The concentration of nurses in a particular area is dependent in part on the concentration of facilities or organized service settings in which they can practice. Therefore, an appropriate evaluation of differences in services provided should take into account available facilities as well as nurses. As can be seen in Table 9, the distribution of registered nurses in California tends to be more 60 Table 9. Registered Nurses Per 100,000 Persons Statewide and by Health Services Areas (1985) (Ratio of Registered Nurses per 100,000 Persons) Statewide 671 Northern California 592 Golden Empire 630 North Bay 837 West Bay 975 East Bay 782 North San Joaquin 521 Santa Clara 715 Midcoast 602 Central Valley 480 S. Barbara-Ventura 678 Los Angeles 633 Inland Counties 618 Orange 751 San Diego-Imperial 658 Source: Board of Registered Nurses Office of Statewide Health Planning and Development, 1988, excerpted from pp. 8-10. 61 heavily concentrated in the Bay Area and in Orange county similar to the figures for physicians. There are 45% more registered nurses per population in the West Bay health services area than there are statewide. On the other hand, there are far fewer registered nurses per population in the Central Valley and North San Joaquin areas (again similar to the distribution of physicians). The effects of the types of area health facilities on the concentration and distribution of employed registered nurses can be seen from some examples of employment setting distributions of nurses in different areas of the country. Although a sizeable majority of registered nurses were employed in hospitals throughout the country in all areas, because of the concentration of the largest, more complex hospitals in metropolitan areas, 69% of the metropolitan area-employed registered nurses were working in hospital settings compared to about 62% of those employed in nonmetropolitan areas. On the other hand, 10% of the nonmetropolitan area nurses were working in nursing homes compared to 7% of the metropolitan area nurses. 62 The proportion of the total registered nurse population receiving initial nursing education in a diploma program has declined considerably since 1977. In that year, it was estimated that 75% of the 1.4 million registered nurse population at that time came from diploma programs. By November 1984, only 54% of the 1.9 million registered nurse population came from diploma programs. An increasing proportion of all registered nurses are being prepared in associate degree programs (24.7% of the total number of registered nurses). The education of registered nurses in the basic program preparing them for licensure constitutes the foundation for their practice. Once licensed, many nurses obtain additional education, either in formal academic programs providing preparation for advanced clinical, administrative, or teaching positions, or in continuing education programs providing preparation for specialized skills or new techniques. Service Environments Hospitals continue to be the leading employer of nursing personnel in the country when compared to all other health care settings. A total of 1,573,465 63 nursing personnel were employed in hospitals in 1985. These individuals represented 38% of the 4.1 million total personnel employed in hospitals. Registered nurses were 60% of the nursing personnel employed in hospitals, licensed practical/vocational nurses were 16%, and nursing aides, orderlies, attendants, and others were 24%. A survey of 2,300 hospitals was carried out by the American Organization of Nurse Executives of the American Hospital Association in December 1986 (cited in U.S. Department of Health and Human Resources, 1988, p. 10-23) to examine the supply of nursing per sonnel in hospitals. The results, based on a 44% response rate, show that approximately 13.6% of regis tered nurse full-time equivalent positions were vacant. The study also showed that 17.6% of the reporting hospitals had no vacancies. Larger hospi tals reported the highest percentage of vacancies (American Hospital Association, 1987). The number of registered nurses employed in community hospitals rose by more than 100,000 from 1981 to 1985 to a total of 851,827, a 13% increase. In contrast, the number of licensed practical nurses declined by 19% to 221,987, and ancillary nursing personnel declined by 16% to 64 272,827. In addition, the number of community hospitals full-time equivalent positions per 100 adjusted average daily census for registered nurses in 1985 was 87, considerably higher than the 73 full-time equivalent positions for registered nurses in 1981. The ratio for licensed practical nurses declined from 27 in 1981 to 23 in 1985, and from 32 to 29% for ancillary personnel. Nursing homes and related facilities continue to grow in numbers and continue to be the second largest employer of nursing personnel. In 1985, the 19,100 facilities had 1,624,200 beds with 1,491,400 residents, representing a 92-percent occupancy rate. Proprietary homes accounted for 75% of all homes in 1985 and 69% of the available beds. More than 75% of all nursing homes were certified as skilled nursing facilities by Medicare and Medicaid, as intermediate care facilities by Medicaid, or as both. Nursing care is the principal service required by residents in nursing homes. Of the estimated 704,300 full-time equivalent nursing personnel working in these facilities, 12% are registered nurses, 17% are licensed practical nurses, and 71% are nursing aides and orderlies. These employees accounted for 61% of the total 1.2 million full-time equivalent hours in 65 nursing homes. This averages to about 43 full-time equivalents for each 100 beds. Nursing aides, who work under the supervision of licensed nurses, were by far the largest group, accounting for over 40% of the total full-time equivalents. There is considerable variation in the distribution of personnel along regional and state lines. Individual states have set minimum requirements for registered nurse staffing in nursing homes. According to the Research Triangle Institute in a study for the Division of Nursing (cited in U.S. Department of Health and Human Resources, 1988, p. 10- 28), 6% of the 19,000 homes in the study are required to have an RN for all shifts; 12% must have a full time RN and the director of nursing must be an RN; 14% must have one full-time RN; 17% must have an RN director of nursing only; and 52% are under no requirement for full-time RN coverage. In the 1985 National Nursing Home Survey (cited in U.S. Department of Health and Human Resources, 1988, p. 10-28), a sample of registered nurse employees in the nursing homes were asked about work characteristics. Preliminary analysis of the data showed that 4 out of 10 registered nurses worked in 66 nursing homes in which they were employed for 5 years or more. Three-fourths of the RNs employed full time earned less than $400 per week. Data also indicated that 21% of the registered nurses were in staff nurse positions and that over half of the registered nurses were employed in some form of supervisory capacity that included direct care responsibility such as charge nurse, head nurse or supervisor. In addition, 17% held the position of director or assistant director of nursing. The resident population of nursing homes includes representatives of all age groups. Of the 1.5 million nursing home residents, 88% were 65 years or over. (Only 5% of the elderly in the U.S. reside in nursing homes.) This group was comprised of 45% 85 and over, 39% age 74 to 85 and 16% aged 65 to 74. Four out of 10 of all nursing home residents were 85 and over. Thus, while only 5% of all elderly persons were in nursing homes, 22% of those over 85 were in such residences. The National Nursing Home Surveys in 1977 and 1985 have also shown that elderly residents were more dependent in performing the activities of daily living in 1985 than in 1977. Sixty-three percent of the 67 elderly residents were estimated to be disoriented or memory impaired to such an extent that it affect their performance of activities of daily living nearly every day in the 1985 study (Hing, 1987). Allied Health Professionals Allied health has been defined and redefined by the various health professions. The current legislative definition identifies an allied health professional as an individual who : 1. Has achieved a certificate, an associate's degree, a bachelor's degree, a master's degree, a doctoral degree, or post baccalaureate training, in a science relating to health care. 2. Shares in the responsibility for the delivery of health care services or related services. 3. Has not received a doctor of medicine, doctor of osteopathy, or other doctor or bachelor of science degree, or a graduate degree in health administration, or a degree equivalent to one of these. Allied health personnel work in numerous settings including: hospitals, ambulatory care facilities, health maintenance organizations, extended care facilities, nursing homes, private practitioners' 68 offices, psychiatrie facilities, independent laboratories, industrial clinics, school systems and a variety of other sites. The predominant setting of employment of allied health workers remains the hospital. In 1985 approximately 12% of hospital full time equivalent workforce consisted of allied health workers. Allied health personnel receive their basic educational preparation in a wide range of institutions. These include junior and community colleges, proprietary programs, four year degree granting colleges and universities, and hospital based programs. Allied health continues to be one of the fastest- growing segments of the general labor market. This growth, combined with the ongoing redefinition of roles and functions of various allied health occupations, has produced a continual discussion and refinement of policies and standards for training and practice. Most recently a number of trends in the health industry have affected allied health occupations. Emphasis on health care cost containment, change in reimbursement policies, entrepreneurial initiatives in 69 service delivery, increases in the numbers of physicians, and increased need for care and rehabilitation of the elderly have all had an impact. The most important problems facing the allied health occupations is the difficulty in attracting students, especially those likely to pursue advanced degrees and become qualified in teaching, research and management; increases in educational costs; and the opening of attractive career opportunities for women in other fields are having their effects on career choices and on the number of applicants to allied health programs. The shifting of interest away from careers perceived as offering limited economic opportunities, combined with a reduction in numbers of students, affects recruitment for allied health fields. With so many factors changing simultaneously, the need for a study of these changes and their consequences on the future of allied health professions became evident. Congress has called for a special study of these professions in the Health Professions Training Assistance Act of 1985 (Health Professions Training Assistance Act of 1985). The Act directed the Secretary to arrange with the National Academy of Sciences for a study that would assess the 70 role of allied health personnel in health care delivery; identify projected needs, availability, and requirements of various types of health care delivery systems; investigate current practices of licensure, credentialing, and accreditation; assess changes in programs and curricula for the education of allied health personnel; and assess the role of the federal, state and local governments, educational institutions, and health care facilities in meeting those needs and requirements. Although the study has limitations, it is expected to assess trends and policy issues among these professions within the larger context of problems of delivering effective health services at reasonable cost. Allied health professions which will be considered here include physical therapists/ occupational therapists and speech-language-hearing personnel. The occupations were selected based on the fact that they interact on a regular basis with the older populations. Data collection on the selected professions proved to be difficult. Professional organizations have data but it is difficult to find, and at best, is outdated. 71 Government agencies, under congressional mandate, are investigating the allied health professions as discussed above, but data used in these studies is old and somewhat unreliable. For these reasons, the information presented here is on a national level, and at best, data is somewhat sketchy. Reliable data on California allied health professionals was scarce. Information is presented on types of services provided, delivery setting and educational preparation. Physical Therapist Physical therapy personnel provide diagnostic, rehabilitative and preventive services with the objectives of restoration of function and prevention of disability arising from disease, trauma, loss of extremity, or lack of use of a body part (U.S. Department of Health and Human Services, 1988). Physical therapy is used in the treatment of nerve or muscular injuries, amputations, fractures, arthritis, burns, congenital anomalies, and neurological disorders. Various therapeutic procedures are used including specific exercise, massage, the application 72 of hot or cold, electrical stimulation, and the application of assistive devices. Increased health services to the growing elderly population will put additional pressure on the existing workforce. Already, the elderly consume 25% of physical therapy services. On a national level, it is estimated that 8,800 (full-time equivalents) physical therapy personnel are involved in treating individuals 65 years of age and older. The increase in home health care for this population, where productivity is reduced (as measured by the number of patients seen per day), will also increase the demand. Over 40% of therapists work in hospitals, 30% in nursing homes, and 15% work independently or in group practice. Others are employed in rehabilitation facilities, schools, home health agencies, and long term care facilities. About 63,000 physical therapists are currently active. Basic occupational preparation for licensed physical therapists is obtained in accredited bachelor's or master's degree programs. 73 Occupational Therapy Occupational therapy provides for the rehabilitation of persons who are physically, psychologically, or developmentally disabled. When functions cannot be fully restored more directly and efficiently by other means, occupational therapy seeks to adapt the client's immediate environment to his or her limitations. The therapist's objective is to return the patient to or secure a new occupation, to be independent in activities of daily living, or to improve mental state or self-esteem. The occupational therapist evaluates the patient or client with reference to physical and mental status, degree of disability, potential for improvement, and vocational and activity demands that need to be met. A plan is then developed and a program is implemented. Currently there are 32,400 registered occupational therapists (1986 data from the American Occupational Therapy Association). This is an increase from 28,850 in 1984 and 7,000 in 1960. Occupational therapists work in a variety of settings. Many are in hospitals, the primary place of employment. Many work in school systems, rehabilitation facilities, intermediate and long-term 74 care facilities and home health agencies. A few are employed in mental health hospitals and clinics. A growing number are in private practice. Significantly, nearly 20% of occupational therapists are now fully or partly self-employed, and if not in private practice, have contracts for their services. Occupational therapists provide substantial services to the elderly population in hospitals and long-term care facilities. They are also expanding their services in other settings such as outpatient I facilities, adult day care centers and home health care programs. It is estimated that in 1982 about 17% of occupational therapy work was with older persons. Another study shows that while only 10% of nursing home residents receive occupational therapy, about 35% of the residents would benefit from it (Office of Nursing Home Affairs, 1975, p. 12) . Education of occupational therapists is provided by programs accredited through the Committee on Allied Health Education and Accreditation. Basic occupational preparation is offered in programs granting the bachelor's degree, a post-baccalaureate certificate, or a master's degree. 75 Speech-Language-Hearing Personnel Speech-language pathologists and audiologists provide specialized assistance to persons with problems in communication, dealing with disorders in the production, reception and perception of speech. In clinical practice, these therapists identify individuals who have such disorders and determine the etiology, history and severity of the conditions through interviews and tests. They plan and initiate or facilitate treatment through remedial procedures, counseling, and guidance. Speech-language pathologists diagnose and treat individuals who suffer from oral language disorders. Audiologists identify and measure hearing loss, issue hearing devices, and work to rehabilitate those with hearing impairments. Teaching is the major nonclinical function of both specialists. Personnel may specialize exclusively in speech- language pathology or audiology, but many are certified in both and have a mixed practice. Educational preparation is not separate. According to data provided by the American Speech-Language-Hearing Association (1986), the number of employed personnel increased from 52,000 in 1984 to about 56,000 in 1986, 76 the great majority being speech pathologists. This is more than double the work force in 1970. Employment information shows that 45% work in schools, 26% in health settings, 10% in private offices, 8% in colleges and universities, and 10% elsewhere. The growing elderly population is creating additional need for speech and hearing services. Sensory deprivation is an important contributor to the disassociation and mental impairment that brings about institutionalization of the elderly. Basic occupational preparation is at the master's degree level. In 1986, there were 237 programs in colleges and universities granting the master's degree, with 9,502 students enrolled and 3,784 graduates annually. There is no specialized accreditation for undergraduate preparation in speech and hearing. 77 CHAPTER 6 PROJECTIONS OF LONG-TERM CARE PERSONNEL Methods and Calculations This chapter presents the methods and calcula tions used to project the number of physicians, nurses, and allied health professionals who will be needed by the year 2020 to provide long-term care services to the elderly population in California. A discussion of the results of the projected numbers of health care personnel and the implications for long term care delivery in California is followed by recommendations for meeting the needs for the appropriate number of health care personnel. In the previous chapters an effort was made to document trends in the numbers of long-term care professionals in California who provide services for the elderly population, the types of services provided and the environment in which those services are rendered based on the demand generated by the changing demographics and health and functional status of the aging population in California. Using the current number of physicians, nurses and allied health personnel and the amount of time spent by these health care personnel in serving the elderly, an estimate can be made of the number of personnel who will be needed to serve the growing long-term care population in the year 2020. Projections of the number of physicians and nurses needed to serve the elderly will then be compared to the Standards of Adequacy of health care personnel developed by the Office of Statewide Health Planning and Development described in Chapter 5. The Long-Term Care Population The total long-term care population is projected to more than double from 956,000 in 1980 to 2.2 million by 2020, representing 5.6% of California's total population. The 65 and older projected long term care population is expected to almost triple between 1980 and 2020, from 522,000 to 1,409,000. The growth in the total long-term care population shown in Table 10 is more closely related to the growth in the 65+ population than growth in the total long-term care population. Almost half of the total long-term care population in 1980 was over age 65. By 2020, the long-term care population over age 65 will equal 63% Table 10. Projected Long-Term Care Population and Its Components Population (1000s) 79 1980 1990 2000 2020 Total Needing Long-Term Care All ages <65 65 + 956 435 522 1251 531 719 1586 672 914 2237 828 1409 Nursing Home Population All ages <65 65 + 125 17 108 167 20 147 217 26 194 288 27 262 Population Needing Home Health or Meals All ages <65 65 + 116 79 37 147 96 51 182 118 64 254 144 110 Population Needing Help w/IADL All ages <65 65 + 427 227 245 617 281 337 778 361 417 1098 451 647 Population Needing Help in ADL All ages <65 65 + 243 111 132 319 135 184 408 169 239 596 206 390 Source: Crimmins, 1990, p. g 80 of the total long-term care population (Rice and LaPlante, 1988.) The estimates of the long-term care population shown in Table 10 are estimates of the population in need of some form of long-term care. Some would be expected to receive formal services, some would receive help informally, and some might be in need but not receive help. The components of the long-term care population who are clearly receiving some kind of assistance include the nursing home population. The nursing home population is primarily an old age population. In 2020, 19% of the 65 and older long term care population, translating to 262,000 persons, will reside in nursing homes. Of the population in need of home health care or meals in 2020, 43% will be over age 65, which represents only 8% of the total population in need of long-term care. Persons needing assistance in Instrumental Activities of Daily Living (lADSs) number 647,000 or 49% of the total long-term care population. The next largest is the group needing assistance in Activities of Daily Living (ADLs), 390, 000 (27%) . Over 100,000 persons need home health care or meal service. National rates for each of these was applied to the projected long-term care population estimates for the state of California. (There are limitations, however, in applying national rates to California's population including not allowing for the age, racial and ethnic diversity of California; the inability to control for socio-demographic factors; insufficient public program data; and the impact of AIDS on the long-term care system (California Health and Welfare Agency, 1988).) The long-term care population also consists of the non-institutionalized elderly who need the help of another person in the performance of either personal care needs such as bathing, dressing, getting around the house (ADLs) or in routine household management needs such as chores, shopping, transportation (lADLs). These people report themselves to be in need of help in performing one of these activities (Crimmins, 1990). They may be receiving help from a family member or from formal service providers or possibly they are not receiving any assistance at all. By 2020, these three subgroups will total 1,037,000 or about 74% of the long-term care population over 65 years of age, an increase of almost 30% from the 1990s and an increase of 20% during the first decade of the next century. These groups represent the population 82 that needs some support in order to maintain a community existence. Even though most of the long-term care is provided by family members, a number of researchers have warned that social, demographic and economic changes over the next 20 to 30 years may reduce the ability of family members to provide such care in the future (Crimmins, 1990). Since three-quarters of those requiring assistance use family members (nonprofessional help) and one-quarter receive some assistance from paid help (professional assistance), the demand for professional care most certainly would increase and only slight changes in the availability of health care professionals would add tremendous burden to those in need. The number of 65+ who will need long-term care is calculated by adding the number of nursing home residents to the percentage of noninstitutionalized persons who receive assistance from health care professionals (refer to Table 10 for categorical figures). The results of that calculation will indicate the number of persons needing professional long-term services by 2020. Table 11 presents the calculation of the long term care population in need of professional 83 Table 11. Calculation of Long-Term Care Population 1980 108,000 + (414,000 X .25) = 211,500 2020 262,000 + (1,147,000 X .25) = 548,750 84 assistance for 1980 and 2020 is shown. In 1980, 108,000 individuals resided in nursing homes. The remaining noninstitutionalized population, which required 25% of their services from professionals, is added to the institutionalized elderly. The resulting figure of 211,500 is the population which will be served by health care professionals. The calculation for 2020 indicates a population of 548,750 individuals in need of services provided by health care professionals. For purposes of further discussions in this paper, this defined population will be called the long-term care (LTC) population. Health Care Personnel Serving the Elderly The growing long-term care population over age 65 will put large demands on physicians, nurses, and allied health personnel by the year 2020. Nationally, the supply of physicians is expected to grow about 2% a year between 1985 and 2000. This rate is slightly greater than the anticipated increase in the 65+ population. Older adults are likely to be utilizing considerably more ambulatory care from physicians. Between 1981 and 1985 the total number of ambulatory visits to physicians by persons 65 years of age and 85 older increased about 20%, or more than 4% per year (National Institute on Aging, 1987), In 1985 the elderly accounted for more than 20% of all ambulatory care visits to physicians, with about half made to physicians in internal medicine and general or family practice. General and family physicians provided about 30% of these services. However, in recent years the proportion of all ambulatory care visits by these types of practitioners has declined while the share provided by other medical specialists has increased (National Institute on Aging, 1987). The proportions of the practices of different medical specialties, such as cardiologists, ophthalmologists, urologists and internists, devoted to serving the older population vary, but generally account for large portions of the practices. If the pattern of increasing services continues, almost all medical specialties will be devoting substantial shares of their efforts to providing services to the older population by 2020. Assuming that the percentage of services to the older population by general and family physicians remains at 30%, and the proportions of the practices of medical specialties increases to that percentage, the overall amount of 86 time devoted to the practice of the elderly will be 30% (National Institute on Aging, 1987). Nurses provide services to elderly persons in many settings, including their homes, doctors' offices, community health clinics, nursing homes, and hospitals. In most situations, nursing personnel are the largest segment of formal caregivers. In 1984 it was estimated that 33% of the efforts of the full-time equivalent (FTE) registered nurse workforce was devoted to the care of persons 65 and older. National studies utilizing the historical trend-based model, estimate that in the future about 35% of the services provided by FTE registered nurses would be needed to meet the demand of persons 65 years of age and older in 2000. Using a criteria trend- based model, it was estimated that future services to the elderly would involve about 46% of the efforts of registered nurses (National Institute on Aging, 1987) . For purposes of this paper, the historical trend-based model, which predicts a 35% share of services, will be used in calculating the number of registered nurses needed to serve the LTC population. The primary allied health professionals actively involved in rehabilitation services include, among others, physical therapists, occupational therapists. 87 and speech-hearing-language therapists. Rehabilitation approaches are at the heart of geriatric health care. Physical therapists attempt to restore and maintain the well-being of older adults through physical activity. Physical therapists spend about 25% of their efforts in serving older persons (National Institute on Aging, 1987). Nationally, about 8, 800 FTE physical therapists spend about 40% of these efforts in hospitals, 30% in nursing homes, and the balance in other settings, such as rehabilitation centers, home health programs, and private practitioners’ offices. Occupational therapists have traditionally provided services to the elderly population in hospitals and long-term care institutions. Now they are broadening their service delivery to outpatient facilities, comprehensive rehabilitation centers, adult day care centers, and home health programs. In 1982 it was estimated that 17% of the work of occupational therapists was provided to the older population. This converts to the FTE of 5,000 occupational therapists for the 65 and older population. 88 Current information indicates that audiologists spend about one third of their time in providing services to the elderly while speech and language pathologists devote about 15% of their time to care of the elderly. It is expected that both groups of allied health personnel will experience increases of 40 to 50% for their services due to the increasing numbers of older persons. Projections of Long-Term Care Personnel in 2020 The section projects the number of physicians, nurses, and allied health personnel who will be needed by the year 2020 to provide long-term care services to the growing elderly population in California. Projections will then be compared to the Standards of Adequacy developed by the Office of Statewide Health Planning and Development in California (OSHPD) (1988) in 197 6 for the first Health Manpower Plan report. The standards are expressed as ratios of the number of health professionals needed per 100,000 within a high, low and mid-range (Table 12) . 89 Table 12. Standards of Adequacy for Selected Health Professionals (Numbers Required per 100,000 persons*) Mid-Range Professions High Ratio Low Ratio Ratio Physicians 211 152 181 Registered Nurses 469 319 394 *A11 ages Source: Office of Statewide Health Planning and Development in California (1988). 90 Physicians Persistent growth in the demand for services by the older population will perpetuate the imbalance between physician supply and the growth of the older age groups. The market for physician services should, however, become increasingly competitive as the presumed excess of supply over requirements continues. Table 12 illustrates the calculation of projections for the number of health care personnel who will be needed by the year 2020 in California to meet the needs of the LTC population. The basis for these calculations is a LTC population in 1985 of 211,500. The projected LTC population for 2020 is 548,750. Each of the health care personnel categories discussed in this section are specified as to number of professionals, percentage of services devoted to the care of the LTC population, the full-time equivalent (FTE) number of professionals, and the ratio of the LTC population to each health care professional (Table 13) . Table 13 illustrates the number of physicians who will be needed in 2020 to maintain services at current standards for a projected LTC population of 548,750 persons. This projection is based on the assumptions that percentage of service to the LTC population and & rH rH rH rH 1 — 1 1 — 1 rH rH 1 — 1 rH o 44 C M O en en M O k O 1 — 1 rH u C S J en L O L O c y > C T » O E h k P C M O 4 -) O 1 — 1 O 1 — 1 1 — 1 1 — 1 L O L O C S J C S J 91 O 4 4 Q . O LO o kO e n o o o lO LO < N O EH 4 4 lO kO kO rH e n o o o en <N lO O b O <N o k O LO o e n <y> OO <N O - H CM O csj c r » 1 —1 1 —1 C 4 - ) <N LO <N - H (S rH (0 -H a M o -H '— \ <0 o O <0 c o -H O T O T 0) <W O CM 0 ) < d o 4 -) r H <0 0 ) K M -l O (0 c : o -H 4 - ) O 0) o M C M to e u eu ü o -H C M > u O C D E h C O i-q 4 4 O O 4 -) o\o <0 E h o o co en o <n ko oo I —I oo oo L O vo w c: r O -H ü -H c y > O T > 1 C M lO O OO (N O to 0 ) to k â 'Ü 2 0 ) 4 -) tO -H tn LO LO LO LO LO LO e n e n CM CM 1 —1 1 —1 CM CM to r H fd c : o - H to to r H to (d CD C 4 4 o O o o O O o o O co - H M r ~ CN e n o CM CM o CM to CM 1 —1 kO 1 —1 o CM OO OK to CD 4 4 o ■kT MD KO CM lO CM 4 4 C MO 1 —1 O CD r H e n r H CM fd > C D - H 0 fd ( T C J W (0 4 4 e 0 ) to u g - H CD - H to (h to EH EH 4 4 eO 4 4 1 to to e n r H - H CD - H C r H (h Si CM o 0 <0 Eh t n fd 1 0 |JL| (4 C! u CD r H - H CD II II Si fd i4 Si EH C (d EH o W O CD EH EH 1 —I - H K CD 0 b LO o et) LO O 4 4 LO o 1 CT' lO co OO CM Ü OO CM eO OO CM Si (d OO CM e n o - H O (h <T> O o 0 CD o 1 —1 CM to 1 —1 CM 3 1 — 1 CM CD CT' 1 —1 CM C D >1 Ü CD C 4 4 Si ü a (d O CM O t o Si % 92 the ratio of physicians to individuals will remain the same. It is projected that this population will require the services of 175, 880 physicians in 2020, or a FTE of 52,765. This calculation is made using the ratio of 10.4 physicians for each person in the LTC population. This number would increase, of course, if a rise in the frequency of ambulatory visits occurred, or if physicians in medical specialties determined that the percentage of their practices devoted to the elderly had increased. The LTC population in California can foresee an increase in the ratio of physicians to persons, but faces the same inequities in the geographic distribution of physicians as the general population. Comparison of these calculations to the Standards of Adequacy in Table 13 indicates a higher ratio of physicians to population than the Health Manpower Plan reports. Nurses The burden of caring for the enormous elderly population will increase the need for nursing in acute care settings, nursing homes and community settings. The distribution of nurses among these settings will continue to change as relatively fewer nurses will 93 work in hospitals, and more nurses are needed to provide services to the elderly in nursing homes as well as in clinics and home health care agencies (Jacobson, 1990). Registered nurses are essential to both quality patient care and to the hospitals that employ them. As a result, California hospitals are concerned about the current shortage of nurses and the underlying causes of this shortage. Hospitals, traditional employers of approximately two-thirds of registered nurses, report major shortages in their registered nurse staffs. Both the licensed practical nurse and registered nurse supply projections are based on assumptions that relate to trends in the behavior patterns of the nurse population. These trends indirectly take into account the labor market in which they are practicing or were entering. In general this has been an expanding market characterized by periodic shortages, particularly of registered nurses. One result of this expanding labor market has been the ability of nurses to temporarily withdraw from the workforce and then return as their family or economic conditions warrant. In California, the number of registered nurses in 1985 was 140,170. Assuming that 35% of services 94 provided by registered nurses to the LTC population remains stable through the year 2020, the FTE RN population will total 127,616. These calculations are based on a ratio of 4.3 nurses for each LTC recipient. The California Employment Development Department (EDD) expects a total of 207,280 nurses by the year 1995. This represents a 47.9% increase from the 1985 figure of 140,170. Assuming a constant rate of increase in the numbers of nurses through 2020 and no increase in demand due to the aging and health status of the cohort groups through 202 0, the EDD estimates that there will be a need for 565,722 registered nurses by the year 2020. It must be noted that the number of licensed registered nurses does not necessarily relate across the board to "practicing" registered nurses. This figure is slightly lower than the high ratio standard of adequacy of 469, but is just slightly above the mid-range standard of adequacy figure of 392. The high ratio of registered nurse to 100,000 population, then, does not necessarily reflect a situation where hospitals and long-term care facilities will see an increase in the numbers of registered nurses available for employment. The trends which have been discussed 95 earlier will continue to affect the workforce participation patterns of registered nurses. By 2020 there will be a decline in the number of graduates (National Institute on Aging, 1987) and an increase in the age of new graduates, resulting in a declining rate of growth in the nurse population. There is also the possibility that there will be a declining number of registered nurses employed in 2020. Adopting the national employment rate of 72%, there will be 262,526 registered nurses employed in the California health care system. Allied Health Professionals Cutting costs, increasing productivity, downsizing and flexing staff have all led to one of the greatest challenges facing hospitals and other facilities today, that of considering alternative methods for delivery high quality care, with creative combinations of health personnel with various levels of skill. Available data indicate that there were approximately 1.33 million allied health personnel in the United States in 1986. There are indications of shortages of occupational therapists (OTs) and physical therapists (PTs) and concerns about impending 96 shortages of other allied health personnel. The physical therapy vacancy rate increased to 12.2% statewide. This rate is nearly double in rural hospitals. This suggests a continuing problem of recruitment and retention of PTs. Allied health schools are encountering increasing difficulties in recruiting qualified faculty, researchers and students. Currently there are over 6,000 PTs active in California. A comparison of the calculations in Table 13 which projects a supply of FTE PTs at 4,000 in 2020 with the EDD assumption that there will be a 54.5% increase in the number of FTE PTs by 2020 to 5,000, indicates a variation in projection. This calculation is based on current supply trends remaining constant and the health care labor market sustaining its need for PTs through 2020. Since Standards of Adequacy have not been established for PTs, there is no other opportunity for comparison of projections, making it difficult to make accurate determinations of sufficient numbers to meet the demands of the LTC population. It is apparent though from national studies, that due to the changing demographics and economics of the aging population, an increasing number of PTs will be 97 providing their services in home health programs, private practitioners’ offices and in nursing homes, perhaps reducing the number who practice in hospitals. The California Association of Hospitals and Health Systems (1987) , concluded, however, that turnover rates among hospital personnel were highest for PTs (25.5%), with the vacancy rate being also the largest at 12.2%, up from 11.8% in 1986 (Beghin, 1989). As mentioned earlier, there is about a 50% increase predicted by the EDD in the health service occupational category which includes PTs and OTs. With OTs currently devoting about 17% of their time to services to the elderly, by 2020, 5,820 OTs will be needed to meet the needs of the LTC population, an increase from the 1985 number of 2,220. The 2020 projection equals 990 FTE OTs. As a comparison, the EDD calculates that in 1995 there will be a need for 3,320 OTs, or the FTE of 565, an increase from 2,220 OTs in 1985. This dramatic increase considers an expected increase in the number of elderly persons and an increase in the number in need of services. In addition, the EDD calculates a need for a minimum of 7,000 OTs for 2020. This translates to the full-time equivalent of 1,400 OTs. Again, since there are no Standards of Adequacy 98 established for OTs in relationship to distribution throughout California, it is difficult to calculate more closely the number of OTs needed in the future. Assumptions based on past practice dominate projections of this kind. Estimates of future numbers of speech-hearing- language pathologists (SHLPs) needed to serve the long-term care population are based on reported current prevalence rates of speech-hearing-language impairment as well as recent patterns of practice. Currently, speech-hearing-language pathologists devote about 25% of their time to care for the elderly. Referring to Table 13, by 2020, it is estimated that 7,420 SHLPs will be needed, or the FTE of 1,855 SHLPs. This estimate could increase by as much as 40% if the proportion of time spent by SHLPs in treating the LTC population were to increase. Strong demand for allied health workers has created one of the fastest growing segments of the labor market. This growth, combined with the already discussed trends in health care delivery and the changing roles of health care professionals, has created a need for changes in education and practice. Assembly Bill No. 1327, which was passed October 1, 1989, requires that the OSHPD enter into contracts 99 with organizations to develop and implement innovative health care career recruitment projects directed toward the recruitment of individuals from groups which have been traditionally underrepresented in health care careers. 100 CHAPTER 7 SUMMARY AND RECOMMENDATIONS On the demand side, the number of persons age 65 and over will grow three times faster than the general population between 1985 and 2020. By 2020 there will be over 1.4 million elderly people potentially at-risk for long-term care services in California. The elderly typically suffer from more chronic diseases, resulting in more frequent visits to physicians. Additionally, the elderly are hospitalized twice as often and stay in the hospital for twice as long as the general population. It must also be remembered that the number of health care personnel is not the critical issue, as it appears from the calculations that adequate numbers of health care professionals will be available to meet the need of the LTC population. Equal distribution of trained personnel throughout the urban and rural counties of California in response to the health care needs of a demographically changing patient population surfaces as the important dimension of this study of 101 health care personnel needs in the long-term care industry. The assumed intensive use of medical services by a larger elderly population has brought into question the perceived "surplus" of physicians. Even when there is an adequate supply of health personnel, there has not been, and without some active intervention, is not likely to be an equitable and proper distribution of health services, especially in rural and inner-city areas. Although the statewide supply of primary physicians appears to be adequate, there are large variations in the number of primary care physicians per population among the counties of the state. Of the 58 counties in the state, 36 have fewer primary care physicians per population than the low standard of adequacy. Nine counties have less than 50 primary care physicians per 100,000 persons, a ratio that is half of the midpoint standard of adequacy. San Francisco County, currently with 244 primary care physicians per 100,000 persons, exceeds the high standard of adequacy. Concentration of efforts for educational preparation in medicine, nursing and allied health profession appears to be one of the beneficial 102 recommendations which can come from this study. Initially though, thorough and analytical research of current employment figures which can be projected to manpower forecasts would benefit practicing professionals, potential students, educational institutions, and health care recipients. Congressional and legislatively mandated reporting initiatives serve the system, but, unfortunately, the long time span between data gathering and publication does not permit effective response. Recommendations for further consideration and action include: 1. All physicians should receive education and training in geriatric medicine as part of their professional preparation in undergraduate and graduate programs and as part of continuing medical education activities. 2. Physicians in family practice, internal medicine, and psychiatry especially should receive increased educational experiences in geriatric medicine and should have available special competency training in geriatric medicine. 3. New entrants in the long-term care professions should be encouraged by state and local governments and private sector institutions to 103 practice in underserved rural and inner city areas. Programs and economic incentives which assist in placing these professionals in the underserved areas should be encouraged. 4. There should be an expansion of the number of fellowship programs to provide extended experiences essential for the long-term career development of academic leaders. 5. Special emphasis should be given to developing training opportunities in health science education as a strategy for improving access and quality health care. 6. More intensive research and assessment of health personnel requirements (numbers and types) across the diverse health care settings, particularly relevant to long-term care services. 7. Continuing national initiatives are required to ensure the appropriate preparation of nurses, especially special preparation in the many aspects of geriatric care. 8. Increased occupational options and economic incentives for licensed registered nurses to return to nursing positions would facilitate shortages in the nursing labor pool. 104 9. Future rehabilitation personnel should receive education and training in aging and geriatrics as part of their basic professional education programs providing competency-based skills. Continuing education activities should emphasize geriatric care. 10. Training programs should include specific skills which can be utilized most effectively in different settings for long-term care, such as hospitals, nursing homes, home care, rehabilitation centers, adult day care centers and outpatient settings. 11. Legislated economic incentives which lure medical personnel away from the urban, heavily populated areas to the rural counties appears to be a viable alternative for the future. 105 REFERENCES American Hospital Association. Hospital Statistics, 1986 Edition. Chicago, IL: 1986. American Hospital Association. Report of the 1986 Hospital Nursing Supply Survey. Chicago, IL: 1987. American Medical Association, Center for Health Policy Research (1986). 1985 Socioeconomic Characteristics of Medical Practice. Chicago, IL: American Medical Association. American Speech-Language Hearing Association. Unpublished Communication and Report to the National Institute on Aging on Meeting the Needs of the Communicatively-Impaired Aging I Population, September 198 6. Beghin, C. (1989) . State hospital labor costs higher than national rate. CAHHS Insight, 1^:8, 1-7. Birren, J.E. & Hirschfield, I.S. (1977). Final report : An analysis of professional education in the State of California for services to the retired and aged. Los Angeles : Andrus Gerontology Center, University of Southern California. Brody, S.J., Poulshock, W. & Masciocchi, C.F. (1978). The family caring unit : A major consideration in the long-term support system. The Gerontologist, 18, 556-561. California Council on Gerontology and Geriatrics (1981). Directory of gerontology and geriatrics education in California. Los Angeles : Andrus Gerontology Center, University of California. California Department of Finance (1986). Projected i total population of California counties 1980 - 2020. Report 86-P-3 revised. Sacramento, CA: j California Department of Finance. 106 California Department of Finance (1988) . Projected total population for California by race/ethnicity Report 88. Sacramento CA: ^ California Department of Finance. California Employment Development Department (1988). Projections of employment by industry and occupation 1985-1995. Sacramento, CA: California Employment Development Department. California Health and Welfare Agency (1988). A study of California's publicly funded long-term care | programs, 1988. Sacramento, CA: California i Health and Welfare Agency. Crimmins, E. (1987). Evidence on the compression of | morbidity. Gerontologies Perspecta, 45-49. | Crimmins, E. (1990). Implications of demographic and | epidemiological trends for California's long- ! term care policies. In P. S. Liebig and W. W. ; Lammers (Eds.), California Policy Choices for Long-Term Care (pp. 7-30) . Los Angeles : University of Southern California. 1 Eribes, R.A. and M. Bradley Rawls (1982) . The ; underutilization of nursing home facilities by Mexican-American elderly in the Southwest. In S.S. Tobin (Ed.), Current Gerontology : Long- Term Care (pp. 21-29). Washington, D.C.: Gerontological Society of America. Fries, J. (1981) Aging, natural health, and the compression of morbidity. New England Journal of Medicine, 303 :130-135. Gilford, R. (1989) . Extent and content of gerontology instruction within the California State University. Unpublished manuscript. Halloran, E. J., and Vermeersch, P. E. H. (1984). Variability in nursing staffing research. Journal of Nursing Administration, 3^:2, 45-55. Health Professions Training Assistance Act of 1985. P.L. 99-129, Section 223. Hing, E. Use of Nursing Homes by the Elderly : Preliminary Data From The 1985 NNHS. Advancedata. No. 135, May 14, 1987. 107 Institute on Medicine (1988) . Allied Health Services: Avoiding Crisis. Washington, D.C.: Institute on Medicine. Jacobson, J.M. (1990) . Nursing's response to the aging population. Home Healthcare Nurse, 8:3, 24-28. Kane, R.L., Solomon, D.H., Beck, J.C., Keeler, E. & Kane, R.A. (1981). Geriatrics in the United States : Manpower projections and training considerations. Santa Monica, CA: Rand. Kane, R.A. and Kane, R.L. (1987) . Long-Term Care : Principles, Programs, and Policies. New York: Springer Publishing Company. Moses, E.G. (1986) . The registered nurse population : Findings from the national sample survey of registered nurses, November 1984. Accession No. HRP 0906938. Springfield, VA: National Technical Information Service. National Institute on Aging (1987). Personnel for health needs of the elderly through the year 2 020. Washington, D.C.: Department of Health and Human Services. Office of Nursing Home Affairs. Long-Term Care facility improvement study. Introductory report. Department of Health Education and Welfare Report No. 05-76-50021, July 1975, p. 12. Office of Statewide Health Planning and Development in California (1988). Health Manpower Plan Report. Sacramento, CA: Office of Statewide Health Planning and Development. Rice, D. P. and LaPlante, M. P. (1988). California's elderly and the disabled: Changing demographies and their impact on long-term care. In California State and Welfare Agency, Report to the Legislature: A Study of California's Publicly Funded Long-Term Care Programs (pp. 49-81). 108 Schneider, E. L. and Guralnilc, J. (1987) The compression of morbidity: A dream which may come true, someday! Gerontologica Perspecta, 1, 8-14. Swanson, L. (1975). California higher education: Study for the aging. Torrance, CA: El Camino College. Tibbits, C., Friedsam, H., Kerschner, P., Maddox, G. & McClusky, H. (1980). Academic gerontology: Dilemmas of the 1980's. Ann Arbor, MI : University of Michigan Institute of Gerontology. The Commonwealth Fund Commission on Elderly People Living Alone (1987). Old, Alone and Poor; A Plan for Reducing Poverty Among Elderly People Living Alone. Baltimore, Md: The Commonwealth Fund. U.S. Department of Health and Human Services (1988). Sixth Report to the President and Congress on the Status of Health Personnel in the United States. DHHS Publication No. HRS-P-OD-88-1. Washington, D.C.: U.S. Government Printing Office.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Determining diabetes risk assessment in the elderly dental patient

PDF

Dental care of the aged patient: Implications of attitudes toward aging among dental students and dental hygiene students

PDF

The effectiveness of nutritional counseling in nutritional status and behavior in the elderly

PDF

A study of professionalism as it relates to the field of counselor education and gerontology

PDF

Nursing and gerontology: A study of professionalism

PDF

Public administration and gerontology: Toward professionalization?

PDF

Caregiver's financial decision making for an older adult with dementia

PDF

Educational status and trends in gerontology and medicine

PDF

Professionalism of adult education and gerontology in California: Interrelationships, training, and implications

PDF

Crisis and values at Angel Crest Manor: a case study in long-term care management

PDF

Institutionalized elderly: design, community, and management effects on life quality

PDF

Social work and gerontology: A study in professionalism

PDF

A comparative study of older and younger adults who have received job-specific classroom training to determine if there are significant differences as they relate to job placement

PDF

The use of cubic splines for estimating the prognostic effect of age at diagnosis in childhood acute lymphoblastic leukemia

PDF

Survey of registered nurses' attitudes toward elderly patients

PDF

Comparison of gene expression of SCG10 and Stathmin/p19 in aging rat brain: an in situ hybridization study

PDF

The reorganization of a junior high guidance program

PDF

A comparison of training methods in cavity preparations in primary teeth for preclinical dental students

PDF

Role accommodation: A study of optometrists in a prepaid medical group as perspective for viewing relations between two professiosl occupations

PDF

A course of study in orthopedic nursing

Asset Metadata

Creator Gentile, Kathleen McMahon (author)

Core Title Health care personnel needs for long-term care in California: Projections through the year 2020

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Degree Conferral Date 1990-08

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health and environmental sciences,OAI-PMH Harvest

Format application/pdf (imt)

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c37-412510

Unique identifier UC11657916

Identifier EP58965.pdf (filename),usctheses-c37-412510 (legacy record id)

Legacy Identifier EP58965.pdf

Dmrecord 412510

Document Type Thesis

Format application/pdf (imt)

Rights Gentile, Kathleen McMahon

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA