Keith Haglund

Dr. Donald Berwick, in his first major speech as administrator of the Centers for Medicare and Medicaid Services, said that he intends to change the U.S. health care system profoundly and do it by aggressively implementing the Affordable Care Act.

The job “I came here to do is helping to change health care in America to realize its full potential,” Dr. Berwick said during the speech to health insurance executives at the America's Health Insurance Plans' 2010 Medicare Conference.

Dr. Berwick asked the executives for their help in taking the Affordable Care Act beyond its current modest beginnings.

“We need your help. Our nation needs your help. You have and will have a profound influence on the direction our country will take in the crucial next few years,” Dr. Berwick said at the conference.

Calling the new act primarily “a question” rather than an answer, Dr. Berwick said it asks, “Will we redesign health care in America?”

In a more sobering note, the CMS chief also said that “those who wish only to preserve the status quo … cannot be effective partners, and we simply do not have time to pretend that they are. We do not have time for games anymore.”

Dr. Berwick, the former president and CEO of the Institute for Healthcare Improvement, said he would guide the CMS by the “triple aim” set of goals he established at IHI: better quality of care for patients through efficiency and “patient centeredness,” better health for populations through illness prevention, and lower costs by cutting waste and medical errors. “I intend to guide CMS toward the Triple Aim as our highest-level goal,” he said.

Dr. Berwick said that too much U.S. health care is now fragmented, and explained in personal terms what he meant.

“Too many of us know what fragmented, disorganized care looks like. You have to tell your name and address and story again and again to everyone you see. No one seems to talk to each other. Your record is forgotten or unavailable. One doctor prescribes a medicine that conflicts with a medicine another doctor prescribed,” he said.

President Obama appointed Dr. Berwick to lead CMS on July 7 during a congressional recess, bypassing what looked to be a lengthy fight in the Senate for the nominee's confirmation. On the day Dr. Berwick spoke at the AHIP conference, however, the president resubmitted his nomination for full appointment – which would require Senate hearings and a vote – for the second time.

In August, Senate Republicans refused to accept the president's first resubmitted nomination, citing the body's brief periods in session.

Dr. Donald Berwick, in his first major speech as administrator of the Centers for Medicare and Medicaid Services, said that he intends to change the U.S. health care system profoundly and do it by aggressively implementing the Affordable Care Act.

The job “I came here to do is helping to change health care in America to realize its full potential,” Dr. Berwick said during the speech to health insurance executives at the America's Health Insurance Plans' 2010 Medicare Conference.

Dr. Berwick asked the executives for their help in taking the Affordable Care Act beyond its current modest beginnings.

“We need your help. Our nation needs your help. You have and will have a profound influence on the direction our country will take in the crucial next few years,” Dr. Berwick said at the conference.

Calling the new act primarily “a question” rather than an answer, Dr. Berwick said it asks, “Will we redesign health care in America?”

In a more sobering note, the CMS chief also said that “those who wish only to preserve the status quo … cannot be effective partners, and we simply do not have time to pretend that they are. We do not have time for games anymore.”

Dr. Berwick, the former president and CEO of the Institute for Healthcare Improvement, said he would guide the CMS by the “triple aim” set of goals he established at IHI: better quality of care for patients through efficiency and “patient centeredness,” better health for populations through illness prevention, and lower costs by cutting waste and medical errors. “I intend to guide CMS toward the Triple Aim as our highest-level goal,” he said.

Dr. Berwick said that too much U.S. health care is now fragmented, and explained in personal terms what he meant.

“Too many of us know what fragmented, disorganized care looks like. You have to tell your name and address and story again and again to everyone you see. No one seems to talk to each other. Your record is forgotten or unavailable. One doctor prescribes a medicine that conflicts with a medicine another doctor prescribed,” he said.

President Obama appointed Dr. Berwick to lead CMS on July 7 during a congressional recess, bypassing what looked to be a lengthy fight in the Senate for the nominee's confirmation. On the day Dr. Berwick spoke at the AHIP conference, however, the president resubmitted his nomination for full appointment – which would require Senate hearings and a vote – for the second time.

In August, Senate Republicans refused to accept the president's first resubmitted nomination, citing the body's brief periods in session.

Dr. Donald Berwick, in his first major speech as administrator of the Centers for Medicare and Medicaid Services, said that he intends to change the U.S. health care system profoundly and do it by aggressively implementing the Affordable Care Act.

The job “I came here to do is helping to change health care in America to realize its full potential,” Dr. Berwick said during the speech to health insurance executives at the America's Health Insurance Plans' 2010 Medicare Conference.

Dr. Berwick asked the executives for their help in taking the Affordable Care Act beyond its current modest beginnings.

“We need your help. Our nation needs your help. You have and will have a profound influence on the direction our country will take in the crucial next few years,” Dr. Berwick said at the conference.

Calling the new act primarily “a question” rather than an answer, Dr. Berwick said it asks, “Will we redesign health care in America?”

In a more sobering note, the CMS chief also said that “those who wish only to preserve the status quo … cannot be effective partners, and we simply do not have time to pretend that they are. We do not have time for games anymore.”

Dr. Berwick, the former president and CEO of the Institute for Healthcare Improvement, said he would guide the CMS by the “triple aim” set of goals he established at IHI: better quality of care for patients through efficiency and “patient centeredness,” better health for populations through illness prevention, and lower costs by cutting waste and medical errors. “I intend to guide CMS toward the Triple Aim as our highest-level goal,” he said.

Dr. Berwick said that too much U.S. health care is now fragmented, and explained in personal terms what he meant.

“Too many of us know what fragmented, disorganized care looks like. You have to tell your name and address and story again and again to everyone you see. No one seems to talk to each other. Your record is forgotten or unavailable. One doctor prescribes a medicine that conflicts with a medicine another doctor prescribed,” he said.

President Obama appointed Dr. Berwick to lead CMS on July 7 during a congressional recess, bypassing what looked to be a lengthy fight in the Senate for the nominee's confirmation. On the day Dr. Berwick spoke at the AHIP conference, however, the president resubmitted his nomination for full appointment – which would require Senate hearings and a vote – for the second time.

In August, Senate Republicans refused to accept the president's first resubmitted nomination, citing the body's brief periods in session.

A hearing of the Senate Special Committee on Aging last month featured complaints from providers about recent Drug Enforcement Administration actions in long-term care settings, as well as agreement from a top DEA official to consider creating a new registration category for nursing homes.

To address concerns about pain management in light of the DEA's recent enforcement of controlled substance regulations in nursing facilities, Committee Chair Herb Kohl (D-Wis.) conducted the hearing under the title “The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Cross Fire.”

American Geriatrics Society (AGS) President Cheryl Phillips spoke on behalf of physicians. “I am here because every day, across the country, the real-life consequence of the [DEA] interpretation of the Controlled Substance Act is that, collectively, we are preventing patients in long-term care settings from receiving much-needed pain relief and other medications in a timely manner.”

In testimony presented to the committee in writing, Dr. Jonathan Musher, representing the American Medical Directors Association (AMDA), explained the problem. DEA's recent stand that in the long-term care (LTC) setting “a nurse is not viewed as an agent of the provider” has had the result that “physicians are being required to bypass giving a class medication order to a nurse and give that order directly to a dispensing pharmacist. … [T]hese actions are causing the delay of the receipt of needed pain medications in the nursing home.”

Dr. Musher concluded, “AMDA believes that nurses should be viewed as the agent of the provider. This would continue to allow the important dialogue between the physician and the nurse, which is essential for proper care and treatment. It also would allow for the necessary checks and balances regarding ordering, receiving, and administering controlled substances to the patients under our care.”

In her testimony, Dr. Phillips described the current situation in nursing homes more personally. “If I am called after hours or I am covering for another physician and I am notified of an acute pain issue, I cannot merely leave the order for the pain medication for the nurse to fill. … In fact, according to the DEA rules, I must identify the dispensing pharmacy and call the pharmacy, most often through a 1-800 number, and leave a message for the pharmacist to return my call. When I am able to speak in person, I must place my order—followed by a fax of that order with my signature. I must then call the nursing home and relay the same order to the nurse where she awaits delivery of the medication or release from the narcotic emergency box by the pharmacist. Even when this goes as described above in perfect order, it is often 30 minutes to an hour to complete the process.”

Testifying for the DEA was Joseph Rannazzisi, the agency's deputy assistant administrator. He asserted that the DEA recognizes the unique nature of the LTC setting and so has implemented numerous regulations over the years to make it easier to dispense controlled substances.

The DEA official also said that his agency would soon publish a rule allowing electronic prescribing of controlled substances by “computer, laptop, or PDA device to send a prescription to a pharmacy from a remote location instantaneously.”

Patients in long-term care settings are not receiving much-needed pain relief, said Dr. Cheryl Phillips.

Source Courtesy Donna Doneski/AHCA

A hearing of the Senate Special Committee on Aging last month featured complaints from providers about recent Drug Enforcement Administration actions in long-term care settings, as well as agreement from a top DEA official to consider creating a new registration category for nursing homes.

To address concerns about pain management in light of the DEA's recent enforcement of controlled substance regulations in nursing facilities, Committee Chair Herb Kohl (D-Wis.) conducted the hearing under the title “The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Cross Fire.”

American Geriatrics Society (AGS) President Cheryl Phillips spoke on behalf of physicians. “I am here because every day, across the country, the real-life consequence of the [DEA] interpretation of the Controlled Substance Act is that, collectively, we are preventing patients in long-term care settings from receiving much-needed pain relief and other medications in a timely manner.”

In testimony presented to the committee in writing, Dr. Jonathan Musher, representing the American Medical Directors Association (AMDA), explained the problem. DEA's recent stand that in the long-term care (LTC) setting “a nurse is not viewed as an agent of the provider” has had the result that “physicians are being required to bypass giving a class medication order to a nurse and give that order directly to a dispensing pharmacist. … [T]hese actions are causing the delay of the receipt of needed pain medications in the nursing home.”

Dr. Musher concluded, “AMDA believes that nurses should be viewed as the agent of the provider. This would continue to allow the important dialogue between the physician and the nurse, which is essential for proper care and treatment. It also would allow for the necessary checks and balances regarding ordering, receiving, and administering controlled substances to the patients under our care.”

In her testimony, Dr. Phillips described the current situation in nursing homes more personally. “If I am called after hours or I am covering for another physician and I am notified of an acute pain issue, I cannot merely leave the order for the pain medication for the nurse to fill. … In fact, according to the DEA rules, I must identify the dispensing pharmacy and call the pharmacy, most often through a 1-800 number, and leave a message for the pharmacist to return my call. When I am able to speak in person, I must place my order—followed by a fax of that order with my signature. I must then call the nursing home and relay the same order to the nurse where she awaits delivery of the medication or release from the narcotic emergency box by the pharmacist. Even when this goes as described above in perfect order, it is often 30 minutes to an hour to complete the process.”

Testifying for the DEA was Joseph Rannazzisi, the agency's deputy assistant administrator. He asserted that the DEA recognizes the unique nature of the LTC setting and so has implemented numerous regulations over the years to make it easier to dispense controlled substances.

The DEA official also said that his agency would soon publish a rule allowing electronic prescribing of controlled substances by “computer, laptop, or PDA device to send a prescription to a pharmacy from a remote location instantaneously.”

Patients in long-term care settings are not receiving much-needed pain relief, said Dr. Cheryl Phillips.

Source Courtesy Donna Doneski/AHCA

A hearing of the Senate Special Committee on Aging last month featured complaints from providers about recent Drug Enforcement Administration actions in long-term care settings, as well as agreement from a top DEA official to consider creating a new registration category for nursing homes.

To address concerns about pain management in light of the DEA's recent enforcement of controlled substance regulations in nursing facilities, Committee Chair Herb Kohl (D-Wis.) conducted the hearing under the title “The War on Drugs Meets the War on Pain: Nursing Home Patients Caught in the Cross Fire.”

American Geriatrics Society (AGS) President Cheryl Phillips spoke on behalf of physicians. “I am here because every day, across the country, the real-life consequence of the [DEA] interpretation of the Controlled Substance Act is that, collectively, we are preventing patients in long-term care settings from receiving much-needed pain relief and other medications in a timely manner.”

In testimony presented to the committee in writing, Dr. Jonathan Musher, representing the American Medical Directors Association (AMDA), explained the problem. DEA's recent stand that in the long-term care (LTC) setting “a nurse is not viewed as an agent of the provider” has had the result that “physicians are being required to bypass giving a class medication order to a nurse and give that order directly to a dispensing pharmacist. … [T]hese actions are causing the delay of the receipt of needed pain medications in the nursing home.”

Dr. Musher concluded, “AMDA believes that nurses should be viewed as the agent of the provider. This would continue to allow the important dialogue between the physician and the nurse, which is essential for proper care and treatment. It also would allow for the necessary checks and balances regarding ordering, receiving, and administering controlled substances to the patients under our care.”

In her testimony, Dr. Phillips described the current situation in nursing homes more personally. “If I am called after hours or I am covering for another physician and I am notified of an acute pain issue, I cannot merely leave the order for the pain medication for the nurse to fill. … In fact, according to the DEA rules, I must identify the dispensing pharmacy and call the pharmacy, most often through a 1-800 number, and leave a message for the pharmacist to return my call. When I am able to speak in person, I must place my order—followed by a fax of that order with my signature. I must then call the nursing home and relay the same order to the nurse where she awaits delivery of the medication or release from the narcotic emergency box by the pharmacist. Even when this goes as described above in perfect order, it is often 30 minutes to an hour to complete the process.”

Testifying for the DEA was Joseph Rannazzisi, the agency's deputy assistant administrator. He asserted that the DEA recognizes the unique nature of the LTC setting and so has implemented numerous regulations over the years to make it easier to dispense controlled substances.

The DEA official also said that his agency would soon publish a rule allowing electronic prescribing of controlled substances by “computer, laptop, or PDA device to send a prescription to a pharmacy from a remote location instantaneously.”

Patients in long-term care settings are not receiving much-needed pain relief, said Dr. Cheryl Phillips.

Source Courtesy Donna Doneski/AHCA

The Centers for Disease Control and Prevention wanted to know how elderly people get around using walkers and canes. Not so well, CDC researchers found out—at least according to emergency department data.

After investigating 3,932 ED visits for fall-related injuries from 2001 to 2006, CDC researchers estimated that each year, 47,312 people aged 65 years and older go to EDs in the United States for mishaps associated with use of canes or walkers. One-third of those people are hospitalized.

The estimated yearly injuries total 17,856 fractures, 14,106 contusions or abrasions, 6,590 lacerations, 3,213 strains or sprains, 3,003 internal injuries, and 2,544 other.

“Injuries and hospital admissions for falls associated with walking aids were frequent in this highly vulnerable population,” Judy A. Stevens, Ph.D., and her CDC colleagues wrote in the Journal of the American Geriatrics Society (2009;8:1464-9). The researchers suggested that the design of walkers and even canes could be improved. They also called for research into the physical and cognitive demands that walking aids put on users.

The team estimated fall injuries in both nursing homes (annually, 6,713 with walkers and 544 with canes) and public places (3,426 with walkers and 749 with canes). But, by far, the most falls associated with aids occur at home: 25,144 with walkers and 3,289 with canes, making up about 60% of all such injuries. About 12% of injuries occurred at unknown locations.

Older women appear to be particularly susceptible. Although they constitute 59% of the 65-and-older population, they suffered 77% of the fall injuries in the study. Most of those involved walkers.

The researchers wrote that other studies support the perception that walkers and canes help elderly people with balance and mobility, but the team added that some studies “suggest that they can be associated with greater fall risk because they can cause tripping or interfere with a person's balance control.”

The numbers of injuries associated with the aids seem “higher than they should be,” said Dr. Stevens. She suggested that many times walkers and canes aren't fitted to an individual's size and capability and that, too often, users receive no instruction. Especially for home use, she said, elders or family members tend to buy whatever device is in a nearby store when the need for a walking aid arises.

Even simple devices call for fitting and proper instruction, said Dr. Stevens. For instance, a cane user could benefit from advice on which side of the body needs the support and how tall the device should be, but those “bought at the corner drugstore” don't come with such instructions, she said.

On walkers, features such as wheels and seats can be inappropriate. Dr. Stevens said that falls commonly occur when a walker rolls away from a user or the person moves too far into a lightweight device and loses control of his or her center of gravity.

Dr. Hosam Kamel of the department of geriatrics at the University of Arkansas, Little Rock, said that, when used properly, the aids can greatly improve elders' quality of life but added, “If not used appropriately, they can cause more harm than benefit.” He stressed the need to fit each elderly person with the proper device and then periodically reassessing the person's physical and cognitive abilities to handle that device.

The Centers for Disease Control and Prevention wanted to know how elderly people get around using walkers and canes. Not so well, CDC researchers found out—at least according to emergency department data.

After investigating 3,932 ED visits for fall-related injuries from 2001 to 2006, CDC researchers estimated that each year, 47,312 people aged 65 years and older go to EDs in the United States for mishaps associated with use of canes or walkers. One-third of those people are hospitalized.

The estimated yearly injuries total 17,856 fractures, 14,106 contusions or abrasions, 6,590 lacerations, 3,213 strains or sprains, 3,003 internal injuries, and 2,544 other.

“Injuries and hospital admissions for falls associated with walking aids were frequent in this highly vulnerable population,” Judy A. Stevens, Ph.D., and her CDC colleagues wrote in the Journal of the American Geriatrics Society (2009;8:1464-9). The researchers suggested that the design of walkers and even canes could be improved. They also called for research into the physical and cognitive demands that walking aids put on users.

The team estimated fall injuries in both nursing homes (annually, 6,713 with walkers and 544 with canes) and public places (3,426 with walkers and 749 with canes). But, by far, the most falls associated with aids occur at home: 25,144 with walkers and 3,289 with canes, making up about 60% of all such injuries. About 12% of injuries occurred at unknown locations.

Older women appear to be particularly susceptible. Although they constitute 59% of the 65-and-older population, they suffered 77% of the fall injuries in the study. Most of those involved walkers.

The researchers wrote that other studies support the perception that walkers and canes help elderly people with balance and mobility, but the team added that some studies “suggest that they can be associated with greater fall risk because they can cause tripping or interfere with a person's balance control.”

The numbers of injuries associated with the aids seem “higher than they should be,” said Dr. Stevens. She suggested that many times walkers and canes aren't fitted to an individual's size and capability and that, too often, users receive no instruction. Especially for home use, she said, elders or family members tend to buy whatever device is in a nearby store when the need for a walking aid arises.

Even simple devices call for fitting and proper instruction, said Dr. Stevens. For instance, a cane user could benefit from advice on which side of the body needs the support and how tall the device should be, but those “bought at the corner drugstore” don't come with such instructions, she said.

On walkers, features such as wheels and seats can be inappropriate. Dr. Stevens said that falls commonly occur when a walker rolls away from a user or the person moves too far into a lightweight device and loses control of his or her center of gravity.

Dr. Hosam Kamel of the department of geriatrics at the University of Arkansas, Little Rock, said that, when used properly, the aids can greatly improve elders' quality of life but added, “If not used appropriately, they can cause more harm than benefit.” He stressed the need to fit each elderly person with the proper device and then periodically reassessing the person's physical and cognitive abilities to handle that device.

The Centers for Disease Control and Prevention wanted to know how elderly people get around using walkers and canes. Not so well, CDC researchers found out—at least according to emergency department data.

After investigating 3,932 ED visits for fall-related injuries from 2001 to 2006, CDC researchers estimated that each year, 47,312 people aged 65 years and older go to EDs in the United States for mishaps associated with use of canes or walkers. One-third of those people are hospitalized.

The estimated yearly injuries total 17,856 fractures, 14,106 contusions or abrasions, 6,590 lacerations, 3,213 strains or sprains, 3,003 internal injuries, and 2,544 other.

“Injuries and hospital admissions for falls associated with walking aids were frequent in this highly vulnerable population,” Judy A. Stevens, Ph.D., and her CDC colleagues wrote in the Journal of the American Geriatrics Society (2009;8:1464-9). The researchers suggested that the design of walkers and even canes could be improved. They also called for research into the physical and cognitive demands that walking aids put on users.

The team estimated fall injuries in both nursing homes (annually, 6,713 with walkers and 544 with canes) and public places (3,426 with walkers and 749 with canes). But, by far, the most falls associated with aids occur at home: 25,144 with walkers and 3,289 with canes, making up about 60% of all such injuries. About 12% of injuries occurred at unknown locations.

Older women appear to be particularly susceptible. Although they constitute 59% of the 65-and-older population, they suffered 77% of the fall injuries in the study. Most of those involved walkers.

The researchers wrote that other studies support the perception that walkers and canes help elderly people with balance and mobility, but the team added that some studies “suggest that they can be associated with greater fall risk because they can cause tripping or interfere with a person's balance control.”

The numbers of injuries associated with the aids seem “higher than they should be,” said Dr. Stevens. She suggested that many times walkers and canes aren't fitted to an individual's size and capability and that, too often, users receive no instruction. Especially for home use, she said, elders or family members tend to buy whatever device is in a nearby store when the need for a walking aid arises.

Even simple devices call for fitting and proper instruction, said Dr. Stevens. For instance, a cane user could benefit from advice on which side of the body needs the support and how tall the device should be, but those “bought at the corner drugstore” don't come with such instructions, she said.

On walkers, features such as wheels and seats can be inappropriate. Dr. Stevens said that falls commonly occur when a walker rolls away from a user or the person moves too far into a lightweight device and loses control of his or her center of gravity.

Dr. Hosam Kamel of the department of geriatrics at the University of Arkansas, Little Rock, said that, when used properly, the aids can greatly improve elders' quality of life but added, “If not used appropriately, they can cause more harm than benefit.” He stressed the need to fit each elderly person with the proper device and then periodically reassessing the person's physical and cognitive abilities to handle that device.

WASHINGTON — Long-term care is “the big missing piece in health care reform” Leonard Burman, Ph.D., said during a panel discussion hosted by the Urban Institute.

While Dr. Burman, codirector of the Tax Policy Center, and his fellow panelists said that long-term care should be included in the health reform discussion, home- and nursing-home care are probably too complex for Congress to tackle this year.

“The system of providing long-term care is just broken,” said Dr. Burman. He and several panelists said the system is unsustainable because it bankrupts individuals and, without reform, will eventually do the same for Medicaid and the state and federal governments.

The Urban Institute and the Brookings Institution, which cosponsor the Tax Policy Center, assembled the panel of experts to discuss long-term care issues as Congress began working on health reform bills.

Although the ongoing health care debate is a “wonderful opportunity” to look for solutions to long-term care, that probably won't happen, said Howard Gleckman, a senior research associate at the Urban Institute. In fact, he predicted, “health care won't be resolved this year,” with many issues to be left on the table even if legislation passes. For action on long-term care, Congress is “waiting for Obama,” said Mr. Gleckman, but the president “has frankly said nothing about this.”

Long-term care “makes Congress nervous,” said Bob Rosenblatt, of the National Academy of Social Insurance, because the government costs involved already are enormous and lawmakers don't know how much higher those costs might go in various reform scenarios.

Anne Tumlinson, a vice president and long-term care expert at the consulting company Avalere Health, said that she sees a “silver lining” in long-term care's exclusion from reform so far: The ability to focus more closely on long-term care reform later.

“We have to get [overall health reform] out of the way,” she said. “The way we design health reform could have major implications for the way we design long-term care reform.”

For instance, if a government-run public plan alternative to private health insurance emerges from the process this year, long-term care's mix of coverage by private insurance and Medicaid—or some other government program—could be fundamentally affected, said Ms. Tumlinson.

William Galston, Ph.D., of the Brookings Institution, pointed out that, ironically, long-term care seems to be “a classic insurable event,” with catastrophic costs incurred by a minority within a large population. Yet, he and Richard Johnson, Ph.D., of the Urban Institute ticked off reasons long-term care insurance has been “intractable” including the fact that people don't want to confront the notion of becoming old and frail, care is expensive wherever it's provided, and insurers are doing a poor job of creating and selling long-term care policies.

WASHINGTON — Long-term care is “the big missing piece in health care reform” Leonard Burman, Ph.D., said during a panel discussion hosted by the Urban Institute.

While Dr. Burman, codirector of the Tax Policy Center, and his fellow panelists said that long-term care should be included in the health reform discussion, home- and nursing-home care are probably too complex for Congress to tackle this year.

“The system of providing long-term care is just broken,” said Dr. Burman. He and several panelists said the system is unsustainable because it bankrupts individuals and, without reform, will eventually do the same for Medicaid and the state and federal governments.

The Urban Institute and the Brookings Institution, which cosponsor the Tax Policy Center, assembled the panel of experts to discuss long-term care issues as Congress began working on health reform bills.

Although the ongoing health care debate is a “wonderful opportunity” to look for solutions to long-term care, that probably won't happen, said Howard Gleckman, a senior research associate at the Urban Institute. In fact, he predicted, “health care won't be resolved this year,” with many issues to be left on the table even if legislation passes. For action on long-term care, Congress is “waiting for Obama,” said Mr. Gleckman, but the president “has frankly said nothing about this.”

Long-term care “makes Congress nervous,” said Bob Rosenblatt, of the National Academy of Social Insurance, because the government costs involved already are enormous and lawmakers don't know how much higher those costs might go in various reform scenarios.

Anne Tumlinson, a vice president and long-term care expert at the consulting company Avalere Health, said that she sees a “silver lining” in long-term care's exclusion from reform so far: The ability to focus more closely on long-term care reform later.

“We have to get [overall health reform] out of the way,” she said. “The way we design health reform could have major implications for the way we design long-term care reform.”

For instance, if a government-run public plan alternative to private health insurance emerges from the process this year, long-term care's mix of coverage by private insurance and Medicaid—or some other government program—could be fundamentally affected, said Ms. Tumlinson.

William Galston, Ph.D., of the Brookings Institution, pointed out that, ironically, long-term care seems to be “a classic insurable event,” with catastrophic costs incurred by a minority within a large population. Yet, he and Richard Johnson, Ph.D., of the Urban Institute ticked off reasons long-term care insurance has been “intractable” including the fact that people don't want to confront the notion of becoming old and frail, care is expensive wherever it's provided, and insurers are doing a poor job of creating and selling long-term care policies.

WASHINGTON — Long-term care is “the big missing piece in health care reform” Leonard Burman, Ph.D., said during a panel discussion hosted by the Urban Institute.

While Dr. Burman, codirector of the Tax Policy Center, and his fellow panelists said that long-term care should be included in the health reform discussion, home- and nursing-home care are probably too complex for Congress to tackle this year.

“The system of providing long-term care is just broken,” said Dr. Burman. He and several panelists said the system is unsustainable because it bankrupts individuals and, without reform, will eventually do the same for Medicaid and the state and federal governments.

The Urban Institute and the Brookings Institution, which cosponsor the Tax Policy Center, assembled the panel of experts to discuss long-term care issues as Congress began working on health reform bills.

Although the ongoing health care debate is a “wonderful opportunity” to look for solutions to long-term care, that probably won't happen, said Howard Gleckman, a senior research associate at the Urban Institute. In fact, he predicted, “health care won't be resolved this year,” with many issues to be left on the table even if legislation passes. For action on long-term care, Congress is “waiting for Obama,” said Mr. Gleckman, but the president “has frankly said nothing about this.”

Long-term care “makes Congress nervous,” said Bob Rosenblatt, of the National Academy of Social Insurance, because the government costs involved already are enormous and lawmakers don't know how much higher those costs might go in various reform scenarios.

Anne Tumlinson, a vice president and long-term care expert at the consulting company Avalere Health, said that she sees a “silver lining” in long-term care's exclusion from reform so far: The ability to focus more closely on long-term care reform later.

“We have to get [overall health reform] out of the way,” she said. “The way we design health reform could have major implications for the way we design long-term care reform.”

For instance, if a government-run public plan alternative to private health insurance emerges from the process this year, long-term care's mix of coverage by private insurance and Medicaid—or some other government program—could be fundamentally affected, said Ms. Tumlinson.

William Galston, Ph.D., of the Brookings Institution, pointed out that, ironically, long-term care seems to be “a classic insurable event,” with catastrophic costs incurred by a minority within a large population. Yet, he and Richard Johnson, Ph.D., of the Urban Institute ticked off reasons long-term care insurance has been “intractable” including the fact that people don't want to confront the notion of becoming old and frail, care is expensive wherever it's provided, and insurers are doing a poor job of creating and selling long-term care policies.

At a hearing of the Senate Aging Committee, hospice and palliative care experts called on Congress to adequately fund end-of-life care and revise federal regulations surrounding care transitions at that time of vulnerability.

Congress “must adequately fund and demand high quality of care for frail, older Americans whose last home is a nursing home,” testified Dr. Joan Teno, associate medical director of Home and Hospice Care of Rhode Island in Providence.

Along with others at the hearing, Dr. Teno called on Congress to reverse action taken this year by the Centers for Medicare and Medicaid Services to cut $2.2 billion in a special adjustment to hospice wages over the next 3 years. Bills to that effect were pending in both the House and Senate at press time.

Dr. Diane Meier, director of palliative care at the Mount Sinai School of Medicine, New York, testified regarding additional funding for end-of-life research.

“Despite the fact that each one of us will eventually get sick and die, almost no federal support for research aimed at improving the quality of life during chronic and serious illness has been available to develop the evidence base necessary to relieve suffering and reliably help patients and families in need,” she said.

Dr. Meier also asserted the need for targeted federal support for physician and nurse training in palliative care, citing “a near total lack of medical and nursing education in palliative care.” In her testimony, she stated that in 9 years of medical education, including geriatrics training, she had never received a lecture on pain management or treatment of symptoms such as shortness of breath or nausea.

Joan Curran, chief of government relations and external affairs at Gundersen Lutheran Medical Center in La Crosse, Wis., testified about the need for federal support for palliative care research and education. Ms. Curran advocated better, more widespread use of advance directives, and recommended increased Medicare reimbursement for facilities that have advance directives for 85% or more of residents and show that they abide by those documents.

“As you move forward, my strongest recommendation to you is to remove barriers and create incentives” for “a system that allows people to make their wishes known and health care organizations that value and respect those choices,” Ms. Curran testified.

Her medical center has implemented an elaborate end-of-life care model, including widespread use of advance directives, that is available for use at other facilities. Gunderson's success in that effort shows that it can save Medicare funds, Ms. Curran said. Data from 2007 showed that the center generated about $18,000 in Medicare costs per patient in the last 2 years of life, while the national average is more than $25,000 and some health care organizations generate average costs as high as $58,000 for those dying patients.

Senate Aging Committee member Sheldon Whitehouse (D-R.I.), who called the hearing, said he did so in part to address “a fundamental disconnect” between patients' end-of-life wishes and physicians' actions. He claimed that surveys indicate that 70% of physicians whose patients have advance directives don't know about them.

Oklahoma Attorney General W. Drew Edmondson called on the committee to end Medicare's “artificial division between ordinary medical care and hospice care.” Patients entering hospice care shouldn't be required to forgo curative care and some palliative care, as is now the case, and the 6-month terminal diagnosis required for the Medicare hospice benefit should be relaxed, he urged.

Sen. Ron Wyden (D-Ore.), who also sits on the Aging Committee, suggested an important subtext for the hearing, as Congress looks beyond the current administration. “Looking to health care reform next year,” he said, “you cannot get that topic right unless you expand options for end-of-life care.”

'Despite the fact that each one of us will eventually get sick and die, [there is] almost no federal support for research.' DR. MEIER

At a hearing of the Senate Aging Committee, hospice and palliative care experts called on Congress to adequately fund end-of-life care and revise federal regulations surrounding care transitions at that time of vulnerability.

Congress “must adequately fund and demand high quality of care for frail, older Americans whose last home is a nursing home,” testified Dr. Joan Teno, associate medical director of Home and Hospice Care of Rhode Island in Providence.

Along with others at the hearing, Dr. Teno called on Congress to reverse action taken this year by the Centers for Medicare and Medicaid Services to cut $2.2 billion in a special adjustment to hospice wages over the next 3 years. Bills to that effect were pending in both the House and Senate at press time.

Dr. Diane Meier, director of palliative care at the Mount Sinai School of Medicine, New York, testified regarding additional funding for end-of-life research.

“Despite the fact that each one of us will eventually get sick and die, almost no federal support for research aimed at improving the quality of life during chronic and serious illness has been available to develop the evidence base necessary to relieve suffering and reliably help patients and families in need,” she said.

Dr. Meier also asserted the need for targeted federal support for physician and nurse training in palliative care, citing “a near total lack of medical and nursing education in palliative care.” In her testimony, she stated that in 9 years of medical education, including geriatrics training, she had never received a lecture on pain management or treatment of symptoms such as shortness of breath or nausea.

Joan Curran, chief of government relations and external affairs at Gundersen Lutheran Medical Center in La Crosse, Wis., testified about the need for federal support for palliative care research and education. Ms. Curran advocated better, more widespread use of advance directives, and recommended increased Medicare reimbursement for facilities that have advance directives for 85% or more of residents and show that they abide by those documents.

“As you move forward, my strongest recommendation to you is to remove barriers and create incentives” for “a system that allows people to make their wishes known and health care organizations that value and respect those choices,” Ms. Curran testified.

Her medical center has implemented an elaborate end-of-life care model, including widespread use of advance directives, that is available for use at other facilities. Gunderson's success in that effort shows that it can save Medicare funds, Ms. Curran said. Data from 2007 showed that the center generated about $18,000 in Medicare costs per patient in the last 2 years of life, while the national average is more than $25,000 and some health care organizations generate average costs as high as $58,000 for those dying patients.

Senate Aging Committee member Sheldon Whitehouse (D-R.I.), who called the hearing, said he did so in part to address “a fundamental disconnect” between patients' end-of-life wishes and physicians' actions. He claimed that surveys indicate that 70% of physicians whose patients have advance directives don't know about them.

Oklahoma Attorney General W. Drew Edmondson called on the committee to end Medicare's “artificial division between ordinary medical care and hospice care.” Patients entering hospice care shouldn't be required to forgo curative care and some palliative care, as is now the case, and the 6-month terminal diagnosis required for the Medicare hospice benefit should be relaxed, he urged.

Sen. Ron Wyden (D-Ore.), who also sits on the Aging Committee, suggested an important subtext for the hearing, as Congress looks beyond the current administration. “Looking to health care reform next year,” he said, “you cannot get that topic right unless you expand options for end-of-life care.”

'Despite the fact that each one of us will eventually get sick and die, [there is] almost no federal support for research.' DR. MEIER

At a hearing of the Senate Aging Committee, hospice and palliative care experts called on Congress to adequately fund end-of-life care and revise federal regulations surrounding care transitions at that time of vulnerability.

Congress “must adequately fund and demand high quality of care for frail, older Americans whose last home is a nursing home,” testified Dr. Joan Teno, associate medical director of Home and Hospice Care of Rhode Island in Providence.

Along with others at the hearing, Dr. Teno called on Congress to reverse action taken this year by the Centers for Medicare and Medicaid Services to cut $2.2 billion in a special adjustment to hospice wages over the next 3 years. Bills to that effect were pending in both the House and Senate at press time.

Dr. Diane Meier, director of palliative care at the Mount Sinai School of Medicine, New York, testified regarding additional funding for end-of-life research.

“Despite the fact that each one of us will eventually get sick and die, almost no federal support for research aimed at improving the quality of life during chronic and serious illness has been available to develop the evidence base necessary to relieve suffering and reliably help patients and families in need,” she said.

Dr. Meier also asserted the need for targeted federal support for physician and nurse training in palliative care, citing “a near total lack of medical and nursing education in palliative care.” In her testimony, she stated that in 9 years of medical education, including geriatrics training, she had never received a lecture on pain management or treatment of symptoms such as shortness of breath or nausea.

Joan Curran, chief of government relations and external affairs at Gundersen Lutheran Medical Center in La Crosse, Wis., testified about the need for federal support for palliative care research and education. Ms. Curran advocated better, more widespread use of advance directives, and recommended increased Medicare reimbursement for facilities that have advance directives for 85% or more of residents and show that they abide by those documents.

“As you move forward, my strongest recommendation to you is to remove barriers and create incentives” for “a system that allows people to make their wishes known and health care organizations that value and respect those choices,” Ms. Curran testified.

Her medical center has implemented an elaborate end-of-life care model, including widespread use of advance directives, that is available for use at other facilities. Gunderson's success in that effort shows that it can save Medicare funds, Ms. Curran said. Data from 2007 showed that the center generated about $18,000 in Medicare costs per patient in the last 2 years of life, while the national average is more than $25,000 and some health care organizations generate average costs as high as $58,000 for those dying patients.

Senate Aging Committee member Sheldon Whitehouse (D-R.I.), who called the hearing, said he did so in part to address “a fundamental disconnect” between patients' end-of-life wishes and physicians' actions. He claimed that surveys indicate that 70% of physicians whose patients have advance directives don't know about them.

Oklahoma Attorney General W. Drew Edmondson called on the committee to end Medicare's “artificial division between ordinary medical care and hospice care.” Patients entering hospice care shouldn't be required to forgo curative care and some palliative care, as is now the case, and the 6-month terminal diagnosis required for the Medicare hospice benefit should be relaxed, he urged.

Sen. Ron Wyden (D-Ore.), who also sits on the Aging Committee, suggested an important subtext for the hearing, as Congress looks beyond the current administration. “Looking to health care reform next year,” he said, “you cannot get that topic right unless you expand options for end-of-life care.”

'Despite the fact that each one of us will eventually get sick and die, [there is] almost no federal support for research.' DR. MEIER

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

SALT LAKE CITY — The Pressure Ulcer Scale for Healing proved superior to assessment by experienced nurses in determining status and progression of long-term care residents' wounds, researchers reported at the annual symposium of the American Medical Directors Association.

"It was surprising because we thought the clinical way was the better way," said Dr. Erica George-Saintilus with Long Island Jewish Medical Center, who presented a poster on her study at the center-affiliated Cold Spring Hills Center for Nursing and Rehabilitation in Woodbury, N.Y.

Whereas nurses assessed the wounds primarily by subjective impressions and wound size, the Pressure Ulcer Scale for Healing (PUSH) tool tallied three parameters:

▸ Wound size in scores representing skin area from none (0) to more than 24 cm

▸ Amount of exudate from none (0) to heavy (3).

▸ Tissue type from closed/resurfaced (0) to necrotic tissue/eschar (4).

The team reviewed records of all residents with stage II-IV ulcers in the 627-bed skilled nursing facility from 2004 through 2006. Weekly reports on the wounds included data sufficient to calculate a PUSH score as well as nurse assessments such as "improved," "deteriorated," or "unchanged." In patients with multiple wounds, the study tracked only one ulcer.

"There's no indication [from statistical analyses] that nurses' observations agree at all with the PUSH," said Dr. George-Saintilus.

Looking specifically at 2 months of data for 30 residents, the researchers determined that PUSH scores were better than the nurses' assessments at indicating the direction that a wound was taking. Dr. George-Saintilus pointed out instances in which a pressure ulcer that a nurse had recorded as "healed" returned and got worse. In contrast, PUSH scores were more likely to indicate the true progression of a wound.

Further, Dr. George-Saintilus and her colleagues discovered that the nurses' assessments were idiosyncratic. "Each nurse has her own way of giving her impression," the researcher said.

PUSH was introduced 11 years ago by the National Pressure Ulcer Advisory Panel, a coalition of corporate and professional organizations that sets care standards. AMDA's "Pressure Ulcers in the Long-Term Care Setting" clinical practice guideline cites PUSH as a "validated tool for characterizing and monitoring pressure ulcers." The guideline includes directions and a blank scoring sheet, and the advisory panel offers the same at http://www.npuap.org/PDF/push3.pdf

Dr. George-Saintilus said that her observations of nurses at the Cold Spring Hills facility, which now uses the PUSH tool, show that PUSH is actually quicker to use than the subjective system. The old record keeping included nurses' assessments and several wound parameters but didn't combine those data into a score that could be tracked as easily as the PUSH score. She said that PUSH "saves time and money."

WASHINGTON — The U.S. health workforce, including physicians, is “woefully unprepared” to deal with the coming onslaught of aging Americans, according to an Institute of Medicine panel that cited poor training and perverse payment incentives in geriatrics as among the chief problems.

Headed by Dr. John Rowe, a geriatrician and professor of health policy and management at Columbia University, New York, the interdisciplinary panel declared even the current workforce “not prepared to deliver the best possible care to older patients.” The panel said in its statement accompanying the report, “All health professional schools and health care training programs should expand course work and training in the treatment of older individuals.” Furthermore, “virtually all” health care workers are or will be treating an elderly population and so should be required to demonstrate competence in that area as a criterion of licensure and certification, the group asserted.

Dr. Harvey Fineberg, head of the Institute of Medicine, said the government-advisory body created the 15-member panel in January 2007 to address the “major demographic shift” looming in this country. He added, “Too few health professionals are well prepared, especially to handle the multiple medical problems that are seen in old age, including such geriatric concerns as dementia and falls and incontinence.”

The work force shortage in geriatric care is especially dire because of remarkably high turnover among nurses' aides (71% annually) and other workers, the panel concluded after more than a year of study. Among physicians, Medicare's low reimbursement rates are mainly to blame for low incomes for doctors choosing elder care: “Medicare should increase its reimbursement rates for services delivered by geriatric specialists,” the report urged. In fact, the panel declared that Medicare currently “hinders the provision of quality of care to older adults” not only with low payment rates, but also with its focus on acute illness and its lack of coverage for preventive services and care coordination.

In a press conference, Dr. Rowe said that ironically, physicians with extra training in geriatrics actually reduce their private-practice incomes. Geriatricians and specialists in nursing and other fields should be offered incentives in the form of increased incomes, loan forgiveness, scholarships, and other awards, according to the report. Nonphysician providers and caregivers face both the disincentives of poor funding from Medicare and Medicaid and “the fact that these workers have not been recognized as the pivotal health care workers that they are,” said panel member Carol Raphael, president and chief executive officer of the Visiting Nurse Service of New York. The panel called specifically for states to boost Medicaid payments that cover these workers' services and benefits.

Warning, as others have, that the health care system isn't close to being prepared for the 78 million aging baby boomers, the panel called for “new models” of long-term and geriatric care that include increased delegation of responsibilities within the health workforce hierarchy, the greater use of interdisciplinary teams, and increased involvement of patients and their families in elders' care. Many good models have been developed, said the panel, but too often have been put on the shelf for lack of funds for implementation.

Members of Congress have turned their attention to the geriatric care workforce. On April 16, the Senate Special Committee on Aging held a hearing on the subject, focusing on the new report. Dr. Rowe testified, and committee members echoed many of his panel's concerns. For instance, Committee Chairman Sen. Herb Kohl (D-Wis.) said, “We know that few nursing programs require coursework in geriatrics and that in medical schools, comprehensive geriatric training is a rarity.”

Sen. Kohl announced plans to introduce a bill later this spring to “expand, train, and support all sectors of the long-term care workforce,” including physicians.

Too few health professionals are well prepared to handle the multiple medical problems seen in old age. DR. FINEBERG

WASHINGTON — The U.S. health workforce, including physicians, is “woefully unprepared” to deal with the coming onslaught of aging Americans, according to an Institute of Medicine panel that cited poor training and perverse payment incentives in geriatrics as among the chief problems.

Headed by Dr. John Rowe, a geriatrician and professor of health policy and management at Columbia University, New York, the interdisciplinary panel declared even the current workforce “not prepared to deliver the best possible care to older patients.” The panel said in its statement accompanying the report, “All health professional schools and health care training programs should expand course work and training in the treatment of older individuals.” Furthermore, “virtually all” health care workers are or will be treating an elderly population and so should be required to demonstrate competence in that area as a criterion of licensure and certification, the group asserted.

Dr. Harvey Fineberg, head of the Institute of Medicine, said the government-advisory body created the 15-member panel in January 2007 to address the “major demographic shift” looming in this country. He added, “Too few health professionals are well prepared, especially to handle the multiple medical problems that are seen in old age, including such geriatric concerns as dementia and falls and incontinence.”

The work force shortage in geriatric care is especially dire because of remarkably high turnover among nurses' aides (71% annually) and other workers, the panel concluded after more than a year of study. Among physicians, Medicare's low reimbursement rates are mainly to blame for low incomes for doctors choosing elder care: “Medicare should increase its reimbursement rates for services delivered by geriatric specialists,” the report urged. In fact, the panel declared that Medicare currently “hinders the provision of quality of care to older adults” not only with low payment rates, but also with its focus on acute illness and its lack of coverage for preventive services and care coordination.

In a press conference, Dr. Rowe said that ironically, physicians with extra training in geriatrics actually reduce their private-practice incomes. Geriatricians and specialists in nursing and other fields should be offered incentives in the form of increased incomes, loan forgiveness, scholarships, and other awards, according to the report. Nonphysician providers and caregivers face both the disincentives of poor funding from Medicare and Medicaid and “the fact that these workers have not been recognized as the pivotal health care workers that they are,” said panel member Carol Raphael, president and chief executive officer of the Visiting Nurse Service of New York. The panel called specifically for states to boost Medicaid payments that cover these workers' services and benefits.

Warning, as others have, that the health care system isn't close to being prepared for the 78 million aging baby boomers, the panel called for “new models” of long-term and geriatric care that include increased delegation of responsibilities within the health workforce hierarchy, the greater use of interdisciplinary teams, and increased involvement of patients and their families in elders' care. Many good models have been developed, said the panel, but too often have been put on the shelf for lack of funds for implementation.

Members of Congress have turned their attention to the geriatric care workforce. On April 16, the Senate Special Committee on Aging held a hearing on the subject, focusing on the new report. Dr. Rowe testified, and committee members echoed many of his panel's concerns. For instance, Committee Chairman Sen. Herb Kohl (D-Wis.) said, “We know that few nursing programs require coursework in geriatrics and that in medical schools, comprehensive geriatric training is a rarity.”

Sen. Kohl announced plans to introduce a bill later this spring to “expand, train, and support all sectors of the long-term care workforce,” including physicians.

Too few health professionals are well prepared to handle the multiple medical problems seen in old age. DR. FINEBERG

WASHINGTON — The U.S. health workforce, including physicians, is “woefully unprepared” to deal with the coming onslaught of aging Americans, according to an Institute of Medicine panel that cited poor training and perverse payment incentives in geriatrics as among the chief problems.

Headed by Dr. John Rowe, a geriatrician and professor of health policy and management at Columbia University, New York, the interdisciplinary panel declared even the current workforce “not prepared to deliver the best possible care to older patients.” The panel said in its statement accompanying the report, “All health professional schools and health care training programs should expand course work and training in the treatment of older individuals.” Furthermore, “virtually all” health care workers are or will be treating an elderly population and so should be required to demonstrate competence in that area as a criterion of licensure and certification, the group asserted.

Dr. Harvey Fineberg, head of the Institute of Medicine, said the government-advisory body created the 15-member panel in January 2007 to address the “major demographic shift” looming in this country. He added, “Too few health professionals are well prepared, especially to handle the multiple medical problems that are seen in old age, including such geriatric concerns as dementia and falls and incontinence.”

The work force shortage in geriatric care is especially dire because of remarkably high turnover among nurses' aides (71% annually) and other workers, the panel concluded after more than a year of study. Among physicians, Medicare's low reimbursement rates are mainly to blame for low incomes for doctors choosing elder care: “Medicare should increase its reimbursement rates for services delivered by geriatric specialists,” the report urged. In fact, the panel declared that Medicare currently “hinders the provision of quality of care to older adults” not only with low payment rates, but also with its focus on acute illness and its lack of coverage for preventive services and care coordination.

In a press conference, Dr. Rowe said that ironically, physicians with extra training in geriatrics actually reduce their private-practice incomes. Geriatricians and specialists in nursing and other fields should be offered incentives in the form of increased incomes, loan forgiveness, scholarships, and other awards, according to the report. Nonphysician providers and caregivers face both the disincentives of poor funding from Medicare and Medicaid and “the fact that these workers have not been recognized as the pivotal health care workers that they are,” said panel member Carol Raphael, president and chief executive officer of the Visiting Nurse Service of New York. The panel called specifically for states to boost Medicaid payments that cover these workers' services and benefits.

Warning, as others have, that the health care system isn't close to being prepared for the 78 million aging baby boomers, the panel called for “new models” of long-term and geriatric care that include increased delegation of responsibilities within the health workforce hierarchy, the greater use of interdisciplinary teams, and increased involvement of patients and their families in elders' care. Many good models have been developed, said the panel, but too often have been put on the shelf for lack of funds for implementation.

Members of Congress have turned their attention to the geriatric care workforce. On April 16, the Senate Special Committee on Aging held a hearing on the subject, focusing on the new report. Dr. Rowe testified, and committee members echoed many of his panel's concerns. For instance, Committee Chairman Sen. Herb Kohl (D-Wis.) said, “We know that few nursing programs require coursework in geriatrics and that in medical schools, comprehensive geriatric training is a rarity.”

Sen. Kohl announced plans to introduce a bill later this spring to “expand, train, and support all sectors of the long-term care workforce,” including physicians.

Too few health professionals are well prepared to handle the multiple medical problems seen in old age. DR. FINEBERG

SALT LAKE CITY — Even among nursing home residents receiving substantial vitamin D supplements, half or more show deficiencies in the nutrient, according to two separate posters presented at the annual symposium of the American Medical Directors Association.

Researchers who conducted both studies suggested that nursing home residents should routinely receive two or more times the dose of the vitamin currently recommended for healthy elderly people.

“We were astounded to find how prevalent the deficiency in vitamin D was,” said Dr. Todd H. Goldberg, director of geriatrics at West Virginia University Health Sciences Center, Charleston, who conducted the study while he was the medical director of Paul's Run Retirement Community, Philadelphia.

Dr. Goldberg and his colleagues reviewed the charts of 105 residents of Paul's Run and the Allegheny Valley School, a home for adults with developmental disabilities, also in Philadelphia, and studied those that included data on concentrations of serum 25-hydroxyvitamin D (25[OH]D). All the residents had taken multivitamins and vitamin D-calcium supplements that yielded a total of 400–1,200 IU of the vitamin daily. Yet 38 of the 45 residents had 25(OH)D levels under 30 ng/mL, the target considered sufficient in most adults. Eleven had levels under 20 ng/mL, which Dr. Goldberg called “severely deficient.”

In the second study, Dr. William Zirker and Dr. Sri Yenupotula of the Crozer-Chester Medical Center in Upland, Pa., tested for 25(OH)D in 100 residents aged 65 years and older in the nursing home affiliated with the medical center. Although 84 residents were on the home's standard regimen of 800 IU of vitamin D with 1,200 mg of calcium daily, 35 (42%) had 25(OH)D levels under 30 ng/mL. Of the 16 residents not receiving the standard supplements, 12 were below the target level. “Our conclusion is that you can't just assume that you're going to achieve a target level by treating with the recommended [supplemental regimen],” said Dr. Zirker, chief of geriatric medicine at the medical center.

Dr. Zirker and Dr. Goldberg suggested different ways in which nursing homes could address vitamin D deficiency despite recommended supplementation.

Dr. Goldberg said that nursing home residents should be given extra over-the-counter vitamin D doses up to 2,000 IU per day routinely, whether or not their 25(OH)D levels are known. He pointed out that it can cost $100 for each test for the metabolite, whereas a hefty dose of vitamin D costs about 2 cents.

Conversely, Dr. Zirker advocated extensive blood testing. “We know that vitamin D deficiency is epidemic, particularly in nursing home residents,” he said. “All long-term care residents should have their 25(OH) D level checked after they have been on a standard [regimen] of 1,200 mg of calcium and 800 IU of vitamin D for at least 1–2 months,” he wrote. Residents with low 25(OH)D concentrations then should receive as much as 50,000 IU a week and then 50,000 IU a month.

In a separate presentation at the AMDA meeting, Dr. F. Michael Gloth III, director of outpatient services for geriatric medicine and gerontology at Johns Hopkins University, Baltimore, said that elderly people absorb 40% less vitamin D than young people do, and older skin produces less vitamin D when exposed to sunlight. The current Institute of Medicine-recommended daily intake of vitamin D (600 IU for people aged older than 70 years) “is nice, but it doesn't really apply to anyone you have in the nursing home,” said Dr. Gloth.

In long-term care, “one of the most beneficial interventions one can do is simply give people vitamin D supplements,” he concluded.

SALT LAKE CITY — Even among nursing home residents receiving substantial vitamin D supplements, half or more show deficiencies in the nutrient, according to two separate posters presented at the annual symposium of the American Medical Directors Association.

Researchers who conducted both studies suggested that nursing home residents should routinely receive two or more times the dose of the vitamin currently recommended for healthy elderly people.

“We were astounded to find how prevalent the deficiency in vitamin D was,” said Dr. Todd H. Goldberg, director of geriatrics at West Virginia University Health Sciences Center, Charleston, who conducted the study while he was the medical director of Paul's Run Retirement Community, Philadelphia.

Dr. Goldberg and his colleagues reviewed the charts of 105 residents of Paul's Run and the Allegheny Valley School, a home for adults with developmental disabilities, also in Philadelphia, and studied those that included data on concentrations of serum 25-hydroxyvitamin D (25[OH]D). All the residents had taken multivitamins and vitamin D-calcium supplements that yielded a total of 400–1,200 IU of the vitamin daily. Yet 38 of the 45 residents had 25(OH)D levels under 30 ng/mL, the target considered sufficient in most adults. Eleven had levels under 20 ng/mL, which Dr. Goldberg called “severely deficient.”

In the second study, Dr. William Zirker and Dr. Sri Yenupotula of the Crozer-Chester Medical Center in Upland, Pa., tested for 25(OH)D in 100 residents aged 65 years and older in the nursing home affiliated with the medical center. Although 84 residents were on the home's standard regimen of 800 IU of vitamin D with 1,200 mg of calcium daily, 35 (42%) had 25(OH)D levels under 30 ng/mL. Of the 16 residents not receiving the standard supplements, 12 were below the target level. “Our conclusion is that you can't just assume that you're going to achieve a target level by treating with the recommended [supplemental regimen],” said Dr. Zirker, chief of geriatric medicine at the medical center.

Dr. Zirker and Dr. Goldberg suggested different ways in which nursing homes could address vitamin D deficiency despite recommended supplementation.

Dr. Goldberg said that nursing home residents should be given extra over-the-counter vitamin D doses up to 2,000 IU per day routinely, whether or not their 25(OH)D levels are known. He pointed out that it can cost $100 for each test for the metabolite, whereas a hefty dose of vitamin D costs about 2 cents.

Conversely, Dr. Zirker advocated extensive blood testing. “We know that vitamin D deficiency is epidemic, particularly in nursing home residents,” he said. “All long-term care residents should have their 25(OH) D level checked after they have been on a standard [regimen] of 1,200 mg of calcium and 800 IU of vitamin D for at least 1–2 months,” he wrote. Residents with low 25(OH)D concentrations then should receive as much as 50,000 IU a week and then 50,000 IU a month.

In a separate presentation at the AMDA meeting, Dr. F. Michael Gloth III, director of outpatient services for geriatric medicine and gerontology at Johns Hopkins University, Baltimore, said that elderly people absorb 40% less vitamin D than young people do, and older skin produces less vitamin D when exposed to sunlight. The current Institute of Medicine-recommended daily intake of vitamin D (600 IU for people aged older than 70 years) “is nice, but it doesn't really apply to anyone you have in the nursing home,” said Dr. Gloth.

In long-term care, “one of the most beneficial interventions one can do is simply give people vitamin D supplements,” he concluded.

SALT LAKE CITY — Even among nursing home residents receiving substantial vitamin D supplements, half or more show deficiencies in the nutrient, according to two separate posters presented at the annual symposium of the American Medical Directors Association.

Researchers who conducted both studies suggested that nursing home residents should routinely receive two or more times the dose of the vitamin currently recommended for healthy elderly people.

“We were astounded to find how prevalent the deficiency in vitamin D was,” said Dr. Todd H. Goldberg, director of geriatrics at West Virginia University Health Sciences Center, Charleston, who conducted the study while he was the medical director of Paul's Run Retirement Community, Philadelphia.

Dr. Goldberg and his colleagues reviewed the charts of 105 residents of Paul's Run and the Allegheny Valley School, a home for adults with developmental disabilities, also in Philadelphia, and studied those that included data on concentrations of serum 25-hydroxyvitamin D (25[OH]D). All the residents had taken multivitamins and vitamin D-calcium supplements that yielded a total of 400–1,200 IU of the vitamin daily. Yet 38 of the 45 residents had 25(OH)D levels under 30 ng/mL, the target considered sufficient in most adults. Eleven had levels under 20 ng/mL, which Dr. Goldberg called “severely deficient.”

In the second study, Dr. William Zirker and Dr. Sri Yenupotula of the Crozer-Chester Medical Center in Upland, Pa., tested for 25(OH)D in 100 residents aged 65 years and older in the nursing home affiliated with the medical center. Although 84 residents were on the home's standard regimen of 800 IU of vitamin D with 1,200 mg of calcium daily, 35 (42%) had 25(OH)D levels under 30 ng/mL. Of the 16 residents not receiving the standard supplements, 12 were below the target level. “Our conclusion is that you can't just assume that you're going to achieve a target level by treating with the recommended [supplemental regimen],” said Dr. Zirker, chief of geriatric medicine at the medical center.

Dr. Zirker and Dr. Goldberg suggested different ways in which nursing homes could address vitamin D deficiency despite recommended supplementation.

Dr. Goldberg said that nursing home residents should be given extra over-the-counter vitamin D doses up to 2,000 IU per day routinely, whether or not their 25(OH)D levels are known. He pointed out that it can cost $100 for each test for the metabolite, whereas a hefty dose of vitamin D costs about 2 cents.

Conversely, Dr. Zirker advocated extensive blood testing. “We know that vitamin D deficiency is epidemic, particularly in nursing home residents,” he said. “All long-term care residents should have their 25(OH) D level checked after they have been on a standard [regimen] of 1,200 mg of calcium and 800 IU of vitamin D for at least 1–2 months,” he wrote. Residents with low 25(OH)D concentrations then should receive as much as 50,000 IU a week and then 50,000 IU a month.

In a separate presentation at the AMDA meeting, Dr. F. Michael Gloth III, director of outpatient services for geriatric medicine and gerontology at Johns Hopkins University, Baltimore, said that elderly people absorb 40% less vitamin D than young people do, and older skin produces less vitamin D when exposed to sunlight. The current Institute of Medicine-recommended daily intake of vitamin D (600 IU for people aged older than 70 years) “is nice, but it doesn't really apply to anyone you have in the nursing home,” said Dr. Gloth.

In long-term care, “one of the most beneficial interventions one can do is simply give people vitamin D supplements,” he concluded.