Globalization, women's migration, and the long-term-care workforce

With the aging of the world's population comes the rising need for qualified direct long-term-care (DLTC) workers (i.e., those who provide personal care to frail and disabled older adults). Developed nations are increasingly turning to immigrant women to fill these needs. In this article, we examine the impact of three global trends-population aging, globalization, and women's migration-on the supply and demand for DLTC workers in the United States. Following an overview of these trends, we identify three areas with embedded social justice issues that are shaping the DLTC workforce in the United States, with a specific focus on immigrant workers in these settings. These include world poverty and economic inequalities, the feminization and colorization of labor (especially in long-term care), and empowerment and women's rights. We conclude with a discussion of the contradictory effects that both population aging and globalization have on immigrant women, source countries, and the long-term-care workforce in the United States. We raise a number of policy, practice, and research implications and questions. For policy makers and long-term-care administrators in receiver nations such as the United States, the meeting of DLTC worker needs with immigrants may result in greater access to needed employees but also in the continued devaluation of eldercare as a profession. Source (supply) nations must balance the real and potential economic benefits of remittances from women who migrate for labor with the negative consequences of disrupting family care traditions and draining the long-term-care workforce of those countries.     

Clinical outcomes of HIV care delivery models in the US: a systematic review

With over 1 million people living with HIV, the US faces national challenges in HIV care delivery due to an inadequate HIV specialist workforce and the increasing role of non-communicable chronic diseases in driving morbidity and mortality in HIV-infected patients. Alternative HIV care delivery models, which include substantial roles for advanced practitioners and/or coordination between specialty and primary care settings in managing HIV-infected patients, may address these needs. We aimed to systematically review the evidence on patient-level HIV-specific and primary care health outcomes for HIV-infected adults receiving outpatient care across HIV care delivery models. We identified randomized trials and observational studies from bibliographic and other databases through March 2016. Eligible studies met pre-specified eligibility criteria including on care delivery models and patient-level health outcomes. We considered all available evidence, including non-experimental studies, and evaluated studies for risk of bias. We identified 3605 studies, of which 13 met eligibility criteria. Of the 13 eligible studies, the majority evaluated specialty-based care (9 studies). Across all studies and care delivery models, eligible studies primarily reported mortality and antiretroviral use, with specialty-based care associated with mortality reductions at the clinician and practice levels and with increased antiretroviral initiation or use at the clinician level but not the practice level. Limited and heterogeneous outcomes were reported for other patient-level HIV-specific outcomes (e.g., viral suppression) as well as for primary care health outcomes across all care delivery models. No studies addressed chronic care outcomes related to aging. Limited evidence was available across geographic settings and key populations. As re-design of care delivery in the US continues to evolve, better understanding of patient-level HIV-related and primary care health outcomes, especially across different staffing models and among different patient populations and geographic locations, is urgently needed to improve HIV disease management.     

Active aging policy in Europe: Between path dependency and path departure

Active aging, that is the idea that policy encourage and enable people to participate actively in social, political and economic life, is a political backwater in Europe. Since demographic aging affects may different policy domains in different ways, the institutional landscapes in which aging and active aging policy takes place are fragmented. This means that two distinct and countervailing institutional settings shape active aging policy agendas. The first institutional setting, national welfare states, concentrates social policy-making at the national level by emphasizing institutional path dependency. Conversely, the other institutional context, which consists of service-oriented policy communities at sub-national level, emphasizes differences between policy domains across national borders. While the former institutional dynamic precludes all but the most general role for European institutions in active aging policy, the second institutional setting would allow for considerable European policy coordination and cooperation. The paper shows how these opposing institutional landscapes shape active aging agendas in Europe as well as points to the opportunities and dangers that emerge from this interaction. His research spans a number of policy domains including social policy, environmental policy, and public management reform. His interests include the development of comparative research both at methodological and substantive level.     

Advancing Geriatrics Research,Education, and Practice: Policy Challenges After the Great Recession

The series of articles in this JGIM issue provides a number of policy-relevant recommendations for advancing geriatrics research, education and practice. Despite the unprecedented pressure to reduce state and federal spending, policymakers must concurrently address the challenges of a growing population of older individuals with increasingly complex health care problems. Thus, there may be opportunities to advance this agenda in creative ways. For example, without new spending, federal research agencies can make changes to encourage needed new directions in aging research, and the ACA provides new funding opportunities such as the Patient Centered Outcomes Research Institute. States and the federal government have an increasing need for the health professions workforce to have collaborative care skills and geriatrics clinical competencies, and are finding ways to invest in relevant initiatives. On the clinical program side, state and federal governments are initiating programs to promote delivery system changes that improve the care of older adults. Nonetheless, in the face of the policy challenges that have persisted after the “great recession,” academic geriatrics and general internal medicine will need to join forces with public and private interests to secure the resources needed to advance this ambitious agenda for geriatrics research, education and practice.     

Future Directions for Residential Care

Abstract. In looking to future directions in residential care, this paper considers a number of factors that make for stability and others that are likely to see a continuation of present trends before turning to sources of new development. While recent policy measures to integrate nursing homes and hostels have focused attention on higher levels of residential care, the scope for change here is seen to be limited by funding and other constraints. Instead of a return to the continuum view of residential care, a redrawing of the paradigm is proposed that builds on initiatives that promote more varied combinations of care and accommodation, more flexible funding arrangements, and more interaction with community care across a range of housing settings. Support for this paradigm of diversification is found in current international developments.     

Privacy in aged care

The extension of privacy laws to cover private sector providers and the proposal of a National Health Privacy Code highlight the importance of examining privacy issues in aged care policy and practice. Although privacy in health and aged care may also include physical, psychological and social dimensions, it is informational privacy that is the focus of these recent changes. In the present paper, a range of privacy practices in aged care are examined, drawing on theoretical, policy, practice and research literature. It is argued that aged care policy makers and providers need to move beyond the setting of privacy principles and management strategies, and also examine specific day‐to‐day privacy practices as they occur in different aged care settings. While privacy is often a valued commodity, the construction of an issue as private can sometimes be seen to limit the expression of diverse identities and to reinforce social inequality.     

Social Work Training for Mental Health Services to the Elderly Within a Multigenerational Context

The Multigenerational Family Project at the University of Washington School of Social Work aims to respond to practice gaps in both mental health and aging services. Given the growth in the number of multigenerational families and the increased employment of middle aged women who have been the traditional family caregivers, it is critical that geriatric social workers in mental health settings take account of the effect of multigenerational dynamics on the delivery of services. A multigenerational approach recognizes the dynamic interplay between the family's resources to provide care and the older person's needs as well as how the family caregiver's well-being interacts with that of the older person. This paper reviews the practice-based rationale for a multigenerational approach in social work education, and then presents curriculum implications. A multigenerational framework is viewed as one way to integrate content on aging with foundation courses in practice, policy, and human behavior with the field practicum. It also allows for the integration of content from other population-focused concentrations (e.g., children, family, and youth) or problem-focused specialization (e.g., health and mental health). Examples of multigenerational content to be integrated in core courses, a course on the multigenerational family, and a procedure to evaluate this curriculum change are discussed.     

Quality care among aging Americans

The unique needs of many elderly Americans are often not heard. However, in the face of an ever-growing aging population, clinicians are more actively planning healthcare for older adults across practice settings. This article examines the home care needs of elderly patients who wish for care, but not aggressive, acute care. The author reviews bioethical considerations that apply to elderly individuals and groups and presents suggestions to promote quality care that is ethically sound. This article also describes clinicians' obligation to identify what quality care means to the very old person and explains the deficiency model of aging along with its impact on medical intervention.     

Evidence Informing the Intersection of HIV,Aging and Health: A Scoping Review

The growing number of people over age 50 with HIV requires research, policy, and practice to develop a more comprehensive understanding of the health consequences of HIV in older individuals. We conducted a scoping review of peer-reviewed and grey literature published since 1996 to explore the impacts of aging on the health of older people with HIV (50 years or older). We included 209 studies (two systematic reviews, 174 quantitative studies, 28 qualitative studies, and five mixed methods studies). Health topics addressed include: HIV- and aging-related comorbidities, disease progression, neurocognitive functioning, mental health conditions, psychological well-being, social supports, stigma, antiretroviral adherence, health care utilization/access, and sexual risk behaviour. We recommend that future research takes a broader view of health, looks at aging from a strength-based perspective and examines the issue using diverse perspectives (i.e., geographic location, multiple methods, time of diagnosis, time on antiretroviral therapy (ART), demographic diversity).     

Effective nurse-led interventions in heart disease

Nurses are increasingly being involved in initiatives to improve the co-ordination, delivery and eventual outcomes of health care. Key components of these initiatives include application of evidence-based treatments, ensuring individualised follow-up and the provision of "seamless" care overall. There is evidence in key areas that nurse-led interventions for patients with heart disease are effective, and that they are likely to work in other areas if properly supported and appropriate structures and systems are put in place to promote such practice. Given the promising results to date, it would be disappointing if these issues remain unresolved and the potential value of this type of interventions unfulfilled.     

Creating Aging-Friendly Communities in the United States

An aging United States population, combined with traditional American values of independence and individualism, is fostering increased interest in community efforts to promote aging in place. This article describes the types of community aging-friendly initiatives that currently exist in the United States, and the roles that various sectors (e.g., public, non-profit, private) have played in their development. Findings from a national internet-based survey identified 292 current aging-friendly community initiatives, of four types: community planning, system coordination and program development, co-location of services, and consumer associations. Most represent local community interventions, developed in the absence of federal funding or guidance and often hampered by limited political authority or economic resources. Private sector solutions, such as mutual-benefit associations, appear to be on the rise; however, such initiatives are not widely accessible, especially to those individuals with insufficient resources or political power to participate in the private market. Taken together, these findings raise questions regarding the sustainability of current efforts, their availability to less-resourced individuals and communities, and the long-term ability of communities in the United States to make the infrastructure changes required to meet the needs of an aging society without an increased government role.     

Structure and quality of outpatient care for people living with an HIV infection

Policy-makers and clinicians are faced with a gap of evidence to guide policy on standards for HIV outpatient care. Ongoing debates include which settings of care improve health outcomes, and how many HIV-infected patients a health-care provider should treat to gain and maintain expertise. In this article, we evaluate the studies that link health-care facility and care provider characteristics (i.e., structural factors) to health outcomes in HIV-infected patients. We searched the electronic databases MEDLINE, PUBMED, and EMBASE from inception until 1 January 2015. We included a total of 28 observational studies that were conducted after the introduction of combination antiretroviral therapy in 1996. Three aspects of the available research linking the structure to quality of HIV outpatient care were evaluated: (1) assessed structural characteristics (i.e., health-care facility and care provider characteristics); (2) measures of quality of HIV outpatient care; and (3) reported associations between structural characteristics and quality of care. Rather than scarcity of data, it is the diversity in methodology in the identified studies and the inconsistency of their results that led us to the conclusion that the scientific evidence is too weak to guide policy in HIV outpatient care. We provide recommendations on how to address this heterogeneity in future studies and offer specific suggestions for further reading that could be of interest for clinicians and researchers.     

Bioterrorism and Emergency Preparedness in Aging (BTEPA): HRSA-funded GEC collaboration for curricula and training

Frail elders living alone or in long-term care settings are particularly vulnerable to bioterrorism and other emergencies due to their complex physical, social and psychological needs. This paper provides an overview of the recent literature on bioterrorism and emergency preparedness in aging (BTEPA); discusses federal initiatives by the health resources and services administration (HRSA) to address BTEPA; describes the collaborative efforts of six HRSA-funded geriatric education centers (GECS) to develop BTEPA geriatric curricula and training; and offers recommendations for BTEPA education and training, clinical practices, policy, and research. The GEC/BTEPA collaboration has produced model curricula, including emergency planning for diverse groups of older persons; enhanced networking among stakeholders in a fast paced environment of information sharing and changing policies; and developed interdisciplinary educational resources and approaches to address emergency preparedness for various settings in the elder care continuum.     

The Value of Integrating Policy People and Space in Research

In this article, we address several tangible and intangible factors, which are difficult to quantify and often overlooked yet are crucial for research success. We discuss three dimensions which encompass: (1) policy, (2) people, and (3) space. Policies, such as rules and regulations, define the culture of any research program/initiative. Governing rules and regulations defined within these policies are dictated by cultural values. Individuals who exhibit strong leadership, promote innovation, and exercise strategic planning often determine the governing policies. People are the most valuable asset available to any institution. Ensuring the professional growth (personal and scientific) and creating an environment which supports collaborative and collegial research through teamwork are factors that are important for individuals. Space, the physical work environment, is the third dimension of our model and is often an underutilized resource. In addition to the physical layout and design of the space, creating a positive work atmosphere which supports research initiatives is equally important and can create valuable momentum to research efforts. Collectively, these three dimensions (policy, people, and space) have a significant impact on the success of any research initiative. The primary objective of this article is to create awareness and emphasize the importance of implementing these variables within research initiatives in academic settings.     

Coordinating services across the continuum of health,housing, and supportive services

This article describes trends in three areas of state long-term care policy for elderly low-income Medicaid beneficiaries--providing home care services to residents in subsidized housing and assisted living; offering nursing home residents opportunities to relocate to community settings; and integrating acute and long-term care services for beneficiaries who are dually eligible for Medicare and Medicaid. The information was obtained from reports and studies on state policy, site visits, and interviews with state officials. Multiple initiatives responding to consumer preferences and fragmentation of the delivery systems were identified. Key components were consumer demand; the availability of nursing facility alternatives; and state priorities for controlling expenditure growth. States use Medicaid to develop broad service menus that include in-home, community, residential, and institutional services. Several states are conducting demonstration programs that improve coordinating or integration of long-term care with the acute care system.     

Pressure ulcers, outcomes, and the nursing shortage

The incidence of pressure ulcers is dependent on a number of variables. This article argues that the current and upcoming nursing shortage will adversely influence the pressure ulcer-related goals of public policy initiatives that strive to reduce the humanistic and cost burden of certain chronic conditions. The current state of the nursing shortage is described herein, along with examples of legislation proposed to control for this crisis and a consideration of the just distribution of goods and services (e.g., pressure ulcer care). Also provided is the voice of a nurse profoundly affected by the situation--a consideration of real and perceived threats to care.