Essay Example on Older Adults in America: Healthcare Utilization and Accessibility

Chapter 1: Introduction

In 2017, there were approximately 61 million older adults in America, and of this population, over 50 million age 65 or older actively accessed various healthcare services (Administration for Community Living, 2018). The number of older adults is estimated to grow to 94.7 million by 2060 (Administration for Community Living, 2018). As of 2018, nearly 60 million older adults were enrolled in the government-funded health insurance, Medicare, and their health care needs that accounted for 15% of the U.S. federal spending or a total of 741 billion dollars (Centers for Medicare & Medicaid Services [CMS], 2019). As the US population ages, the demand for health care providers grows, with an increasing demand for nurses able and willing to work with older patients to improve their quality of life and decrease healthcare expenditure (CMS, 2019). Despite the high demand for gerontology trained nurses, less than 1% of the 3.6 million practicing registered nurses in the U.S. are geriatric certified (Geriatrics Workforce Improvement Act S.2888, 2018). In acute care, although sixty-one per cent of the 3.6 million registered nurses care for older adults only 7,716 were certified in gerontology as of 2018 and the remaining number of nurses in the workforce, only 6.3% RNs reported working with older adults in the communities and residential care facilities ( American Nurses Credentialing Center, 2018).

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The shortage of registered nurses working in gerontology negatively affects the quality of care available to older adults (Hsieh & Chen, 2018). Kurichi et al. (2017) noted that older patients represent the majority of patients in acute and long-term care settings, In 2017, Patients aged 65-84 years old accounted for 75% of all hospital stays and patients ages 85 and older accounted for 35.5% of all inpatient stay (Freeman, Weiss, & Heslin, 2018). The continued lack of health care providers willing to work with older adults resulted in an annual expense of 11.1 billion due to health care access discrimination, $28.5 billion due to a failure to provide appropriate early treatments related to negative age stereotypes, and $33.7 billion in age-related self-care-deficit health complications such as cardiovascular illnesses and diabetes (Levy, Slade, Chang, Kannoth, & Wang, 2018). The inadequate number of nursing staff to care for older adults leads to a 12% increase in mortality for patients on medical-surgical units, and a 2% to 7% increase in the mortality rate for patients in intensive care units (Bradley University Publication, n.d.). Furthermore, Wheatley (2018) noted that due to the nursing shortage, nurses work overtime to supplement staffing needs, which has led to an increase in the medication error. The medication errors reported include wrong intravenous infusion rates, administration of two doses of the same medication instead of one dose as prescribed, omission to administer prescribed medication, giving the wrong medication, and giving medication to the wrong patient. Nurses shortage is also associated with an increase in falls, pressure ulcers, nosocomial infections, hypoglycemic events, and pneumonia deaths (Wheatley, 2018). Registered nurses report high patient-to-nurse ratio and exhaustion as the primary reasons for medication errors and adverse patient outcomes (Bradley University publication, n.d.)

The growth in the older adult population also brought a corresponding surge in the number of individuals with cognitive and functional limitations (Congress of the United States, 2019). There are an estimated 5.6 million older adults suffering from Alzheimer's disease, and an estimated 4.1 million older adults at home who need assistance with clinical needs such as medication administration, wound care, intravenous therapy, and respiratory care. Older adults in the community who need clinical care often require frequent visits from a registered nurse (Scholz & Minaudo, 2015). According to Scholz and Minaudo (2015), registered nurses are more effective than unlicensed personnel in providing high quality care to older adults in the community because they do not require the same level of oversight as an unlicensed caregiver. Registered nurses in home care reduced emergency department visits, decreased mortality, and improve patient confidence in self-management of care. However, because of the shortage of RNs in the gerontology field, 19.8 million non-clinical Americans who provide care to older individuals reported performing clinical tasks for their loved one in the absence of trained clinicians (Family Caregiver Alliance, 2019). The lack of trained providers to administer clinical care leads to 20% avoidable readmissions to acute care within 30-days of discharge (Gusmano, Rodwin, Weisz, Cottenet, & Quantin, 2015). Older adults admitted to acute care with preexisting cognitive or functional dependencies are more vulnerable to further decline and functional loss (Wijk et al., 2018). In acute care, functional decline occurs due to strickly enforced bed rest, use of sedating drugs, and physical restraints which lead to confusion and loss in daily functions of walking, bathing, dressing, and eating (Wijk et al., 2018). According to Hoyer, Brotman, Chan, and Needham (2015) up to 50% of older adults hospitalized with an acute medical illness experience a persistent decline in their ability to maintain activities of daily living (ADLs). Such activities are prerequisites to self-care and independent living. This declined is known has a hospital-associated disability (HAD) (Reichardt et al., 2016). Sudden changes in mental or functional status are often overlooked by healthcare providers because of the lack of knowledge in gerontology (Scholz, & Minaudo, 2015). The loss of functional abilities leads to prolonged hospital stays, need for institutionalization or inpatient rehabilitation services, and increased mortality rate (Reichardt et al., 2016). Patients age 65 and older make up 50% of acute care admissions and two-third of hospital stay (Fulmer et al., 2016).

Although the majority of older adults live at home, approximately 1.6 million older adults live in long-term care facilities (Allen, 2017). In nursing homes, RNs conduct daily physical assessments to promote residents' health and promptly address potential health issues (Center for Medicare and Medicaid Services, 2018). Registered nurses also provide complex care to older adults on different forms of life supports such as mechanical ventilation machine, which assists in breathing when patients are unable to breathe independently; left ventricular assist devices (LVAD) which help the left bottom chamber of the heart pump blood effectively to the body; life vests which correct life-threatening arrhythmias, and tube feedings which provide alternative ways to feed older adults with swallowing problems. Previous studies showed higher staffing levels in long-term care facilities were associated with decreased unwanted patient outcomes (Backhaus et al., 2017). McKnight's Long-Term Care News (2018), however, estimated the national turnover rate of RNs in nursing homes at 33.94 per cent. Because of to the shortage of RNs willing to work with older adults, RNs went from spending an average of 3.3 hours per day caring for older adults in residential care facilities in 1993 to spending 2. 25 hrs or less per day in 2019 (Allen, 2017). The lack of time to assess the residents as a result of the staff shortage leads to failure to capture preventable health complications and hospital transfers (CMS, 2018).

Per Hseih and Chen (2018), there are not enough nurses willing to work with the older adult population. The lack of gerontology trained registered nurses willing to work with older individuals has widespread social and economic consequences (CMS, 2018). According to the Agency for Healthcare Research and Quality (2016) due to poor health management, older adults are often readmitted to acute care within 30 days of a previous discharge for conditions such as heart failure, pneumonia, chronic obstructive pulmonary disease, hip and knee replacement and coronary artery bypass graft surgery. Thirty-day readmissions significantly increase mortality rate (CMS, 2019). To improve patients outcome, CMS developed the Hospital Readmissions Reduction Program (HRRP) that reduces payments to acute care with readmission rate higher than the national average and the Skilled Nursing Facility Value-based Purchasing (SNF-VBP) program that imposes a 2% reimbursement penalty or a Medicare incentive payments to SNFs based on their readmissions performance (McCarthy et al., 2019). In 2018, 82% of the 3173 hospitals and 73% of approximately 15000 SNFs in the U.S. received a penalty (McCarthy et al., 2019).

Stakeholders in the United States have established a robust academic and clinical geriatric nursing infrastructure to meet the needs of the growing older adult population (American Association of Colleges of Nursing [AACN], 2014; ANA, 1976; Johnson & Connelly, 1990; Fulmer & Matzo, 1995). Despite the efforts within professional nursing organizations, private and federal funding, and support for training, the number of nurses specializing in geriatrics remains fewer than 10,000 (American Nurse Credentialing Center, 2018)

In 1999, Rosenfeld, Bottrell, Fulmer, and Mezey surveyed to evaluate the status of geriatric nursing in baccalaureate nursing programs. Using the National League for Nurses database, Rosenfeld et al. mailed surveys to all 598 existing bachelors of science in nursing (BSN) programs. They received an 80.3% response rate or 480 completed surveys, and they found 177 nursing programs had stand-alone geriatric courses, while 299 integrated geriatric content within other courses (Rosenfeld et al., 1999). Of the 177 nursing programs that offered stand-alone courses, 62 % of programs made the course mandatory. Rosenfeld et al. concluded the progress made was notable, but insufficient to meet older adults' needs.

In 2005, Berman et al. reassessed the geriatric capacity of BSN programs in the United States by sending surveys electronically to 623 programs retrieved from the AACN database. Berman et al. received 556 complete responses revealing that 92%, or 514 programs, offered geriatric content through a threaded format. This number represented an increase of 29% from the numbers of programs that reported on the integration of geriatric content in 1997. Markedly, though the number of BSN programs offering stand-alone courses increased from 177 to 190, the percentage of BSN offering stand-alone geriatric course declined from 37% in 1997 to 34% in 2005 (Berman et al., 2005). According to AACN (2017), the decline in the percentage of BSN programs offering stand-alone gerontology course was due to an increase in the number of associate degree nursing programs over baccalaureate programs because of 4-year programs struggled to expand their capacities to meet the demand for more nurses. The American Associaton of Colleges of Nursing (2020) reported the existence of more 996 bacca...