6

Facilitated Table Discussions

Following each of the three panel sessions, there were 15-minute facilitated discussions among small groups of workshop participants. These discussions were intended to explore ways to bring good, effective methods for workforce training and care coordination to scale; to bring technologies to scale; and discuss what the various research and data gaps are that, if addressed, might strengthen the workforce to support community living and participation for older adults and people with disabilities. A rapporteur at each table then reported those discussions to the workshop audience at large—the reports from the table rapporteurs were not recommendations from the workshop participants as a whole. The topics that were reported by the table rapporteurs were grouped by theme for the purposes of presenting the information in this Proceedings of a Workshop.

The reports from the table discussions were delivered by the following individuals, listed alphabetically: Davis Baird, National Association of Area Agencies on Aging; Elizabeth Blair, Center for Elder Care and Advanced Illness; Margaret Campbell, Campbell & Associates; Karl Cooper, American Association of Health and Disability; Kevin Cordeiro, The John A. Hartford Foundation; Thomas Edes, Department of Veterans Affairs; Valerie Edwards, Centers for Disease Control and Prevention; John Hough, National Center for Health Statistics; H. Stephen Kaye, University of California, San Francisco; Tracy Lustig, National Quality Forum; Rebecca Mabe, Eldercare Workforce Alliance; Rebecca Paxton, Eldercare Workforce Alliance; Leo Quigley, Health Workforce Institute at

George Washington University; Irwin Tan, AARP; Glen White, University of Kansas; and Daniel Wilson, Paraprofessional Healthcare Institute.

TRAINING

Training Content

• Create person-centered and outcomes-oriented training designed for implementation in the real world that is beyond the walls of the hospital and that listens to the voice of the consumer. (Lustig)
• Account for the need for flexibility in the approach to training; prepare the caregiver to be flexible and able to react to the specific care site and the specific individual’s needs and desires. (Lustig)
• Determine how familiar or aware consumers are with their own capacities, capabilities, and rights with regard to the type of training they need and want their caregivers to have. (Hough)
• Integrate competency into training and de-emphasize theory. (Wilson)
• Expose health care professionals to community settings early in their training to help incentivize them to work in those settings after completing their training. Such training for dentists has been shown to increase the likelihood that they will care for patients in these communities. (Lustig)
• Consider the role that value-based purchasing can have on training. Payment policies drive a great deal of how and where training happens, so reimbursement for trainings provided within a consumer’s home could incentivize the personalized training methods discussed during the workshop. (Lustig, Wilson)
• The American Board of Internal Medicine should add a requirement for home visits, similar to the family medicine requirement. This group should also establish an interdisciplinary home care experience, such as home-based primary care or home-based palliative care, at every academic institution. (Cordeiro)
• Develop incentives for workers to engage in continuing education to enable them to build on the baseline skills training that they previously received, particularly when that additional training addresses the specific needs of the clients they are serving. (Wilson)

Potential Data and Research Needs for Training

• Collect and examine outcomes data and patient satisfaction to see if outcomes improve with better training. (Blair, White)

• Enlist business schools to conduct research on training efficiency. (Hough)
• Find data on the effectiveness of patient navigator programs and whether they should be adopted and scaled. (Hough)
• Examine patient outcomes and cost outcomes for existing models, and examine the frequency of interactions among the interdisciplinary teams and individual team members. (Cordeiro)
• Collect and aggregate data within professions and across health care sectors on existing training methods. (Cooper)
• Collect data on compensation for training, particularly for geriatricians. (Cordeiro)
• Examine readmission rates for hospitals and extended care facilities, how nursing homes are used, and the amount of time spent in hospitals, at home, and in extended care facilities, as well as patient satisfaction as these things relate to training. (Cordeiro)
• Collect data on workforce feedback from known effective models and how workers are being engaged in, and satisfied by, the training afforded by those models. (Cordeiro)
• Address data gaps regarding training issues for family caregivers in order to identify possible incentives that would drive family caregivers to be trained and the type of training that would best serve their needs. (Blair)
• Collect data on the reasons for turnover among health care workers and to determine if a lack of training is a cause of high turnover. This will require data from both quantitative and qualitative methods and could require modeling and surveying. (Blair, Cordeiro, Hough)

Bringing Training Methods to Scale

• Develop research and evaluation strategies, including testbeds, to define and identify the common elements of effective training models that are person-centered and outcome-oriented and that account for the changing infrastructure, including changing technologies. (Campbell, Wilson)
• Understand states’ statutes on different professions’ scopes of practice that may preclude or act as barriers to addressing training needs. (Hough)
• The Administration for Community Living should fund interdisciplinary community-based training and education programs for the workforce. (Lustig)

COORDINATION

Features to Include in Programs to Enhance Coordination

• Create an official, government-sponsored or quasi-government-sponsored convening activity on home and community-based delivery systems and their integration with health care that supports both community living and health. The purpose of this convening would be to develop a common language between the aging and disability communities and between organizations working within and outside of the long-term services and supports area. This convening would also aim to identify outcome measures and a structured process for transitions between the health care system and the community. (Kaye, Mabe)
• Create a national repository of promising practices and the accompanying evaluation data, history of use, and other details. The Agency for Healthcare Research and Quality’s Health Care Innovations Exchange¹ could serve as a model for this type of repository, which would need to have a strong dissemination component to raise awareness of its existence. (Kaye, Mabe)
• Examine successful programs of coordination, such as CATCH-ON (see Chapter 4), in order to identify effective elements that are common across programs, with the understanding that effective elements might work well in some settings but not in others. (Lustig)
• Look at the models for care coordination and patient navigators that are commonly used with oncology patients as possible examples for improving care coordination for individuals with Alzheimer’s disease or with intellectual and developmental disabilities. (Hough)
• Provide clinicians and caregivers with more information about the effectiveness of their efforts in terms of patient satisfaction and cost effectiveness. This feedback could increase provider satisfaction, help reduce burnout, and serve as an incentive. (Quigley)

Potential Data and Research Needs for Coordination

• Develop the necessary data sharing infrastructure to enable the direct-care workforce to connect to the many people involved in a coordinated care system. (Mabe, Quigley)

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¹ For more information, see https://innovations.ahrq.gov (accessed September 27, 2016).

• Mine electronic health records for data on referral rates among different teams to analyze how good those teams are based on how often they receive a referral. (Cordeiro)
• Consider the different perspectives and data needs of the range of stakeholders who could be interested in a given dataset—e.g., patients, individuals in the community, providers, researchers, or federal agencies—when determining what data to collect because organizations sometimes measure what is easily measured rather than what is important. (Tan)
• Use qualitative and quantitative data to produce a collective story demonstrating the potential importance of integrating the medical and social service systems. Quantitative data are important for demonstrating desired outcomes such as reducing costs, hospital readmissions, institutionalization, and emergency department utilization, while qualitative data are needed to understand the impact of interventions on patient-reported outcomes such as satisfaction with care and worker-reported outcomes. (Cordeiro, Edes, Lustig, Tan)

Bringing Coordination to Scale

• Use collaboration itself as an incentive to scale programs. If caregivers train and gain experience as part of an interdisciplinary team, especially a team that includes community partners, then they will think and behave like a team and will be more likely to engage in their communities. (Edes)
• Demonstrate how programs might generate cost savings that could be used elsewhere within a program or service site. (Hough)
• Create a baseline manual on how a provider should coordinate services to avoid reinventing the wheel when creating an infrastructure to coordinate services. (Paxton)
• Create geriatric-friendly emergency departments that would have expertise not only in geriatric medicine, but in the social services and transitional programs that could serve the additional needs of older patients. (Hough)

TECHNOLOGY

Potential Design Features

• Design new technologies so that they are interoperable. (Baird, Mabe)

• Design sensitive and responsive monitoring systems that are able to produce data that are actionable and customizable. (Baird)
• Develop intergenerational models of instruction to take advantage of the fact that younger generations may adopt technologies more rapidly and enthusiastically; identify ways in which technological understanding can flow seamlessly from one generation to the next. (Baird)

Financing

• Consider financing as technologies are developed so that implementation of technology solutions does not create disparities between those who can afford the technologies and those who cannot. (Lustig)
• Evaluate whether rapidly changing technologies might require policy changes to address how often and how many times payers will provide reimbursement for new equipment; the inconsistent speed at which technology and policies change could inhibit technology adoption. (Lustig)
• Develop outcome measures that can be used to create a return-on-investment case for new technologies. (Baird)
• Medicare and Medicaid reimbursement will serve as important incentives for the adoption of innovative technology and the use of social capital to bridge the digital divide that leaves many underserved communities and populations out of the conversation about technology adoption. (Baird)

Potential Data and Research Needs for Technology

• Ensure open access to data as a bedrock principle for technology adoption, interoperability, and the successful application of metrics. (Baird)
• Develop metrics to determine how the adoption of technologies that are useful at a system level, rather than a consumer level, trickles down to produce benefits for the individuals in that system. (White)
• Data are needed to identify what older adults and individuals with disabilities want from technology, whether the technology they have received is actually being used, and to what extent these systems are adaptable, modularized, and usable in different situations. The missing measures to generate such data represent a data gap. There is also a gap in understanding how comfortable individuals in different age groups are with the technological

• solutions being developed to help them live independently in the community and how they would make use of different types of technologies. (Cordeiro, Edwards, Hough)

• Collect and analyze data on cost-effectiveness in order to demonstrate whether the upfront costs often associated with adopting new technologies have a worthwhile return on investment. Many payers may not have a long-term incentive to pay for these upfront costs, given that individuals may change their insurance plans or go on Medicare. As a result, the payer who makes that initial investment may not realize the long-term benefits. (Lustig)
• Gather information on the factors that consumers, particularly older adults, believe would break down barriers to technology adoption. Participatory consumer research that engages a broad range of people from the design through testing phases of technology development could generate such data and help ensure that those data are actually informing technology development. (Edwards)

Bringing Technologies to Scale

• Keep usability and customer satisfaction as central attributes of any technology that is to be adopted at scale. (White)
• Develop efficient access to telecommunication technology across providers and settings. (Mabe)
• Create technology advisors who can match consumers with specific disabilities and needs with the technologies that can make the biggest difference in their lives. (Cordeiro)
• Develop technologies that are widely useful so as to achieve the greatest success in the marketplace. (Baird, Lustig)

ADDITIONAL OPPORTUNITIES FOR STRENGTHENING THE WORKFORCE TO SUPPORT COMMUNITY LIVING

• Create an accessibility report card that would enable consumers and their caregivers to determine in advance if a medical practice or social service facility is accessible physically and behaviorally. (Hough)
• Scale the National Core Indicators^TM2 measures to include more states and to tie medical care measures to quality-of-life measures. (Cooper)

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² For more information, see http://www.nationalcoreindicators.org (accessed September 27, 2016).

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