Long-Term Care Quality
Confronting the Global Demands
Opening Remarks / Speech
October 2005
Jennie Chin Hansen
Member, AARP Board of Directors
International Forum on Long-Term Care - Delivering Quality Care with A Global Workforce
Washington, DC
October 20, 2005
Good morning.
On behalf of AARP, it is my pleasure to welcome you and to thank you all for coming. You are at the forefront of an international dialogue on long-term care that will surely increase in importance as so many of our countries experience a dramatic increase in our over 65 populations.
You are the leaders in this discussion; the ones who will identify the challenges and map out the opportunities we have for improving the quality of services we provide for our aging citizens.
Issues like this one highlight how much we are all interconnected and interdependent.
I know from my own experience how much can be gained when different cultures come together to find solutions.
I recently retired from my position as executive director of On Lok, Inc., a family of non-profit organizations that provide community-based long-term care services to seniors, along with a variety of other services.
On Lok was created in the Chinatown-North Beach community of San Francisco during the 1970’s when older immigrants from Italy, China and the Philippines and their families saw the need for long-term care services, especially services that could help keep older family members at home and within the community.
The name On Lok means "place of peace and happiness" in Cantonese, and this reflects both our organization’s roots and its philosophy of care.
On Lok has multi-cultural, multi-lingual, multi-generational programs for seniors that have become the models for other organizations all across the United States.
We have brought the best of our many cultures together to create an environment that respects and supports older consumers, their families, and their caregivers. I am also fortunate to serve on the board of directors at AARP.
Since its inception in 1958, AARP has reached out internationally as a key source of information and advocacy on issues affecting aging populations.
Forums like this remind us of what we have in common, what challenges we all must face, and show us how we can apply what we learn from each other to our own particular circumstances and needs.
Thanks to advances in science and technology, we now face the prospect of living longer. But along with the gift of longevity comes the chance that our longer lives may be marked by chronic illnesses and disabilities. And our families, once the primary caregivers, will not be able to provide the care we need, without help.
Many of our countries are confronting not only increased demands for long-term care workers, but we are also faced with addressing the impact these demands place on us economically, politically, and socially.
In many of our countries, the workforce for long-term care presents an immediate and growing problem that requires far-reaching solutions. Long-term care workers are often in short supply, and that’s only the beginning of the problem.
The work is typically low-paying and difficult, and it is common for these workers to have another job, just to get by. It’s no wonder that turnover in the field can be, in some institutions, as high as 100 percent a year. This is not a recipe for high-quality care.
The first question to ask is: how is first-rate care delivered? Clearly, it is not delivered by people with little or no training, who are underpaid, and overworked. We need standards for training that are appropriate to the actual duties of the workers. Workers need adequate wages and better working conditions.
If first-rate care is best delivered by skilled workers, then we next need to know where will the developed countries find these workers?
While cultivating a domestic base of workers for the provision of care, many countries, like the U.S., may also have to look abroad to find additional nurses and direct care workers to fill the need. Temporary work visas may be only a partial solution.
In many European countries, such “temporary” workers may live in a country for decades or even generations without being able to become citizens.
Moreover, immigration restraints often encourage illegal immigration. In Italy, for example, 83 percent of home helpers are, as they characterize it, "undeclared" by their employers.
The UK is one of the largest importers of professional healthcare workers in the world. A large percentage is employed in the long-term care system, and more and more are coming, often from former colonies in developing countries.
By contrast, Sweden and Norway employ relatively few foreign-born workers in long-term care.
And, in Austria, substantial cash benefits, little regulatory oversight of home care and a tradition of family caregiving have led to substantial use of international long-term care workers. Many of them are illegal, but are openly recruited by agencies for short-term rotating care duty.
At the same time, the source countries face their own set of challenges. The situation is most critical in Africa, which bears 25 percent of the world’s burden of disease but has only 0.6 percent of the world’s health care professionals to combat those diseases.
Many sub-Saharan African countries have fewer than 20 nurses per 100,000 population, compared to more than 1,000 in Norway and Finland.
The exodus of African nurses is especially relevant to long-term care employment in the UK and the US, since disproportionate numbers of immigrating nurses from Africa work in long-term care settings.
Whether the movement of health care professionals is a "drain," a "strain," or a "gain" on developing countries depends on at least three factors:
- the number of health care workers a source country has compared to its health needs;
- the percentage of the skilled workforce that migrates; and
- the patterns of migration from and return to less developed countries.
Even as we learn more about the impact on these developing countries, one thing is clear for us in the United States: we need to invest—directly or indirectly—in developing, training, and retaining more and more professional long-term health workers, regardless of whether they are foreign or native born.
We will not reach a level of adequate care if workers continue to view long-term care as a stop-gap position or a second job, often the low rung on the ladder.
It is not surprising that many direct care workers are recent immigrants, with limited skills and often limited ability in the language of the country where they are working.
This direct care work must be seen as a profession, not a low-level, even menial, job. We need required standards for training, properly delivered, to those who are already on the job—especially to foreign and native born workers who are already doing that work.
Much of the long-term care industry, at least in the U.S., is low tech. Let’s apply more technology to both training and the actual delivery of care.
But while technology has an important role to play in long-term care services, the human component — the touch of the hand, the kind word, the strong arm to support the frail body — remains critical to successful and compassionate care.
Last spring, AARP issued a report that predicted a growing gap between the number of people likely to need care and the number of people who are most likely to provide it here in the United States.
According to that report, between the years 2000 and 2030, the US population age 85 and older – those most likely to need personal care services—is projected to more than double, from 4.3 million to 8.9 million.
Meanwhile, the traditional caregiving population – women aged 20-54—is projected to increase by just 9% during this time. Add to that the fact that the number of direct care jobs is projected to increase at a much higher rate than employment in the overall labor market.
Then add, as well, the fact that Medicaid, the US program that is one of the chief sources of funds for long-term care, is facing the threat of budget cuts that could affect the delivery of services.
And we can be sure that finding workers to fill all the job openings will force us, in the future even more than in the present, to look abroad.
But the US is not the only country facing these challenges. As we’ll hear today, many of your countries are also struggling with the same labor shortage, the same need to recruit and retain workers from beyond your borders. The source countries, the countries the workers come from, are facing a whole range of different but related challenges.
We know from our own experience that national policies alone are no longer adequate. International arrangements are needed to address the needs and aspirations both of those who need long-term care and those who would provide that care.
This morning you will hear the findings from a new AARP report on the international migration of long-term care workers. This landmark report examines demographic, economic, and political factors driving the increased international migration of workers to provide long-term care services in developed countries.
The report takes a look at the factors that have an impact on the availability and quality of long-term care services in the developed countries, as well as the healthcare and economic systems in the developing countries. You will hear about the global trends that are driving changes in migration patterns and service delivery. And how these trends affect the individual workers and clients whose lives have been brought together in the most intimate of care by these global changes.
The report raises policy questions that must be dealt with by our individual countries as well as by international organizations concerned with meeting the needs of both developed and developing countries in our complex and changing world.
Questions that will get us thinking and talking. Questions about whether increased immigration is the best way to address worker shortages and what developed countries can do to meet the demand for unskilled workers. What responsibility do developed countries have for the impact on source countries? Do migrants depress wages and undermine working conditions? Should we establish international qualifications?
How do cultural and linguistic differences affect the quality of care? And how can we better integrate and allow for a smooth transition of foreign born workers into the long-term care work settings?
We may not find all the answers but we may learn new ways to approach these issues.
As we confront the demands of our changing world, demands for better long-term care services, demands for better working conditions for caregivers, we also confront our own demands that we work together to create a world in which we can all age with dignity and purpose.
I’m very much looking forward to hearing your presentations. Thank you.