Advocacy Correspondence: PA Department of Aging Secretary, Meeting the Needs of Older Adults

March 20, 2024

The Honorable Jason Kavulich Secretary
Pennsylvania Department of Aging
555 Walnut St. 5th Floor
Harrisburg, PA 17103

Dear Secretary Kavulich:

On behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), thank you for the opportunity to comment on the commonwealth’s 10-year roadmap to meet the needs of older adults. HAP represents more than 230 hospitals and health systems across the commonwealth as well as the patients and communities they serve.

Hospitals and health systems play a vital role caring for and enhancing the health of older Pennsylvanians—both through the care they provide and community/population health initiatives—and are focused on meeting an increasing need for care as the commonwealth’s population ages. Hospitals are also closely connected with other providers along the health care continuum. When one part of the continuum is strained, that stresses the other parts.

The commonwealth’s plan rightfully identifies access to services along the entirety of the health care continuum as a key factor in the ideal experience for older Pennsylvanians. While the plan includes important tactics related to physical and behavioral health care, the commonwealth’s approach to supporting older residents must put a greater emphasis on:

• Developing the health care workforce needed to care for Pennsylvania’s aging population.
• Meeting the unique behavioral health needs of older adults.
• Addressing barriers to care in rural communities.

Workforce Development

The commonwealth’s plan rightfully recognizes the need to increase Pennsylvania’s direct care workforce but must acknowledge the immediate urgency of statewide collaboration to grow health care professionals along the entire continuum, including in hospitals and primary care settings.

There is a national health care workforce shortage and the challenges in Pennsylvania are among the most severe. HAP’s November 2023 survey of Pennsylvania hospitals found that vacancy rates for many key positions remain in the double digits, with statewide average vacancy rates as high as 19 percent for nursing support professionals and 14 percent for registered nurses.

Beyond filling current vacancies, Pennsylvania needs to dramatically increase our health care workforce as our population ages and requires more care. A 2021 Mercer report projected that, by 2026, Pennsylvania will need an additional:

• 20,345 registered nurses (worst shortfall nationally).
• 277,711 nursing support professionals (third-worst shortfall nationally).
• 6,330 mental health professionals (third-worst shortfall nationally).

Workforce shortages in any setting strain services along the entire continuum. For example, patients must wait longer to be discharged from the hospital if there are limited opportunities for placement in long-term care facilities or behavioral health services.

As Pennsylvania ages, more professionals are retiring from the health care workforce just as the need for the services they provide is increasing. There are proportionally fewer working-age Pennsylvanians to fill these positions and—also due to retirements and other factors—fewer faculty and clinical educators to develop the next generation of health professionals.

As the commonwealth considers how to meet the health needs of older Pennsylvanians, we believe the plan must include strategies to:

• Expand opportunities to train and educate the next generation of health professionals, including increasing faculty, preceptors, and clinical education space.
• Keep providers in Pennsylvania through incentives like student loan forgiveness.
• Bring to scale proven partnerships between health care organizations, educators, community groups, and/or government that create or strengthen pipelines into health care careers.

Behavioral Health

Pennsylvania’s older adults face unique behavioral health needs. We have an opportunity now to put plans in place to ensure that we can meet this growing need.

In particular, the commonwealth must be prepared to address the needs of older adults who:

• Have long-term mental health and/or substance abuse issues.
• Develop new behavioral health challenges late in life.
• Have dementia and co-occurring behavioral health concerns.

Older adults too often go undiagnosed and untreated, exacerbating their medical conditions and diminishing their independence, quality of life, and overall well-being. The status quo is an untenable patchwork of funding streams and county, state, and federal contracts. Vulnerable older adults often slip through the cracks of the Medicare, Medicaid Behavioral Health, and Medicaid Community Choices programs.

Pennsylvania hospitals are a part of the necessary behavioral health delivery system but not the whole solution. Across the commonwealth, older adults experience discharge delays (sometimes getting “stuck” for 100 plus days) awaiting placement into clinically appropriate post-acute care and recovery supports. This is unacceptable. Older adult behavioral health needs will continue to go unmet without a comprehensive plan to address them.

Depression, anxiety, addiction, and other mental illnesses should not be a normal part of aging. HAP is working closely with other stakeholders, including Pennsylvania Association of Area Agencies on Aging, to identify promising care models and advocate to ensure that older adults have access to the care they need.

The commonwealth’s vision for aging should prioritize older adult behavioral health services and put forward a comprehensive plan to ensure that every older adult in every county has timely access to a full continuum of mental health and addiction services. With intention, we can:

• Increase access to in-home and telehealth behavioral health and addiction services.
• Integrate behavioral health and addiction services in long-term care settings.
• Co-locate behavioral health care in primary care settings.
• Augment the workforce and educate caregivers across the continuum about the unique needs of older adults.

Rural Access

Many older Pennsylvanians live in rural communities and face unique barriers to accessing health care.

The commonwealth’s plan notes the importance of transportation to older adults’ ability to access services. In rural communities—where there is a shortage of reliable transportation options, such as public transportation, taxis, and rideshare programs—transportation represents a significant barrier to both patients and providers.

Rural hospitals especially often need to transport patients to other facilities, such as other hospitals, post-acute care, nursing homes, or assisted living facilities. Rural hospitals often struggle to find appropriate transportation for these transfers or to take patients home, resulting in patients waiting in the hospital longer than needed. Patients often cancel appointments due to lack of transportation, leading to greater health challenges.

The commonwealth’s plan should emphasize bolstering emergency medical services and other transport options to better meet the health needs of older Pennsylvanians.

While ensuring the long-term sustainability of hospital care is vital throughout the commonwealth, it’s especially important to older, rural Pennsylvanians because of the limited access that already exists in many rural communities and the amplified financial pressures on rural hospitals. Hospitals across the nation face severe financial challenges as the cost of providing care increases while payments from Medicare, Medicaid, and commercial insurers have not kept pace. Rural hospitals often care for patients who are disproportionately dependent on Medicare and Medicaid and serve fewer patients than their urban and suburban counterparts. This combination makes it challenging, if not impossible, for rural hospitals to achieve economies of scale, even as their fixed operating costs remain high. It also means that hospitals that serve a greater share of older adults are often the most at risk financially. The commonwealth’s plan must include targeted recommendations to ensure that health care providers throughout the continuum of care are able to sustainably meet an increasing need for care as Pennsylvania ages.

Thank you for the opportunity to comment. We would be happy to discuss any of these priorities in greater detail. HAP looks forward to being a partner in supporting the health of the commonwealth’s older residents.

 

Sincerely,

 

Nicole Stallings
President and CEO

 

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Topics: Behavioral Health, Population Health, Public Health, Regulatory Advocacy, Rural Health Care, State Advocacy, Workforce

Revision Date: 3/20/2024

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