Critical Workforce Gaps in Dementia Education and Training.

The US Department of Health and Human Services and the Foundation for the National Institutes of Health, through private sector support, sponsored the National Research Summit on Dementia Care: Building Evidence for Services and Supports (Summit) in 2017. Various workgroups were asked to address topics of interest in dementia care and develop recommendations addressing the goals of the Summit. Workforce education and training was identified to be a key issue. As a result, a Workforce Development Workgroup (the Workgroup) was created and addressed two of the Summit's goals. The first goal is to improve the quality of care and support provided to persons living with dementia and those who care for them. The second goal is to accelerate the development, evaluation, translation, implementation, and scaling-up of evidence-based and evidence-informed services for persons living with dementia, their families, and caregivers. In this article, the Workgroup identified gaps in educating and training a dementia-capable workforce. The Workgroup consisted of an interprofessional team with expertise in dementia workforce development from academia, professional organizations, and the federal government. Four recommendations are presented concerning research topics that will advance the education and training of a dementia-capable workforce, which includes health professions students, faculty, practitioners, direct care workers, persons living with dementia, and those who care for them. J Am Geriatr Soc 68:625-629, 2020.

BACKGROUND

The National Research Summit on Dementia Care: Building Evidence for Services and Supports (Summit) was held in 2017 on the campus of the National Institutes of Health. Various workgroups were asked to address topics of interest in dementia care and develop recommendations addressing the goals of the Summit. Workforce development was identified as a key issue and subsequently a Workforce Development Workgroup (the Workgroup) was created to identify research recommendations to develop a dementia‐capable workforce. For the purpose of this article, the workforce includes patients, families, caregivers, direct care workers, and health professions students, faculty, and clinicians. Research on the workforce will identify evidence‐based and evidence‐informed practices with a goal to improve care for persons living with dementia and those who care for them. The knowledge gained will be translated into workforce development and practice.

The Workgroup made four recommendations to address areas of critical workforce gaps (Table 1), which were presented at the 2017 Summit. The areas of critical workforce gaps for which the recommendations proposed are: (1) recruitment and retention of a dementia‐capable workforce, (2) financing and cost of workforce education and training, (3) interprofessional education and training for care coordination and management, and (4) translation and implementation of effective dementia care (Figure 1). Table 2 includes recommended research focus areas to address these critical workforce gaps.

Table 1

Recommendations for Areas of Critical Workforce Gaps to Increase the Size and Level of Expertise of a Dementia‐Capable Workforce

Area of Critical Workforce Gaps	Recommendation
1. Recruitment and retention of a dementia‐capable workforce	Recruitment and retention of a dementia‐capable workforce requires organizations to collaborate, identify, and meet workforce dementia education and training needs.
2. Financing and cost of workforce education and training	The emerging education and training needs of the dementia care workforce must be cost‐effective.
3. Interprofessional education and training for care coordination and management of dementia care	Research must show how to improve the delivery of dementia care and services, increase satisfaction with care, and reduce costs to improve care coordination and care transitions.
4. Translation and implementation of effective dementia care	Evidence‐based practices of effective care must be broadly disseminated to translate and implement effective care.

Figure 1

Four areas of critical workforce gaps in dementia education and training.

Table 2

Research Focus Areas and Recommendations Regarding Areas of Critical Workforce Gaps in Dementia Education and Training

Critical Workforce Gaps	Recommended Research Focus Areas
Recruitment and retention of a dementia‐capable workforce	Identify the minimum competencies. Identify necessary content of training programs and curricula. Determine how to recruit a workforce reflective of the population receiving care and services. Determine what demographics impact the workforce. Study the impact of dementia certification. Study the effect of raising the required level of knowledge on the ability of the workforce to obtain training. Study how direct service workers can be motivated, compensated, and empowered to become caregivers. Identify ways to recruit and retain caregivers and clinician educators.
Financing and cost of workforce education and training	Investigate the costs of updating curricula, providing additional training, and having individual specialty certifications. Evaluate the cost savings/cost benefits of providing dementia‐capable training. Compare costs associated with dementia certification vs a learning certificate in dementia care. Identify the impacts of expanding options for paid caregiving in Medicaid and for self‐directed service delivery. Study the impact of current technologies on caregiving. Ascertain what persons impacted by dementia want from home‐monitoring technologies. Determine the effectiveness of dementia‐capable vs nondementia‐capable professionals.
Care coordination and management of dementia care	Collect baseline information on interprofessional education and training needs of the workforce. Determine how persons affected by dementia define “high‐quality” care. Examine strategies to introduce advanced care planning to all. Determine the critical elements of goal‐of‐care conversations. Determine workforce‐training needs in technology applications and data management. Determine ways to integrate caregivers into the interprofessional team. Investigate how to train the workforce to cover care transitions. Identify the ethical considerations of the use of technology. Identify the uses and limitations of technology. Explore the use of technology in providing continuing education. Utilize technology to support data‐driven clinical decision making to contain costs.
Translation and implementation of effective dementia care	Determine the effects of translational research on the adoption of experiential and collaborative practice and team‐based learning. Ascertain effective ways to deliver research outcomes. Identify the characteristics of an effective dissemination and implementation plan. Identify impacts of educational interventions for disseminating and implementing research. Determine how to evaluate press and social media reports for reliability. Establish a process for vetting reliable internet sites.

The Workgroup recognizes that none of these recommendations will be realized in a vacuum. It will take collaboration between health professions accrediting organizations, health professions licensing bodies, federal agencies, and professional organizations to develop a consensus process to identify core competencies, domains, and milestones to codify improvements in educating and training a dementia‐capable workforce. Health information technology organizations will have a leading role in developing and promoting technology to assist healthcare practitioners, persons living with dementia, and those who care for them. Health systems, primary healthcare delivery systems, community‐based organizations, and federal, state, and local agencies all play an important part in workforce development, cost containment, care coordination, and the dissemination of ideas and solutions. Each of the four research topics and their recommendations are described below.

Research Topic 1: Recruitment and Retention of a Dementia‐Capable Workforce

Recommendation 1: Recruitment and Retention of a Dementia‐Capable Workforce Requires Organizations to Collaborate, Identify, and Meet Workforce Dementia Education and Training Needs

Increasing the number of people providing dementia care requires strategies for both recruitment and retention. Many caregivers are “recruited” to dementia care because of personal circumstances, perhaps when they choose to provide dementia care to a friend or family member. Others enter this workforce as a career. Ways to encourage both groups to join and remain in the workforce need to be identified. Understanding the motivations of caregivers and meeting their training needs may improve their recruitment and retention rates. To address health professional and direct care workforce shortages, recruitment and retention strategies need to be developed.

The healthcare needs of upcoming generations of older adults will be much different than those of previous generations. Upcoming generations will be more racially and ethnically diverse and will have higher levels of educational attainment, increased longevity, and a variety of household structures, with families being more widely dispersed.1 Training health professionals to capitalize on these strengths while supporting these challenges requires continuous work. Despite progress in health professions education in training the workforce to become culturally competent, competence standards must continuously evolve to address the changing needs of differing populations. Training of informal or family caregivers also needs to be updated to reinforce their capacity to engage in home‐based care. Suggested areas for competency include basic skills, such as accessing/navigating healthcare and home‐ and community‐based services and social supports. Further skills development should incorporate issues such as understanding implicit bias, health inequities, caregiver stress, health literacy, and sex/gender appropriateness.

The Workgroup identified eight research focus areas for recruiting and retaining a dementia‐capable workforce (Table 2). The recommendations include ways to recruit and retain caregivers and clinician educators and the impact of dementia certification.

Research Topic 2: Financing and Cost

Recommendation 2: The Emerging Education and Training Needs of the Dementia Care Workforce Must Be Cost‐Effective

The costs of healthcare, including long‐term services and supports (LTSSs), for persons living with dementia are substantial. Total payments in 2017 for all individuals with dementia were estimated to be $259 billion, approximately half of which is covered by Medicare and Medicaid. An additional $56 billion in out‐of‐pocket spending is borne by untrained caregivers, such as family and friends.2 With an average income of $45, 700, these caregivers report emotional and financial strain3 while providing assistance with daily activities, administering medical therapies, and providing direct care as well as navigating complex healthcare and social services systems.4 Much of the financing for long‐term care in the United States is borne by the Medicaid program, a partnership between the federal government and the states. In 2016, the federal government and states spent approximately $167 billion on Medicaid LTSSs, which includes institutional care and home‐ and community‐based services. Of that amount, 57% was for home‐ and community‐based services and supports.5 Medicare does not cover the LTSSs needed as dementia progresses. The types of LTSSs provided by Medicaid are constrained by the limits of state budgets.6

Better training of healthcare professionals, persons living with dementia, and those who care for them is needed to help the healthcare system meet the goals of improving population health, improving the personʼs experience, and reducing per capita cost. Research on assessing the cost of providing targeted benefits to unpaid caregivers for persons living with dementia that include education, care linkages, person‐centered planning, adult day health services, counseling and other behavioral health services, caregiver education/training, home‐delivered meals, support groups, and respite care indicates improved satisfaction combined with savings that exceed program costs.7 The cost of educating a dementia‐capable workforce is unknown. The reported costs of dementia training to individuals across the educational continuum, healthcare systems, and public programs are not available.

The Workgroup identified seven research focus areas in financing, and costs to inform this recommendation of cost containment that are listed in Table 2. The recommendations include investigating the costs of curricula development, training, and certifications and the financial impact of expanding options for paid caregiving in Medicaid.

Research Topic 3: Care Coordination and Care Management

Recommendation 3: Research Must Show How to Improve the Delivery of Dementia Care and Services, Increase Satisfaction With Care, and Reduce Costs to Improve Care Coordination and Care Transitions

Care coordination is “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patientʼs care to facilitate the appropriate delivery of healthcare services.”8 Implementation of care coordination and case management is essential to provide person‐ and family‐centered care across the disease trajectory. Several data‐driven models of care coordination have reduced cost and improved healthcare outcomes.9, 10

Care coordination and service interventions can reduce caregiver burden, increase skills/knowledge, and enhance satisfaction of the caregiver as well as prevent or delay institutionalization of the person living with dementia.11, 12 They also improve quality of care, reduce healthcare costs, decrease unnecessary medical services utilization, delay institutionalization, and improve the quality of life of both persons living with dementia and their caregivers.13

Care coordination and care management can be achieved through interprofessional collaboration and the development of reciprocal working partnerships between community‐based service providers, clinicians, and all other team members.14 The utilization of trained dementia care navigators to assist persons living with dementia and their caregivers in accessing dementia supports and services is growing in both for‐profit and not‐for‐profit sectors.15 Successfully linking needs, avoiding duplication, and filling gaps in services require coordination to address all concerns. Training a workforce to be aware of multiple needs and services and to be able to coordinate and manage that care requires specialized training.

The Workgroup identified 11 research focus areas to inform the recommendation of education and training for care coordination and management that are listed in Table 2. The recommendations include introducing current and emergent technologies used for education/training, monitoring (eg, telehealth) patients, and just in time interventions for training and management of challenging behaviors or situations.

Research Topic 4: Translation and Implementation of Effective Dementia Care

Recommendation 4: Evidence‐Based Practices of Effective Care Must Be Broadly Disseminated to Translate and Implement Effective Care

Research drives education, practice, and policy. Without a well‐developed dissemination and implementation plan, research results will not be used effectively. Dissemination and implementation are complex processes, involving many disciplines and partners. No single strategy is universally applicable in every situation.16 The who, what, when, where, why, and how of a dissemination plan vary with topic, content, and audience.

Education is an essential part of any dissemination and implementation plan. Good educators are adept at taking complex information and communicating in a culturally appropriate manner at the educational level of the learner. They also evaluate how educational inputs lead not only to educational outcomes, but also to patient, practice‐level, and health systems outcomes. With the advent of educating and training the workforce in healthcare delivery systems, educators are now evaluating how their learners are improving patient care, increasing patient and clinician satisfaction, and reducing costs.

Grant makers who support research of education and training should require that grant recipients provide a dissemination plan that ensures that results go beyond publications and presentations and are integrated into healthcare practice and delivery systems. In addition, grant recipients should be required to report on their successful dissemination activities. The Workgroup identified six focus areas to inform the recommendation of translating and implementing effective care (Table 2). The recommendations include ascertaining effective ways to deliver research outcomes and characteristics of effective dissemination and implementation plans.

SUMMARY

Described in this article are research focus areas and recommendations to help facilitate the size and expertise of a dementia‐capable workforce. The purpose of identifying these areas of critical workforce gaps is to assist investigators in identifying important research questions in education and training that would lead to the provision of high‐quality, cost‐effective dementia care. Funding for this type of research has rarely been a priority. This article is designed to help interested researchers to make stronger arguments to governments, foundations, associations, and other potential funders for support of their work in promoting workforce development for dementia care. The Workgroup challenges both new and experienced researchers, as well as new and experienced funding agencies, to explore these gaps and related recommendations. With new and continued commitment of financial support that includes requirements for dissemination into healthcare practice and delivery systems, it is hoped that researchers will become experts who will support the ever‐expanding dementia‐friendly community that strives to provide dementia‐capable care for persons living with dementia and those who care for them.