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Addressing the Health Needs of an Aging America | 1

The Stern Center for Evidence-Based Policy

Addressing the Health Needs of an Aging America New Opportunities for Evidence-Based Policy Solutions



Addressing the Health Needs of an Aging America | 2

The Stern Center for Evidence-Based Policy


The Stern Center for Evidence-Based Policy (“Stern Center”) fosters, supports, and leads rigor- ous scientific research initiatives that generate actionable, evidence-based health policy recommen- dations. By leveraging significant advances in evidence-based research methods and collaborating with key stakeholders, the Stern Center aims to empower policymakers with the best research infor- mation available. The goal of the Center is to improve the health of the U.S. population by increasing the use of evidence in the policymaking process.

Housed in the University of Pittsburgh’s Health Policy Institute, the Stern Center brings together ex- perts from across the health sciences, including medicine, public health, pharmacy, nursing, dentistry and the rehabilitation sciences, to collaborate on applied policy research. Subject matter experts are supported by a team of political scientists, health economists, biostatisticians, information scientists and regulatory experts who provide the methodological and analytical backbone for the Center’s projects. The Center partners with other academic institutions, research organizations, associations, stakeholder groups and governmental entities to enrich our work and disseminate findings.

We would like to acknowledge the multidisciplinary team of researchers at the University of Pittsburgh that conducted this study. The team was led by Dr. Sally Morton (Graduate School of Public Health) and Dr. William Dunn (Graduate School of Public and International Affairs). Researchers that contrib- uted were: • Johanna Bellon, MS, CFA, PhD (Health Policy Institute) • Kim Coley, PharmD, FCCP (School of Pharmacy) • Stephen Coulthart, PhD (Graduate School of Public and International Affairs) • Howard Degenholtz, PhD (Graduate School of Public Health) • Anthony Delitto, PhD, PT, FAPTA (School of Health and Rehabilitation Sciences) • Julia Driessen, PhD (Graduate School of Public Health) • Meredith Hughes, (Health Policy Institute) • Everette James, JD, MBA (Health Policy Institute) • Taafoi Kamara, MPH (Aging Institute) • Alyssa Landen, MPH (Graduate School of Public Health) • Sally Caine Leathers (Health Policy Institute) • Melissa McGivney, PharmD, FCCP (School of Pharmacy) • Maqui Ortiz (Health Policy Institute) • Ana Progovac, PhD (Health Policy Institute) • Charles Reynolds, MD (Aging Institute) • Philip Rocco, PhD (Health Policy Institute) • Jogeshwar Singh, MHA, MD (Graduate School of Public Health) • Joel Stevans, PhD (Health and Rehabilitation Sciences) • Barb Folb, MLS, MPH (Health Sciences Library System) • Charles B. Wessel, MLS (Health Sciences Library System)



Addressing the Health Needs of an Aging America | 3

Table of Contents

Executive Summary 4

Introduction 7

The Challenges of Caring for an Aging America 8

Identifying Opportunities for Evidence-Based Policy Solutions 10

Where Evidence and Policy Meet 13

Evidence Searching for Policy Levers 24

Policy Recommendations Searching for an Evidence Base 26

Conclusion 32

Appendix A: Research Methodology 33

Appendix B: Results 35

Addressing the Health Needs of an Aging America | 3



Addressing the Health Needs of an Aging America | 4

Executive Summary

The U.S. population is rapidly aging. And its healthcare needs are changing.

Evidence-based policymaking can improve the cost and quality of care for the aging.

This study is the first to systematically map health policy recommendations for the aging to the body of research evidence

By 2050, adults over the age of 65 will make up 20 percent of the U.S. population. The budgetary and policy implications of this demographic shift represent two of the greatest challenges faced by federal and state governments today. An aging population will place intense stress on our healthcare system, its funding sources, and American families. Lack of personal savings for long term-care and a fragmented and institutionally-dependent delivery system will pose significant risks to the health and quality-of-life of aging Americans. Our healthcare workforce will need to be re-tooled to manage the multiple chronic conditions prevalent in this vulnerable population. Addressing the needs of the elderly will be a top priority of policymakers at every level.

Meeting the health needs of an aging America requires policy proposals based on the best-available research evidence about how to improve access, affordability and the quality of health services. To- day, for many reasons, health policymaking often fails to fully consider scientific research evidence. With aging Americans and their loved ones at risk, policymakers have a responsibility to inform their decisions with rigorous, objective evidence. At the same time, health policy researchers must find a way to present scientific results in a manner that is relevant to and applicable by policymakers. This study is the first in a series of efforts to connect research evidence to the set of policy recommenda- tions being made to address the health needs of older adults in the United States.

In an unprecedented effort to map evidence to health policies, a multidisciplinary team of research- ers conducted a two-phase study to identify opportunities for policymakers seeking to improve the cost and quality of healthcare for the aging. Results of a broad literature search of medical research evidence were matched and compared to policy recommendations from multiple, cross-cutting health- care stakeholder groups. From an initial search return of over four hundred thousand literature cita- tions and over 493 health stakeholder organizations, researchers conducted a scoping study and policy scan to identify unique stakeholder policy recommendations and studies related to the health of the aging population. An expert panel used these results to organize the information into 10 us- able policy categories (further divided for easy reference into 75 subtopic areas), which combine to present a comprehensive and unbiased view of the best-available evidence and policy activity around healthcare for older adults. The study intends to inform future policymaking in this critical area with an easily applied index of evidence-based policy research mapped to the full range of policy options.

Matching these results allows policy makers and the stakeholder community to identify potential areas of interest:

1) Where there is significant policy interest and evidence to support proposed changes; 2) Where policy topics have a strong evidence base but are receiving little attention; and 3) Where there is policy activity but a lack of scientific evidence.



Addressing the Health Needs of an Aging America | 5

Where Evidence and Policy Meet

Evidence That Deserves Greater Attention From Policymakers

The study revealed three areas in which a rich base of research evidence and a high level of demand for policy change exist:

Prevention and Wellness interventions lower the cost of care and improve health outcomes by preventing the onset of disease entirely, detecting the early onset of disease through screening, and slowing or stopping the progression of disease. Within this broad category, the study revealed specific focus areas where evidence and policy demand strongly converge: screening and early detection; nutrition and diet; and patient education, empowerment, and physical activity.

The Healthcare and Informal Caregiver Workforce reforms seek to address a significant short- age in the number of professionals who have the necessary skills to treat complex geriatric patients. Policy interventions could support the use of new models of care to expand the role of family care- givers, leverage the unique skills of nurses and other advanced practice providers, train the work- force in geriatric competencies, coordinate interprofessional teams to manage care, and identify opportunities for engaging community health workers. Coordinated Care interventions encourage healthcare payers and providers to move toward a more accountable system, where a greater portion of reimbursement is tied to patient health outcomes. The study revealed significant evidence and policy activity on interventions related to care pathways and bundles, disease management programs, specialized units, discharge coordination and pa- tient navigation, and coordinated delivery of primary and long-term care.

The following topics had an extensive, rigorously conducted evidence base but received lim- ited attention in the policy arena.

Patient Self-Care and Self-Management initiatives encourage patients to work with their providers to preserve their health status and minimize avoidable complications. These initiatives utilize strate- gies such as patient education to encourage healthy decisions and behaviors as well as technology enabled self-care. Better management of chronic disease can help patients with complex, co-morbid conditions avoid unnecessary interactions with the healthcare system, such as costly trips to the emergency room.

Palliative and End-of-Life Care refer to approaches that focus on relieving symptoms for patients with pain and terminal illnesses and providing support and resources for their family members. Ap- proximately one-third of Medicare dollars are spent on patients in their last two years of life; these initiatives seek to reduce the suffering of patients at the end-of-life while creating considerable oppor- tunities for healthcare cost reduction. Such initiatives hope to improve patient and caregiver satisfac- tion.



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Two topics were notable for a large number of policy recommendations within the sampled stakeholder organizations, but a lack of research evidence to support these recommenda- tions.

Medical Malpractice: A cost-effective, high-value healthcare system would ideally eliminate wasteful and unnecessary care associated with the practice of defensive medicine. Yet the study found consid- erable gaps in the evidence base on the potential consequences of malpractice reform on the costs and quality of care for the aging population

Long-Term Care: While reforming the current long-term care system is a major policy priority for many stakeholder organizations in the study, the evidence base on the effects of proposals to re- form the system for financing and delivering long-term care is limited, particularly at the federal level. A great deal of policy activity in long term care is happening at the state level, as state leaders use policy levers such as Medicaid waivers to deliver long-term services and supports in innovative ways. However, many significant gaps remain and additional evaluation and research are needed to provide an evidence-base for these policies.

Policy Recommendations That Demand an Evidence Base



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The U.S. population is rapidly aging. By 2050, older adults, age 65 and older, will make up 20 per- cent of the total U.S. population, up from 12 percent in 2000 and just 8 percent in 1950. The number of people age 85 or older will grow the fastest over the next few decades, constituting 4 percent of the population by 2050, or 10 times its share in 1950 (see Figure 1).

Figure 1. Growth in U.S. Aging Population, 1950-2060 (Projected)

Source: U.S. Census Bureau Note: * indicates projection 2014 Population Projections

The budgetary and policy implications of this demographic shift represent the greatest chal- lenges faced by the government and the U.S. health system today. While the U.S. population of adults aged 65 and older currently account for only 13 percent of the population, this cohort con- sumes more that 34 percent of national health expenditures. On average, the older adult population spends $18,424 annually per person, with more than one-third of those expenditures occurring after the age of 85. The Medicaid program accounted for more that 40 percent of overall U.S. nursing home costs in 2012, and 65 percent of these costs in graying states like Pennsylvania. Together with Medicare, these programs comprise more that 31 percent of all U.S. health expenditures.1


1 G. Burtless, Trends in the Well-Being of the Aged and Their Prospects through 2030, Brookings Institution Report, June 2015, avail-

able from: BeingSeniors.pdf?la=en; U.S. Senate, Commission on Long-Term Care, Report to Congress, September 2013, available from: http://



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The Challenges of Caring for an Aging America

What policy solutions have been advanced to address the challenges of reducing healthcare costs and improving health outcomes in the elderly population, and are these solutions sup- ported by rigorous scientific evidence? Over the last year, a multidisciplinary team at the Stern Center for Evidence-Based Policy conducted an unprecedented study that answers these questions.

Researchers systematically analyzed scientific evidence related to the cost and quality of care for the aging population from across the entire domain of published biomedical literature, as well as health policy recommendations from a sampled set of stakeholder organizations (advocacy, membership, and trade organizations) in the United States.

The results of this study provide policymakers with essential insights into the current state of evidence-based health policy in the United States. The findings will thus drive the future work of the Stern Center in this politically, economically, and socially critical area of health policy research.

Meeting the health needs of an aging America requires sizable changes to our existing ap- proach to treatment and service delivery. Unless policymakers take action now, aging Ameri- cans and their loved ones will soon experience unsustainably high costs for healthcare cover- age as well as significant declines in the access to and quality of care. Care needs among the U.S. aging population are changing rapidly. An aging America will experi- ence increasingly severe and complex health conditions. Almost half of the U.S. population is expect- ed to have at least one chronic disease by 2020. By 2030, over 40 percent of the 65+ population is likely to have diabetes; nearly 80 percent will experience hypertension. The number of aging individu- als with three or more chronic conditions has also increased significantly within the last ten years, and this is expected to grow to 40 percent among the 65 and over population by 2030. Complicating the task of treating multiple chronic conditions is the rising prevalence of age-related functional impair- ments. This will dramatically expand the number of individuals requiring assistance to perform daily activities to maintain quality of life and independence. By 2050, the number of Americans needing long-term services and supports (LTSS) will more than double to 27 million.2

The fragmented U.S. healthcare system is ill-suited to address an expanding aging popula- tion’s complex needs. While multiple chronic conditions can be effectively managed through coor- dinated approaches to treatment, providers rarely coordinate with one another and often lack appro- priate incentives for improving the overall health of the patient. This places individuals with multiple chronic conditions at a significantly higher risk for adverse drug reactions and preventable hospitaliza- tions. Fragmented service delivery also makes it more difficult for aging individuals to navigate their health choices.3

2 Id.

3 R. Gijsen, N. Hoeymans, F.G. Schellevis, et al., Causes and consequences of comorbidity: a review, Journal of Clinical Epidemiology




Addressing the Health Needs of an Aging America | 9

Gaps in the caregiver workforce will place an increasing number of older adults at risk of los- ing their health and independence. Less than 3 percent of medical students enroll in geriatrics elec- tives, while less than 1 percent of nurses and pharmacists have gerontological certifications. Training requirements for direct care workers, which vary from state to state, are often inadequate. Across health services professions, certification programs fail to emphasize competencies related to caring for older adults. Finally, surveys of family caregivers also reveal that they have little access to neces- sary training and skills. These workforce gaps will make it increasingly difficult to provide high-quality care to aging Americans and will limit access to home or community-based long-term care, which the vast majority of Americans prefer to nursing homes.4

Though an increasing number of Americans will need long-term care, few will have the capaci- ty to finance that care, shifting the burden to taxpayer-funded programs. Less than 1/3 of Amer- icans 50 and older have begun saving for long-term care. Without such savings and with a diminish- ing long-term care insurance market, most individuals will be forced to spend down their savings in order to qualify for Medicaid-provided Long-Term Services and Supports (LTSS). The rise in demand for LTSS will place a significant burden on Medicaid spending, which is expected to increase by 68 percent between 2015 and 2025, reaching to $576 billion dollars.5 If these present trends continue, the federal government and the states may be forced to roll back support for other taxpayer priorities, such as raising school performance, solving the housing crisis, and fixing our decaying transportation infrastructure.6

Our approach to caring for the aging is fiscally unsustainable for taxpayers and consumers alike. Absent changes to a fragmented system of care delivery which rewards high-cost rather than high-quality care, the burden of healthcare spending for the aging population will soon become un- sustainable for taxpayer-funded programs like Medicare and Medicaid, as well as individual consum- ers paying out-of-pocket. Between 2015 and 2025, annual Medicare spending is projected to double to $1.2 trillion dollars. The median annual out-of-pocket costs for Americans age 65 will rise to $6,200, nearly double what it was in 2010.7

The Patient Protection and Affordable Care Act (ACA) alone cannot address these challenges. While the ACA represents the most significant advance in health reform in half a century, its advances in addressing the challenges of an aging population have been comparatively modest, limited to several, albeit promising, demonstration programs. As Medicare and the Older Americans Act reach their fiftieth anniversaries continue to improve aging America’s access to affordable, high-quality care, it will be necessary to identify, evaluate, and scale- up policy interventions that work.8

4 Institute of Medicine, Retooling for an Aging America: Building the Health Care Workforce, 2008 Report, available from: http:// 5 Updated Budget Projections: 2015 to 2025, Congressional Budget Office, March 2015, available from:

6 U.S. Senate, Commission on Long-Term Care, Report to Congress.

7 Centers for Medicare and Medicaid Services, National Health Expenditure Projections, 2013-2023, Forecast Summary, available

from: Downloads/Proj2013.pdf 8 H. Goldbach, The Affordable Care Act and Older Americans, Stanford Aging Institute, December 8, 2013, available from: https://



Addressing the Health Needs of an Aging America | 10

Addressing the health needs of an aging America will require actionable insights based on the best- available research evidence about how to improve the affordability and quality of care for this rapidly expanding demographic. Policy choices are often made without adequate insights from the full range of available effectiveness research, and all too often, policy research treats health prob- lems narrowly, ignoring evidence that reveals effective interventions.

With aging Americans and their loved ones at risk, policymakers have a responsibility to base their decisions on rigorous, objective analysis about which policy proposals work and which do not. Evi- dence-based health policy should examine the widest array of available research and informa- tion to identify actionable recommendations that improve the cost and quality of care. It also seeks to highlight policy proposals on which additional effectiveness research is necessary.9

To target opportunities for evidence-based policymaking, researchers at the Stern Center undertook a systematic two-phase study to the map the full landscape of research evidence and policy ideas. In the first phase, as Figure 2 shows, a multidisciplinary team conducted a Scop- ing Study, systematically sampling the entire domain of biomedical literature on the cost and quality of care for the aging (over 24 million citations) to identify areas in which there exists a wide base of up-to-date research literature. To ensure the search captured the broadest range of current litera- ture, researchers identified systematic reviews, and rigorous, highly cited individual studies published between 2010 and 2014 that were relevant to older adults and included data on either cost or clinical outcomes. This resulted in an inventory of 1196 citations, which included 333 systematic reviews and 836 individual studies.

In the second phase, the team conducted a Policy Scan in order to map the universe of existing policy recommendations related to aging and health in the United States. As Figure 3 shows, researchers used major databases U.S. organizations to identify 493 health stakeholder groups whose central purpose is to advocate, research, or lobby in the area of health care, health outcomes, or physical wellness of older adults. They then targeted all groups producing actionable policy recommendations and identified 98 health policy organizations from a database. From these organizations, researchers extracted more than 600 policy proposals.

To identify areas where a significant level of evidence and policy demand existed, researchers cate- gorized all policy recommendations and citations into 10 valid categories and 75 subtopic areas. They then ranked topics based on the strength of the evidence base and policy demand from multiple, cross-cutting stakeholder groups.

> See Appendix A for a full description of the methodology.

9 See, among others, Pew-MacArthur Results First Initiative, Evidence-Based Policymaking: A Guide for Effective Government,

November 2014, p. 2, available from:

Identifying Opportunities for Evidence-Based Policy Solutions



Addressing the Health Needs of an Aging America | 11

The results of this study provide an inventory of areas in which actionable, evidence-based policy is possible. The study intends to provide a useful inventory of topics on which there exists sufficient research evidence, along with policy recommendations put forth by multiple stakeholders, thus improving prospects for meaningful evidence-based reform. Second, the study illustrates evi- dence-based interventions that deserve more serious attention from policymakers. Finally, the study highlights areas where policy recommendations require a more substantial evidence base.

> See Appendix B for a full list of the results.

Figure 2. Scoping Study Diagram



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Figure 3. Policy Scan Diagram



Addressing the Health Needs of an Aging America | 13

Numerous opportunities exist for evidence-based policymaking that will improve the qual- ity and affordability of care for the older adult population in the United States. In particular, the study found a sizable basis of both research evidence and policy demand on interventions related to prevention and wellness, the healthcare and informal caregiver workforce, and care coordina- tion (results are summarized in Figure 4). Within each of these major topics, the study also identi- fied focus areas where policymakers and researchers should invest the greatest amount of time and energy in developing actionable evidence-based policy proposals.

Figure 4. Results of Scoping Study and Policy Scan, by Major Topic

Where Evidence and Policy Meet



Addressing the Health Needs of an Aging America | 14

Prevention activities seek to avoid the onset of disease entirely, detect the onset of disease early through screening, and stop disease from progressing or worsening. In addition to healthcare ser- vices such as cancer screening and vaccinations, patient education to promote nutrition and physical activity can help prevent the onset or worsening of disease. Within prevention and wellness, the study revealed three focus areas where there exists an especially strong evidence base and high policy de- mand: screening and early detection; nutrition and diet; as well as patient education, empow- erment, and physical activity.

Focus Area: Screening and early detection

Screening and early detection refer to a broad range of instruments—including exams, tests, and clinical guidelines—used to identify a disease in individuals who do not have symptoms. While not all screenings have proven effective, employing evidence-based detection techniques has the potential to improve health outcomes and lower the cost of treatment by detecting and mitigating the progres- sion of numerous diseases associated with aging, including multiple forms of cancer, cardiovascular disease, chronic kidney disease, diabetes, hepatitis, as well as Alzheimer’s, dementia, depression, and alcohol abuse.

Examples of Policy Levers:

• Ensuring that national clinical guidelines adequately include evidence-based screening procedures for age-related diseases

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