Damian Sendler: There is a rapid aging of the American populace. Leaders in long-term care have never been included in the category of public health workers. However, long-term care has not been incorporated into the public health workforce taxonomy thus far. Graduate public health education geared toward long-term care is examined in this article and a case study of a successful program at East Carolina University is provided (ECU).
Damian Jacob Sendler: According to an investigation of 135 graduate programs from January to July 2019, only eight institutions offered long-term care administration master’s degree programs. With eight programs, only one of them directly linked coursework with licensing as a long-term care administrator: ECU Brody School of Medicine’s Department of Public Health. In addition to the 30 program graduates, five MPH students are in the process of finishing their Administrator in Training (AIT). Twenty-seven students graduated with North Carolina licenses in hand.
Dr. Sendler: Taking care of an aging population necessitates a skilled public health workforce with specialized knowledge and training. As a part of the public health workforce, long-term care workers should be recognized as such. More than a decade ago, the Institute of Medicine recommended this course of action.
It is defined as “all public, private and voluntary organizations that contribute to the delivery of essential public health services in any jurisdiction.”
Public health is concerned with improving the health of communities by reducing the health disparities that are prevalent in underserved lower socioeconomic groups. Public health advocates for policy changes to improve access to health care by recognizing how social determinants of health affect the distribution of health for populations. 2 The passage of Title 19 of the Social Security Act in 1965, which established the Medicaid program, was one of the most significant public health policy achievements of the twentieth century in the United States. 3 It has been found that one in three Americans will need long-term care at some point in their lives, with Medicaid covering the care of six in every 10 patients. 4 The public health system would be incomplete without nursing homes. 5,6 Private nursing homes in the United States account for two-thirds of all facilities, but these businesses remain part of the public health system. 1,7
Public health workers play a crucial role in ensuring the health of their communities.
8 But in the United States, more than half of this workforce lacks formal training in public health. Many of the one-third of public health professionals with formal training report a need for management education.
Damian Sendler
An especially vulnerable segment of our population is at risk from the current COVID-19 pandemic, which is affecting senior citizens living in skilled nursing facilities.
10 For this reason and others, the CDC has provided nursing homes with explicit policy guidance that mandates the immediate classification and management of sick patients, as well as the importance of prevention education. 11 Nursing home administrators must demonstrate strong leadership when confronted with global crises of this magnitude. The foundation of the program described in this article is the recognition of long-term care workers in the US public health workforce as essential. The lack of public health training for long-term care workers in the United States is comparable to or even worse than that in other public health areas. Licensed long-term care administrators who are also MPH graduates with training in prevention, data management, health policy, administration and leadership are the focus of this article.
By 2030, one-fifth of the US population will be over the age of 65. There are expected to be 78 million people 65 and older by the year 2035, compared to 76.7 million people under the age of 18. 12 First time in US history, people 65 and older will outnumber those under 18 for the first time in history. In addition to hospitals, skilled nursing facilities and other long-term care facilities will see an increase in demand due to the unprecedented rise in the number of seniors in the United States. 13 Expenditures on hospitals, nursing homes, and home health care accounted for 47.2% of total health care costs in 2016. In 2015, skilled long-term care facilities, also known as “nursing homes,” cared for more than 1.3 million residents, the majority of whom were employed by for-profit companies (69.3%). 7,14
Nursing home administrators must be licensed by the federal government in order to run their facilities.
15 However, not all states require a state license. For licensure and continuing education requirements, there is a wide range in the minimum age for licensure, educational degree, length, and time spent in Administrator in Training (AIT), as well as the number of hours required. 19 states require no more than a high school education or a GED to apply for a position as a nursing home administrator.
The public health workforce has been difficult to classify and count.
17 The Center of Excellence in Public Health Workforce Studies at the University of Michigan convened national experts in 2013 to define the public health workforce by 287 classifications across 12 domains (axes), providing definitive job classifications including occupational setting and employment. Hospitals are listed as a local public health setting in Axis 2: Local Setting, but long-term care facilities are not. 17 But in 2019, there were twice as many nursing homes as there were hospitals in terms of the number of health care facilities. Nearly 1.7 million licensed beds and more than 1.3 million residents are cared for by more than 15 600 nursing homes in the United States. 7 There were 6 210 hospitals totaling 931 203 beds, with an admissions total of 36,510,207 in this comparison. 18
Damian Jacob Sendler
It is mandated by 42 USC 1396g of the Public Health and Welfare United States Code that nursing home administrators be licensed by the federal government.
15 However, long-term care or nursing home administration is not listed in Axis 9 as an area of expertise or under 1.1.12 Licensure/Regulation/Enforcement worker in the Axis 1: Management and Leadership section. Traditional federal and state positions in public health can be found in Axis 1: Management and Leadership (1.11–1.1.6). 17 There is a pressing need, according to the Institute of Medicine (IOM), to improve health care workers’ training and competency when it comes to caring for the elderly. The IOM issued a challenge to public health in 2008 to do just that. 19 42 USC 1396g15 is included in the US Public Health Code, but leaders of nursing homes and other long-term care facilities are hindered by their employees’ lack of enumeration in this workforce. Academic practice and long-term care industry leaders collaborated to formally integrate graduate public health education with long-term care administration, leading to graduates obtaining licensure as long-term care administrators. Other universities can learn from East Carolina University’s (ECU) program.
Damian Jacob Markiewicz Sendler: Only eight of the CEPH MPH programs and schools of public health, according to a review conducted from January to July of this year, offered graduate-level courses in long-term care management. University at Albany-SUNY and New York Medical College, two of the eight institutions, each offered two long-term care courses. One graduate MPH course in long-term care was offered by the Oregon State University School of Public Health. The MPH Health Policy Administration & Leadership (HPAL) concentration offered by the ECU Department of Public Health at Brody School of Medicine includes three courses devoted to long-term care. The Master of Health Administration (MHA) program at the School of Public Health at the University of Nevada, Las Vegas, includes one long-term care course. The Brooks College of Health at the University of North Florida offers two graduate courses as part of the MHA degree. The University of Alabama at Birmingham’s Master of Science in Health Administration (MSHA) degree includes a long-term care course; the University of Minnesota’s postbaccalaureate certificate in public health includes a long-term care course. ECU Brody School of Medicine’s Department of Public Health was the only one of the eight institutions to offer courses directly related to licensure.
The successful collaboration between research and practice led to the successful integration of long-term care administration into the MPH degree. To carry out this project, a long-term care administrator and a local director of public health joined forces with the director of field placement for the MPH program and the department chair to bring together health care leaders from both academia and practice including the president and vice president of the North Carolina Health Care Facilities Association, the North Carolina Hospital Association president, and long-term care administrators. The members of this working group collaborated with ECU faculty to develop the curriculum for the HPAL concentration in the Brody School of Medicine’s MPH program. With the help of a working group, a new Long Term Care Administration course was developed. Members of the work group frequently give guest lectures on their areas of expertise..
Core classes in public health foundations are included in the MPH HPAL concentration’s 45-hour curriculum. The long-term care concentration necessitates the completion of nine credit hours of core coursework, six credit hours of electives, a three-credit internship, and a three-credit professional paper. 21 The North Carolina Board of Examiners for Nursing Home Administrators mandates that anyone seeking to become a licensed administrator of a nursing home in the state must complete an AIT requirement. 22 To prepare for state and federal licensure, MPH students pursuing licensure must complete a rigorous field placement and may choose to take a second internship course as an elective. It’s not unusual for students to take their state and national exams right before they graduate.
It was also determined that a training continuum for the current long-term care workforce should be developed and implemented for individuals with associate degrees in nursing in order to allow them to pursue their BSN degrees online through the ECU College of Nursing. They also suggested that long-term care workers with associate degrees in fields other than nursing pursue a bachelor’s degree in Health Services Information Management at ECU before pursuing a master’s degree in public health.
In addition, the members of this task force stressed the importance of preparing future long-term care workers with public health knowledge and skills. The Duke Endowment funded this initiative, demonstrating the power of partnerships and philanthropy in preparing current and future long-term care administrators with a master’s degree in public health for current and future administrators. Duke Endowment’s Long-Term Care Training Continuum proposal aimed to develop an educational multistep program responsive to the needs and challenges of ECU students pursuing training in long-term care administration. After receiving a bachelor’s degree in either nursing or health services management, grant funding supported long-term care workers to pursue a Master of Public Health (MPH) degree. Area Health Education Centers provide the continuing education required for licensure renewal.
The MHA and MPH programs are not interchangeable, despite the fact that some health care executives have earned the MHA. The MHA curricula tends to focus more on financial/business management than on the public organizations that are critical to public health education and practice. 24,25 Health disparities can be reduced by improving the public’s understanding of the importance of social deprivation, which is the focus of HPAL’s MPH program in biostatistics, epidemiology and environmental health policy administration and leadership, health behavior, research methods/data management, disaster preparedness and health policy. 21 CEPH accreditation requires specific MPH competencies to be met before a degree can be awarded, including planning, management, and leadership skills. 26
Achieving competency at tier 3 is expected of health care leaders, according to the Council on Linkages between Academia and Public Health Practice.
Damien Sendler: In order to maintain their license, nursing home administrators are required to serve as the facility’s primary point of contact. 15 The CDC’s COVID-19 directives for nursing homes require systems management and monitoring for the early detection and management of diseased patients, surge capacity planning, human resources staffing, and fiscal evaluation and compliance. ” 11 Nursing home administrators must have exceptional leadership skills to deal with the influx of media and family inquiries, as well as the coordination required with multiple local, state, and federal agencies during a pandemic. However, these abilities are not currently required for nursing home administrator licensure under current educational requirements.
To maintain the health of the US population and the health of the healthcare workforce, the HPAL concentration’s long-term care component is essential. Since the program began, there has been an increase in the number of long-term care administrators with public health training. In the context of public health, managers and policymakers with an MPH can put their experience in these areas to good use. These people understand the importance of preventing outbreaks and are well-versed in the proper management and implementation of isolation and quarantine measures in the event of an outbreak. An MPH-educated administrator of a nursing home is well-versed in all aspects of the health care system. They have been trained to be effective communicators and managers so that they can respond to pandemics in a timely and appropriate manner, as we are currently experiencing around the world. Long-term care is also fulfilling the International Organization for Migration (IOM2008 )’s mandate to train more of the eldercare workforce in public health by focusing on this area. 19 Preceptors with MPH degrees are now available to train future public health administrators who are prepared and able to respond to future public health disasters.
Despite the fact that women make up the majority of public health workers, they have lower chances of achieving executive-level leadership positions.
28 With the HPAL program’s long-term care strategy, more women and minorities are becoming public health leaders. The fact that 16 out of 17 licensed administrators had received and accepted job offers as long-term care administrators by the time they graduated with their MPH should reassure anyone concerned about the disconnect between educational degrees and workforce skills29.
The COVID-19 pandemic has raised awareness of the increased demand on the health care workforce as a result of the aging population in the United States. Public health workers must now be prepared to address not only social and environmental issues, but also diseases that are caused by microorganisms, biological systems, and physiological processes. ECU’s MPH program now offers a specialization in long-term care administration as a result of collaboration between academics and industry leaders in North Carolina. This program is a model for other graduate programs in public health because it prepares students for state and federal licensure as nursing home administrators.