BPHC Enrichment Series for Grantees: Serving an Aging Population (65+) in Health Centers

1. BPHC Enrichment Series for Grantees:Serving an Aging Population (65+) in Health Centers Thursday, May 24, 2012 2:00 PM – 3:30 PM EST

2. Serving an Aging Population: Learning Objectives • Identify key demographic trends of the 65+ population • Understand key issues for serving the 65+ population in health centers • Name key services being provided to the 65+ population in health centers • Describe successful grantee programs at improving health outcomes in the 65+ population • Identify where to go for additional TA and resources on aging

3. Agenda in Brief Welcome Dr. Matt Burke, HRSA Profile of Older Americans Bob Hornyak, Administration for Community Living Caring for the Elderly in Community Health Centers Marty Lynch, Executive Director/CEO, LifeLong Medical Care Wellness Information for Senior Empowerment Allison Dubois, Chief Operations Officer Elizabeth L. Phillips, Director of Health Education Services Hudson River HealthCare, Peekskill, NY Serving an Aging Population (65+) in Health Centers Dr. Lynda Jackson-Assad, Medical Director Dr. Debra Bartley-Rice, Director, Adult Medicine Department Dr. Robert Hutchins, Physician, Adult Medicine Department Jackson-Hinds Comprehensive Health Center, Jackson, MS

4. Profile of Older Americans Robert Hornyak Director, Office of Performance and Evaluation Department of Health and Human Services Administration for Community Living Center for Disability and Aging Policy

5. Administration for Community Living (ACL) • New agency of U.S. Department of Health and Human Services announced by Secretary Kathleen Sebelius on April 16, 2012 • Single agency brings together the efforts of the Administration on Aging (AoA), Office on Disability (OD), and Administration on Developmental Disabilities (ADD) • Charged with developing policies and improving supports and services for seniors and people with disabilities “For too long, too many Americans have faced the impossible choice between moving to an institution or living at home without the long-term services and supports they need. The goal of the new Administration for Community Living will be to help people with disabilities and older Americans live productive, satisfying lives.“ - Secretary Kathleen Sebelius

6. Administration for Community Living (ACL) Administration on Aging

7. Profile of 65+ Older Americans (2011) The Older Population • 65+ = 40.4 million (13.1% of the population) in 2010, i.e., a 5.4 million (15.3%) increase since 2000. • Persons reaching age 65 have an average life expectancy of an additional 18.8 years (20.0 years for females, 17.3 years for males) • Older women outnumber older men at a ratio of 13:10 (i.e., 23.0 million older women to 17.5 million older men) • 85+ = 5.5 million (1.8% of the population) in 2010. Future Growth of Older population • 65+ population is projected to increase to 55 million in 2020 (36% increase within the decade). By 2030, 65+ will grow to 19.3% of the population • The 85+ population is projected to increase to 6.6 million in 2020 (19% increase)

8. Profile of 65+ Older Americans (2011) Marital Status • Older men were much more likely to be married than older women • 72% of men vs. 42% of women • 40% older women in 2010 were widows Living Arrangements • About 29% (11.3 million) of non-institutionalized older persons live alone (8.1 million women, 3.2 million men) • 47% of older women age 75+ live alone • About 485,000 grandparents aged 65 or more had the primary responsibility for their grandchildren who lived with them

9. Profile of 65+ Older Americans (2011) Income • Median income of older persons in 2010 = $25,704 for males, $15,072 for females • Median money income (after adjusting for inflation) of all households headed by older people fell 1.5% from 2009 to 2010 • Households containing families headed by persons 65+ reported a median income in 2010 of $45,763

10. Profile of 65+ Older Americans (2011) Poverty • Almost 3.5 million elderly persons (9.0%) were below the poverty level in 2010 • This poverty rate is not statistically different from the poverty rate in 2009 (8.9%) • In 2011, the U.S. Census Bureau released a new Supplemental Poverty Measure (SPM) which accounts for regional variations in livings costs, non-cash benefits received, and non-discretionary expenditures but does not replace the official poverty measure. • The SPM shows a poverty level for older persons of 15.9%, an increase of over 75% over the official rate of 9.0% mainly due to medical out-of-pocket expenses.

11. Profile of 65+ Older Americans (2011) Minority Population • Up from 5.7 million in 2000 (16.3% of the elderly population) to 8.1 million in 2010 (20% of the elderly)

12. Profile of 65+ Older Americans (2011) Future Growth of Minority Population • Projected to increase to 13.1 million in 2020 (24% of the elderly). • Projected to increase by 160% between 2010-2030, comparing with 59% for Whites

13. AoA Helps 11 Million Seniors (and Their Caregivers)Remain At Home Through Low-Cost Community Based-Services AoA 56 State Units, 629 Area Agencies & 256 Tribal Organizations 20,000 Service Providers & 500,000 Volunteers Provides Services and Supports to 1 in 5 Seniors 26 Million Rides 35 Million Hours of Personal Care 135,000 Caregivers Trained 4 Million Hours of Case Management 792,000 Caregivers Assisted 240 Million Meals 6.4 Million Hours of Respite Care

14. Who AoA Serves:The Poor and Near Poor • 3 million Older Americans Act (OAA) clients receive intense services such as home-delivered nutrition and homemaker services • Near Poor is defined as below 150% of poverty

15. Who AoA Serves:The Frail and the Vulnerable • In-Home Services include services such as homemaker, case management, and home-delivered nutrition. • US Minority & Rural figures are for the 65+ population

16. Partner with Aging Network • Find an Area Agency on Aging in your area at: http://www.Eldercare.gov

17. Aging Data Resource Links • American Community Survey (ACS) Demographic Data (2004-2010) on AGID http://www.agidnet.org/ • Minority Aging http://www.aoa.gov/AoARoot/Aging_Statistics/minority_aging/Index.aspx • US Administration on Aging's “A Toolkit for Serving Diverse Communities”http://www.aoa.gov/AoARoot/AoA_Programs/Tools_Resources/DOCS/AoA_DiversityToolkit_Full.pdf • Department of Health and Human Services, Office of Minority Health http://minorityhealth.hhs.gov/

18. Contact Information Robert Hornyak Director, Office of Performance and Evaluation (202) 357-0150 Robert.Hornyak@aoa.hhs.gov http://www.hhs.gov/acl

19. Caring for the Elderly in Community Health Centers Marty Lynch Executive Director/CEO Lifelong Medical Care

20. Baby Boomers: we are them Community Health Centers (CHC)45-64 age has grown 87% Doubling of the over-65 population to 70 million by 2030 85+ population from 2% to 5% by 2030 Consumer preference: remain in the community if at all possible Afraid of nursing homes Population Aging Review

21. Number of Persons 65+,1900 – 2030 (numbers in millions)

22. Take-Aways for CHCs • Existing patients aging & communities aging • High levels of poverty in elder population especially at health centers • More disability as age increases • Disability very common in old-old populations

23. Special Populations Aging Also • Homeless population aging • Average age of homeless in many areas is now in 50’s • Homeless person at 55 has the health problems of a 70 year old • CHC must be prepared to deal with difficult substance abuse, mental health, and housing issues as well as medical issues • Disabled population who pioneered independent living is now aging • HIV/AIDS population

24. Health Centers and Elderly • UDS data says 7% elderly in health centers now… numbers up about 47% from 10 years ago • Over one million elders served by CHCs • Age 45-64 has grown 87% • History of moms and kids in many CHCs • Some CHCs >15% elders

25. How are Disabled or Frail Elders Different from Younger Elders? • Young elders, if healthy, are similar to your adult population except they have Medicare • Every individual is different but, in general, by age 75 and over there are more: • Functional disabilities • Dementia related disability • Co-morbid chronic medical problems causing disability

26. Functional Disabilities • Patient needs assistance with normal Activities of Daily Living (ADL): • Bathing • Dressing • Toileting • Transfer • Continence • Feeding

27. Use Phone Shop Food Preparation Housekeeping Or Instrumental Activities of Daily Living (IADL) • Laundry • Transportation • Taking Medications • Handle Finances

28. Impact on Providing Medical/ Dental/Mental Health Care • Daily living problems become as important, or more important, than traditional medical care • Difficult to provide effective medical care without dealing with these problems • Health Centers often not as familiar with arranging disability care

29. Core Services for Elders • Physicians or mid-level providers who are interested in both chronic medical care and functional disability care • Multiple medications management • Multi-disciplinary team care with both hallway consults and team meetings

30. Core Services for Elders • Case management/care coordination services available to assist disabled patients, their families, and work with medical provider • Dental, Podiatry, Mental Health, Neuro-Psych Testing

31. Medical Care • Internists, Geriatricians, NP’s, PA’s • Training and interest • Longer visit times for complex histories and problems • Chronic disease management/motivation • Functional and dementia issues interact with medical problems – may overshadow medical issues • Depression, isolation, substance use

32. Case Management for Elders • Many definitions • Nurse management to assist with medical management, transitions, durable medical equipment, prescriptions, education • Social work case management to work on psycho social issues, functional disability, personal care arrangements, family, housing

33. Case Management for Elders • Community health workers and peers can help with these functions • Regular team meetings with other providers to discuss complex patients

34. Special Clinical Issues • Dementia care and management including neuro-psych testing • End-of-life care, palliative care: different cultures and beliefs • Advance directives • Elder sensitive mental health services: warm hand-off is key • Dignity driven decision making

35. Customer/Patient Experience • RESPECT • Age and cultural competency interaction • No infantalization (forget “Dear” & “Honey”) • Staff trained in aging-related disabilities and dementias • Changing expectation by age cohort • Phone Issues: Live operator vs. auto-attendant for older ages

36. Adapting the Health Center • Separate clinic times/spaces or not? • Layout to accommodate wheelchairs, walkers, slow pace • Hand-rails & physical modifications • At least one power exam table • Accessible transportation • Daylight hours/security concerns

37. Special Services or Partnerships to Serve Elders • Adult Day Health Care • Home Health Care • Assisted Living • Skilled Nursing Facilities • Senior Housing or Supportive Housing for Elders • Dementia Care • Respite Care • Senior Centers/Exercise/Nutrition Programs, Area Agencies on Aging • Village Models

38. Business and Policy Issues • Medicare FQHC rates are capped • 75% of CHCs have rates higher than cap • Data now being gathered to new base rate • New rate may still be lower than Medicaid FQHC but better than commercial rates

39. Business and Policy Issues • Elderly take more time and a team approach, like any complex population, more costly care, productivity will be lower than family practice • Case management can be difficult to pay for – varies by state • Health plans will compete for your patients

40. On the Positive Side • Huge untapped market for health centers • Elders require the health home approach that CHCs are comfortable with • Populations are aging • We are familiar with other complex populations like homeless and HIV/Aids

41. On the Positive Side • Medicare Advance Practice Medical Home Demo • Potential case management/disease management fees • Possible shared savings/bonuses with health plan contracts

42. Data Issues • Many CHC cost and quality studies done for mom’s and kids population. Need same data on over 55 population • Will need measures on functional disability, ADLs/IADLs and dementia • UDS does not collect data on Duals… as we go into Duals pilots/demos we don’t know how many Duals health centers serve • Paradigm shift in both service and data

43. Existing Specialized Health Plans/Demos Expanding • Program of all-inclusive care for the elderly (PACE) • Medicare Advantage special needs plans for dual eligibles, or nursing home residents, or special chronic disease populations • State-based demonstration programs under home and community-based waivers or integrated managed care for dual eligibles

44. Health Reform Opportunities • Many states working with CMS on Duals Plans to integrate medical care, long term services and supports and mental health • Medicare Accountable Care Organizations present a bundled payment/share of savings, and integrated care opportunity • Hospitals will be encouraged to work with community partners on transitions of care/avoiding readmissions • Growing role for technology, in home monitoring, specialty tele-health, web portals for at least some elders

45. Recommendations • Plan for expanding your elderly care. Some CHC elderly patients will have disabilities and special needs. Health Centers should also plan how they will meet those needs. Use PCMH as a tool to get there. • Case Management or care coordination is critical for this subset of elders. • Adult day health care and other long term services and supports can be an important part of a health center’s approach to primary care for elders with disabilities.

46. Recommendations (cont.) • Partnering with other health and aging social service agencies is essential to assure access to resources not available at CHC. • If CHC has significant Medicare/Medicaid eligible group, carefully examine benefits of contracting with or developing a Medicare Special Needs Plan (SNP) or a Duals pilot. Demand a share of any savings. • CHCs with large number of disabled elders may wish to consider partnering with or developing a PACE program, although this is a major undertaking.

47. Contact Information Marty Lynch Executive Director / CEO LifeLong Medical Care mlynch@lifelongmedical.org www.lifelongmedical.org (510) 981-4123

48. WISEWellness Information for Senior Empowerment Allison Dubois Chief Operations Officer & Elizabeth Phillips Director of Health Education Services Hudson River Healthcare, Inc.

49. Overview of Hudson River Healthcare Learn about various HRHCare programs for Seniors Discuss challenges Discuss lessons learned Learning Objectives

50. Organizational History Mission: To increase access to comprehensive primary and preventive health care and to improve the health status of our community, especially for the underserved and vulnerable. In the early 1970's a group of local residents and religious leaders addressed the lack of appropriate health services in their community. In particular, a group of four women, fondly referred to as our founding mothers, spearheaded the efforts and have remained committed to the organization since its inception.