BPHC Enrichment Series for Grantees:

Serving an Aging Population (65+) in Health Centers

Thursday, May 24, 2012

2:00 PM – 3:30 PM EST

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• 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

Serving an Aging Population: Learning Objectives

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Agenda in BriefWelcome

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

Robert HornyakDirector, Office of Performance and Evaluation

Department of Health and Human ServicesAdministration for Community LivingCenter for Disability and Aging Policy

Profile of Older Americans

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“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

• 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

Administration for Community Living (ACL)

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Administration on Aging

Administration for Community Living (ACL)

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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)

Profile of 65+ Older Americans (2011)

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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

Profile of 65+ Older Americans (2011)

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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

Profile of 65+ Older Americans (2011)

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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.

Profile of 65+ Older Americans (2011)

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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)

Profile of 65+ Older Americans (2011)

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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

Profile of 65+ Older Americans (2011)

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AoA

20,000 Service Providers &500,000 Volunteers

56 State Units, 629 Area Agencies & 256 Tribal

Organizations

Provides Services and Supports to 1 in 5 Seniors

26MillionRides

26MillionRides

35 Million Hours of Personal

Care

35 Million Hours of Personal

Care

135,000 Caregivers

Trained

135,000 Caregivers

Trained

4 Million Hours of

Case Managemen

t

4 Million Hours of

Case Managemen

t

792,000 Caregivers Assisted

792,000 Caregivers Assisted

240 Millio

n Meals

6.4 Million Hours of Respite

Care

AoA Helps 11 Million Seniors (and Their Caregivers)Remain At Home Through Low-Cost Community Based-Services

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• 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

U.S. Population OAA Clients

60+ Population 57.8 million 11 million

Poverty 9.3% 30%

Near Poor 15-20% 73-85%

Who AoA Serves:The Poor and Near Poor

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• In-Home Services include services such as homemaker, case management, and home-delivered nutrition.

• US Minority & Rural figures are for the 65+ population

U.S. Population 60+ OAA Clients(In Home Services)

Live Alone 27% 55%-69%

Diabetes 9.3% 26%-35%

Near Poor 15-20% 43%-53%

Minority 20% 25%

Rural 13% 37%

Who AoA Serves:The Frail and the Vulnerable

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

Partner with Aging Network

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• American Community Survey (ACS) Demographic Data (2004-2010) on AGIDhttp://www.agidnet.org/

• Minority Aginghttp://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 Healthhttp://minorityhealth.hhs.gov/

Aging Data Resource Links

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Robert Hornyak

Director, Office of Performance and Evaluation

(202) 357-0150

Robert.Hornyak@aoa.hhs.gov

http://www.hhs.gov/acl

Contact Information

Caring for the Elderly in Community Health

CentersMarty Lynch

Executive Director/CEOLifelong Medical Care

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Population Aging Review• 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

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

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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

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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

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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

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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

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Functional Disabilities

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

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Or Instrumental Activities of Daily Living (IADL)

• Use Phone

• Shop

• Food Preparation

• Housekeeping

• Laundry

• Transportation

• Taking Medications

• Handle Finances

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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

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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

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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

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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

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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

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Case Management for Elders

• Community health workers and peers can help with these functions

• Regular team meetings with other providers to discuss complex patients

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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

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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

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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

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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

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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

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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

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On the Positive Side

Huge untapped market for health centersElders require the health home approach

that CHCs are comfortable withPopulations are agingWe are familiar with other complex

populations like homeless and HIV/Aids

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On the Positive Side

Medicare Advance Practice Medical Home Demo

Potential case management/disease management fees

Possible shared savings/bonuses with health plan contracts

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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

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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

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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

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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.

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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.

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Contact Information

Marty Lynch

Executive Director / CEO

LifeLong Medical Care

mlynch@lifelongmedical.org

www.lifelongmedical.org

(510) 981-4123

Allison DuboisChief Operations Officer

&Elizabeth Phillips

Director of Health Education ServicesHudson River Healthcare, Inc.

WISEWellness Information for Senior

Empowerment

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• Overview of Hudson River Healthcare• Learn about various HRHCare

programs for Seniors• Discuss challenges• Discuss lessons learned

Learning Objectives

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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.

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.

Organizational History

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Map of New York

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• HRHCare currently provides services at 22 sites to 80,000 patients through 300,000 visits annually.

• Escalating numbers of under – and uninsured in HRHCare’s service area and increasing demand for services along with expanded medical capacity and service expansion have increased the patient population by 80% since 2006 (44,423 to 80,000)

Size and Scope

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• Wellness Information for Senior Empowerment• Program serves seniors in 2 housing complexes,

but welcomes community members• Hosted by social worker• Group meets weekly, healthy meals are served• Information is shared about health issues• Addresses social isolation• Provides setting for group visits

WISE Program

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• Seniors encompass a large age range, 65-85+, different cultures and both men and women• Difficult to find activities that interest this broad age

range, that are culturally and gender appropriate• Some seniors have difficulty with chewing or other

issues related to their teeth, making it more difficult to find appropriate food to serve

• Seniors may have physical limitations such as arthritis

Challenges

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• Taking the time to understand the needs and wants of the group

• Finding activities that are appropriate across a broad age range and across cultures

• Bingo has been a popular activity that is universally enjoyed

• Choose foods that are easy to chew• Choose activities that require less fine motor skills

Overcoming Challenges

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• Health Unites Generations• Group meets twice monthly, includes residents from

one senior housing facility and youth members• Addresses social isolation of residents• Discuss health topics, cultural events and social and

holiday celebrations• Provides meaningful cross generational interactions• Youth receive small stipend – helps to promote

positive youth development

HUGS Program

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• Difficulty of youth and seniors interacting on a meaningful level

• Group stereotypes

Challenges

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• Find common ground among group members

• Address group stereotypes and dispel

Overcoming Challenges

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• Evidence based program• Training offered through Stanford University • Program teaches principles of Self

Management for people with any chronic disease or their caregivers

• Program at HRHCare called “Healthy Choices”

Chronic Disease Self Management Program

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• The interdisciplinary staff includes:• Registered Dietitians • Registered Nurses• Certified Diabetes Educators • Clinical Assistants• Social Workers• Case Managers• Certified Health Educators• Patient Care & Outreach

Healthy Choices

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• From May 2011 – Dec. 2011, staff delivered 7 workshops hosted in various locations (each workshop runs for 6 weeks each).

• We reached 80 workshop participants (majority being adults ages 55 +) of which 75% attended at least 4 sessions or more.

• Our 2012 – 2013 organizational goal is to deliver 2-3 workshops per year; with a regional approach to activate multiple counties.

Healthy Choices

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• Initially in 2011 the health centers HIV Capacity grant provided funding for the CDSMP/PSPMP training and start up

• Collaboration with other social service agencies

Healthy Choices

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• Peer Leader Activation and Retention• Time commitments required

• Developing Workshop schedules

• Recruiting Workshop host sites

Challenges

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• Conduct ongoing marketing of programs • Build upon existing relationships, get

referrals from host sites• Have open houses to introduce potential

participants to workshop• Be flexible – work within existing groups

Overcoming Challenges

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• Senior Prom

• Gerontology Services

Other Programs

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Elizabeth L. Phillips MPH, MCHES

Director of Health Education Services

(914) 734-8612

Lphillip@hrhcare.org

Hrhcare.org

Allison Dubois

Chief Operations Officer

(914) 734 - 8503

adubois@hrhcare.org

Hrhcare.org

Contact Information

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Presenters:Dr. Lynda Jackson-Assad

Medical Director

Dr. Debra Bartley-RiceDirector of Adult Medicine

Dr. Bob W. HutchinsAdult Medicine Physician

Jackson-Hinds Comprehensive Health Center

Serving an Aging Population (65+) in Health Centers

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Dr. Jasmin Chapman

Chief Executive Officer

Main Clinic

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Jackson-Hinds Comprehensive Health Center was established in 1970 and is one of the largest providers of primary health care services to the uninsured and under-served in Central Mississippi and one of the oldest Federally Qualified Health Centers (FQHC) in the nation.

About Jackson-Hinds

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Jackson-Hinds ComprehensiveHealth Center Services at a Glance

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• Jackson Hinds Comprehensive Health Center operates 15 clinics serving Hinds, Warren & Copiah counties which includes 5 free-standing school based clinics . Seventeen (17) additional schools are served via 2 Mobile Units.

• Dental services are provided via mobile unit in Jackson Public School District, Hazlehurst & Hinds County Schools

Where We Are

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• Objective 1 – Understanding the challenges that are experienced by the geriatric patient when they receive healthcare.

• Objective 2 – Understanding the provider and other staff involvement in the healthcare of the geriatric patient.

• Objective 3 – Understanding the need to integrate ancillary and enabling services when caring for the geriatric patient.

Learning Objectives

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Patients 65+ by Gender: Over 60% female

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Diagnosis Patients 65+

Hypertension 1457

Diabetes 656

Heart Disease 209

Chronic Bronchitis/Emphysema 91

Depression 52

Top 5 Diagnoses of Patients 65+ Treated at JHCHC

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Total Number of Patient Visits (65+)

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1. Transportation

2. Visit• Scheduling • Registration

3. Medical History

4. Medical Examination

5. Reconciliation of Medication List

6. Pharmacy

7. Social Services

8. Home Evaluations

9. Durable Medical Equipment (DME) Suppliers

Challenges faced with the Geriatric Population 65+

79Transportation Van

Transportation to the Health Center needed. Patients must pay for private transportation.

Solution:•JHCHC has a van that is used to pick up appointed patients.

Challenge #1- Transportation

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Clinic visits for Geriatric patients take much longer, especially when they are in a wheelchair or on walkers. Some elderly patients may need assistance with registration.

Solution:Preparation starts with scheduling Geriatric for morning appointments with extended visit time if deemed necessary by the provider. JHCHC has scheduling staff available to assist Geriatric patients with registration and completing forms.

Challenge #2- Visit

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Family member or caregiver need to accompany patients on their visits, especially if the patient cannot give a good health history.

Solution:

At JHCHC, geriatric patients are encouraged to bring a family member/caregiver who is knowledgeable of their health issues when this is possible.

Challenge #3-Medical History

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MA gets data needed and reviews health maintenance information and instructs patients and family members concerning health maintenance issues i.e. flu, pneumonia, smoking documentation and the need for age/ disease specific referrals inclusive of podiatry, optometry and dental.

Solution:

The MA assigned to a provider gets to know her/his patients. This familiarity promotes trust.

The provider may need assistance from a MA/Nurse during the examination to help patient get on and off exam tables.

Nurse needs to go over medications. Sometimes there is a need to

repeat instructions several times. Geriatric ADL is noted in the patient EHR and is addressed by the provider.

Challenge #4- Medical Examination

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Reconciliation of Medication list can be challenging when dealing with geriatric patients.

Solution:

Patients are asked to bring all medications at each visit. Review medication list of actual medications at each

visit and discard medication that has been discontinued.

To ensure compliance and understanding of medications.

Provide a new copy of prescribed medications and Clinical Summary.

Challenge #5 Reconciliation of Medication List

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Many of our elderly patients have problems obtaining their medication due to lack of resources, lack of transportation to the pharmacy and no third party coverage for medications.Solution:

JHCHC has an in-house pharmacy that participates with the 340B Program.

Eliminates transportation concerns and cost to obtain medications.

Readily available information on compliance, availability and prescription plan coverage.

Challenge #6 - Pharmacy

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Prescription Assistance Program & Enabling Services

Solution:•JHCHC Social Workers perform eligibility assessments and assist patients that cannot afford their medications via the prescription assistance program and other ancillary prescription programs.•Social Workers sometimes make home visits if requested by the provider due to some type of extenuating circumstance.

Challenge #7 -Social Services

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Home Evaluations: Living quarters of geriatric patients may sometimes pose health and safety risks. Home inspections are necessary. The living quarters of elderly patients sometimes have improper lighting, positioning of furniture and rugs that may contribute to injuries.

Solution:Home Evaluations: JHCHC has utilized Home Health agencies as well as our center’s Social Workers to help identify and find solutions to:

Home dangers Education on fall safety and fall risk Involvement of agencies that provide handicap or safety

equipment for the elderly i.e. bathtubs, shower stalls etc.

Challenge #8-Home Evaluations

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Durable Medical Equipment (DME) Suppliers: Confusion, potential fraud. Many patients are bombarded with “cold call” solicitations from Diabetic and DME suppliers. This results in multiple forms being sent to the provider resulting in duplication and potential fraud.

Solution: Patients are asked to bring forms in to the provider to

ensure this is a legitimate company and the service was requested by the patient.

Use well known national or local vendors or request referrals from friends/family’s sales person with their vendor performance satisfaction.

Challenge #9 – DME Suppliers

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Medications:•Medication panels change•Difficulty in reaching decision makers at the pharmaceutical plan administrators

Billing:

When patients have one of the five (5) advantage plans JHCHC verifies the correct advantage plan that covers the patient. These plans are as follows:

Advantra Freedom, Todays Option, Humana, Wellcare, Windsor

These plans differ in the time frames allowable for billing. Windsor has a limited billing time of 120 days (4 months). The other Medicare plans allow up to one year to bill.

Experience Dealing With Medicare

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Alexander Waites ElderlyHousing Complex

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JHCHC under its corporate umbrella operates an elderly and handicapped housing complex. A JHCHC employee acts as a facilitator for the residents.More than 70% of the tenants are 65 years or older.Approximately 80% of the tenants use JHCHC as their primary health care provider.

Alexander Waites Elderly Housing Complex

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When necessary, primary care providers are kept abreast of resident’s medical issues by the Manager.

Residents are assisted in receiving enabling services such as transportation to physician offices as well as other activities in the community.

Activities such as educational presentations and bible study are done on site.

Inspection of the apartments for any hazards and HUD requirements are done regularly.

Alexander Waites Elderly Housing Complex

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Transportation provided by the health center is very helpful. Cooperation with scheduling by clerks and providers is

necessary. Cooperation with family/caregivers of elderly patients is

key. Education of patients (bringing meds, any paperwork and

family/caregivers to each visit). Additional staff available to provider for care of the elderly.

Lessons Learned/Tips For Other Health Centers

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On-site Social Services Department to assist in case management and enabling services will enhance geriatric patient management.

In-House pharmacy is beneficial due to its affiliation with the HRSA 340B Program.

Collaboration with Home Health Agencies is beneficial.

Lessons Learned/Tips For Other Health Centers

Contact InformationDr. Jasmin Chapman

Chief Executive OfficerJackson-Hinds Comprehensive Health Center

601-364-5142jhchc@comcast.net

http://www.jackson-hinds.com

THANK YOU