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Why CHCs Should Care About Aging and Caregiving

Friday, May 20, 2016   (0 Comments)
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Why CHCs Should Care About Aging and Caregiving


by Tina Castañares, MD

Board member and former Medical Director/family physician

One Community Health, Hood River and The Dalles, Oregon

Convener, Aging in the Gorge Alliance / Alianza de la Tercera Edad



I’m aging, and so are you. 100% of our CHC patients are aging. Nearly all of us, along with our loved ones and families, will face advanced illness, disability, and the special challenges of the last months of life. Although most of us say we hope to be “healthy until we die” (a nice aspiration), only a tiny fraction of us will be quite so lucky. And we’ll need help. As former First Lady Roslyn Carter famously put it, “There are only four kinds of people in the world: those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need a caregiver.”


But what does all this have to do with our health centers? After all, most of us have fewer than 10% Medicare patients in the “payer mix.”


Back to statistics: 100% of our current patients will reach Medicare age unless they die prematurely. (Whether they qualify for Medicare does depend on having legal immigration status, of course. That’s worth an article in itself.) Most of our current patients on Medicaid will then find themselves “dually eligible,” a beneficial situation overall, but complicated – confusing to enroll in, confusing to take full advantage of, confusing to providers, often outside the coordinated care organizations and alternative payment methodologies we’ve recently become familiar with.


So count on our payer mix to change substantially, and quickly. On the day you read this, 10,000 people living in the USA are turning 65. That trend, launched in 2014, will continue for at least another 19 years. Imagine the impact of this “elder boom” on the phone lines and websites of Medicare and Social Security, every single day.


By 2030, 1 in 5 of us will be 65 or older. That’s a bigger demographic bulge than those under 14. The fastest growing age demographic in America is 85 years and older. The third fastest is 100 years and older. Within a generation, nearly three-quarters of a million people in our country will top 100 years old. Sooner than that, the group 85 and up will double today’s figures, exceeding 11 million. This is an unprecedented, profound societal change…and we aren’t yet ready for what it requires of us.


But wait: isn’t 80 the new 60? 60 the new 40? Unfortunately, that’s just a comforting Hollywood concept. For every 80 year old who might be windsurfing in my region, there are hundreds more of that age who are struggling -- usually physically, and often financially and socially as well.

More than two-thirds of people over 65 have at least two functional limitations or disabilities. Especially in rural areas, they may be socially isolated. They are at higher risk of crime, elder abuse, inadequate resources or navigation. There is insufficient affordable housing , transportation or caregiving options. In our CHCs, these elders may not be receiving expert geriatric care. Such expertise is quite variable, and isn’t well captured by our UDS and other reported measures. Specialized attention to elders and caregivers is in competition for our providers’ time and attention with all of our more ‘traditional’ services to younger adults and children.


Already, one in four working adults over 25 is a family caregiver for another adult, and on average spends 18 hours per week in caregiving tasks – while usually working full time, and often taking care of children at home too. Let’s think about this when it comes to our CHCs’ employees: look around and imagine one in four of your staff being concerned for the care of another adult at home. Perhaps your employee rushes home at lunch to give meds. Perhaps s/he must take PTO time to transport an elder to the doctor. Perhaps the loved one at home is seriously ill, yet the employee must focus without distraction at work. Can we make our workplaces more accommodating to family caregivers? We will have to. We will have to be innovative, to be the best employers we can be.


This also means arranging for more clinical training for our providers. Elders have many different needs than children and younger adults when it comes to oral health, physical health, and behavioral health. Our medical clinicians must feel comfortable being front-line palliative care providers, since foreseeably there will be long-term shortages of palliative care specialists or geriatricians. We need to learn to ask elders, the disabled, and their family members new and more focused screening questions about their health conditions, their ability to age in place, and caregiver stress. When it comes to the epidemic of dementia which is already upon us, our skills need to be sharper still, and our services more creative and intentionally re-designed. Our Community Health Worker programs must discover new outreach and health promotion methodologies for elders and caregivers, and contribute more to bridge the cultural differences around some of the most sensitive, challenging and difficult topics human beings face (death, dying, dementia, disability).


Non-clinical leaders and Boards of Directors must educate themselves and staff about Medicare eligibility and enrollment, Medicare “elections” (such as the end-stage renal disease election, hospice, PACE, and others), dual eligibility, traditional Medicare vs. Medicare advantage, case management and care coordination, billing, coding, alternative payment methodologies and Merit-Based Incentive Payment systems , Accountable Care Organizations and Medicare Shared Savings, long term care, and much more. We should all be recruiting and hiring trained geriatric case managers.


And all of us must look at the Elder Boom and the Caregiver Crisis through the broader, population-based lens we’ve acquired in learning about the Social Determinants of Health. Elders and their caregivers need everything a younger person needs: social capital; high-quality, accessible health and social services; transportation; housing; ways to contribute at work or as volunteers; infrastructure; opportunities for physical activity; general support. But elders are simply more vulnerable than younger people whenever these things are lacking, when their health inevitably declines, and when income is no longer being earned. Likewise, social determinants such as poverty, trauma, food insecurity, and discrimination affect elders and caregivers just as much – if not more – than younger people.


The Golden Rule – “do unto others as you would have them do unto you” -- can serve as a terrific conscience for our communities when it comes to serving our elders and those who take care of them. Let’s plan and carry out at our health centers the kinds of things we’d like for ourselves when we reach advanced age and disability– and the things we’d like right now for our parents, grandparents or other beloved elders.

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