What do Social Workers need to be aware of relating to substance use in older adults? ???What are some considerations for a

Jean Galiana & William A. Haseltine

Solutions to the Most Pressing Global

Challenges of Aging

Aging Well

Aging Well

Jean Galiana • William A. Haseltine

Aging Well Solutions to the Most Pressing Global

Challenges of Aging

ISBN 978-981-13-2163-4 ISBN 978-981-13-2164-1 (eBook) https://doi.org/10.1007/978-981-13-2164-1

Library of Congress Control Number: 2018962361

© The Editor(s) (if applicable) and The Author(s) 2019. This book is an open access publication. Open Access This book is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adapta- tion, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made. The images or other third party material in this book are included in the book’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the book’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Cover illustration: Halfpoint

This Palgrave Macmillan imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Jean Galiana Vital Research Los Angeles, CA, USA

William A. Haseltine ACCESS Health International New York, NY, USA

v

This book is a product of ACCESS Health International (www.accessh. org). ACCESS Health is a think tank, advisory group, and implementa- tion partner dedicated to assuring that everyone, no matter where they live and no matter what their age, has access to high-quality affordable healthcare. ACCESS Health works in low-, middle-, and high-income countries. In high-income countries, our focus is on care of older adults and those with dementia. This book identifies and analyzes policies and practices in the United States that serve as models of excellence in elder care and optimal aging. We chose the title Aging Well because we believe that well-being should be the number one focus of all aging care, sup- ports, and interventions. A companion book Aging with Dignity exam- ines similar topics in Sweden and several Northern European countries.

Our method was to identify organizations in the United States that exemplify the best in elder care and optimal aging. We then interviewed the leaders and champions of those organizations and programs. The full text of the interviews is available on the ACCESS Health website or at this link: www.accessh.org/agingwell. Here, we analyze our findings and present them in the broader context of elder and dementia care and social inclusion. Our focus areas include long-term care financing, person- centered care, coordinated primary care, home-based palliative and pri- mary care, support for those living with dementia and their caregivers, acute and emergency care in the home and community, the combination

Preface

vi Preface

of health and social care that addresses the social determinants of health, and housing, social inclusion, purpose, and lifelong learning.

From these interviews we abstract eight key lessons for achieving high- quality affordable elder care and effective systems that support social inclusion and purposeful aging. Those lessons are:

• The availability of affordable long-term care insurance is essential to improve access and sustain the costs of caring for older adults.

• Person-centered care is a lynchpin of high-quality care and well-being for older adults.

• Support and palliative care in the home and community setting is essential for making care accessible to older adults that honors their care and late-life priorities.

• Coordinated primary healthcare improves elder care quality and acces- sibility and lowers healthcare costs.

• It is imperative that we build systems of support and inclusion for those with dementia and their caregivers.

• Delivery of acute and hospital-level care in the home and community is essential to lower healthcare costs and improve access, health out- comes, and well-being for older adults.

• Social inclusion and the opportunity to live a purposeful life are essen- tial to the happiness and well-being of older adults.

• Combining health and social care with upstream interventions to treat the biopsychosocial and environmental needs is the way forward to sustainable systems of care that improve function, well-being, and independence.

The book identifies and details global aging challenges and, chapter by chapter, offers innovative and impactful solutions to those challenges that our interviewees have designed. It is our genuine hope that providers and government entities around the globe that are seeking methods to improve their elder care and social support systems will find ideas, inspiration, and possibly collaborative opportunities to enhance the well-being of older adults.

Los Angeles, CA Jean Galiana New York, NY William A. Haseltine July 2017

vii

We thank all those who contributed their time and thought to help us understand the issues facing older adults and what can be done to ensure that all have access to high-quality affordable care and the opportunity to live productive and active lives.

Claude Thau patiently described the rocky history of the long-term care insurance industry and why many still do not have long-term care insurance today.

We learned the true meaning of patient-centered care culture from Christopher Perna, the former CEO and President of the Eden Alternative.

Rebecca Priest from St. John’s explained how to build an operational culture around person-centered philosophies.

The leadership of Beatitudes Campus brought the person-centered concept to a new light with their Comfort Matters™ palliative care for those living with dementia.

Dr. Allen Power made us think about the possibility of not segregating those who have dementia from the rest of the community.

They all convinced us that person-centered communication and care is almost always a better option than the use of antipsychotic medications to meet the needs of someone living with dementia.

Dr. Allan Teel of Full Circle America, Dr. Diane E. Meier of the Center to Advance Palliative Care, and Dr. Kristofer Smith of Northwell Health

Acknowledgments

viii Acknowledgments

inspired us with their dedication to enabling aging in place and where patients receive the right care in the right setting and live with dignity throughout their life.

Kristofer and Allan have been making house calls for all of their careers because they know that it improves access to care, costs less, and signifi- cantly contributes to the well-being of their patients.

Allan connects his patients to local supports and services so that his patients stay engaged and connected to their neighborhoods.

Diane remains vigilant in her pursuit to make palliative care available in all care settings.

Drs. Michael Barr and Erin Giovannetti of the National Committee for Quality Assurance gave us a compelling case for the patient-centered medical home to improve coordinated efficient primary care.

The Director of the James J.  Peters VA Medical Center, Dr. Erik Langhoff, uses technology to improve access to high-quality care for veterans.

Dr. Mark Prather and Kevin Riddleberger with DispatchHealth and Dr. Kristofer Smith with Northwell Health are proof positive that deliv- ering acute medical care in the home and community improves access and quality at a fraction of the cost.

Dr. Bruce Leff with Johns Hopkins School of Medicine showed us that providing hospital-level care in the home to patients who qualify can reduce care costs and produce higher-quality health outcomes.

Timothy Peck, Garrett Gleeson, and XiaoSong Mu with Call9 are con- tributing to the well-being of patients living in skilled nursing by provid- ing technology-enabled emergency care and palliative care around the clock.

Dr. Mary Mittelman with the NYU Caregiver Intervention has proven the value of supporting the informal caregiver for someone living with dementia.

Jed Levine and Elizabeth Santiago tirelessly support those in the early stages of dementia and their caregivers with their vigorous programs at CaringKind.

Davina Porock impressed upon us the importance of the built envi- ronment of the hospital for those living with dementia.

ix Acknowledgments

Karen Love and Jackie and Lon Pinkowitz remind us of the vital importance of fighting the stigma of dementia with thoughtful community conversations. They also noted the importance of involving those with dementia in policy and program design.

Brian LeBlanc shared his journey of living for dementia and his stories about his impactful advocacy efforts.

June Simmons with the Partners in Care Foundation impressed upon us the need to combine social care and healthcare and address social determinants of health through evidence-based prevention programs.

Sarah Szanton with CAPABLE proved that it is possible to improve function in frail older adults by providing home modifications with nurs- ing and occupational care to support the goals and priorities of participants.

Joani Blank invited us into her home at the Swan’s Market cohousing community in Oakland, California. We spent a half-day seeing how cohousing promotes community inclusion and multigenerational connections.

Rebecca Priest with St. John’s and the management of Beatitudes Campus regaled us with stories of resident-run activities that facilitate productive living and generativity.

Anne Doyle surprised us with the amount of lifelong learning  and intergenerational connections taking place at Lasell Village, a retirement community on the campus of a college.

Mia Oberlink formerly  with the Center for Home Care Policy and Research impressed the importance of involving older adults in the design of all initiatives that serve them. Ruth Finkelstein formerly  with the Robert N. Butler Columbia Aging Center and the International Longevity Centre USA is committed to ensuring that employers who retain and attract older employees are honored so others will follow suit. Ruth and Dorian Block are combating the stigma of aging by telling the stories of older adults who exceeded life expectancy in New York City and are liv- ing vibrant productive lives.

Lindsay Goldman with Age-Friendly NYC expressed the need for public and private partnerships to make environments accessible to those of all ages and abilities. She explained that older adults must be consid- ered in all areas of city planning and policy making.

x Acknowledgments

Emi Kiyota showed us how multigenerational community hubs con- tribute to resilience after natural disasters and serve as places of produc- tive engagement and social inclusion.

Dr. Paul Tang, formerly with the Director of the David Druker Center for Health Systems Innovation, uses social connections as a form of health prevention by connecting patients to a timebank where they exchange tasks and teaching of hobbies and new skills.

Our research was supported by the William A.  Haseltine Charitable Foundation Trust.

xi

ACCESS Health International is an independent, nonprofit think tank that works for the provision of high-quality, affordable care for all, includ- ing the chronically ill. Our method is to identify, analyze, and document best practices in helping people and to consult with public and private providers to help implement new and better cost-effective ways to offer care. We also encourage entrepreneurs to create new businesses to serve the needs of this rapidly expanding population. Our goal is to inspire and guide healthcare professionals and legislative leaders in all countries to improve care for their own people.

About ACCESS Health International

xiii

1 Demographics 1

2 Healthcare in the United States 7

3 Long-Term Care Financing 19

4 Person-Centered Long-Term Care 29

5 Home-Based Palliative Care and Aging in Place and Community 59

6 Coordinated Primary Care 79

7 Emergency Medicine and Hospital Care in the Home and Community 91

8 Support for Those Living with Dementia and Their Caregivers 117

Contents

xiv Contents

9 Merging Health and Social Services 139

10 Purpose and Social Inclusion 159

11 Eight Lessons for Social Inclusion and High-Quality Sustainable Elder Care 203

Index 217

xv

William A. Haseltine, PhD He is the Chair and President of ACCESS Health International. He was a professor at Harvard Medical School and Harvard School of Public Health from 1976 to 1993, where he was founder and the chair of two academic research departments, the Division of Biochemical Pharmacology and the Division of Human Retrovirology. He is well known for his pioneering work on cancer, HIV/AIDS, and genomics. He has authored more than 200 manuscripts in peer-reviewed journals and is the author of several books, includ- ing Aging with Dignity: Innovation and Challenge in Sweden and Affordable Excellence: The Singapore Healthcare Story.

Jean  Galiana, MASM, RCFE In her role at ACCESS Health International, Jean Galiana successfully promoted key messages about elder care and optimal aging to engage policy makers, healthcare providers, the general public, and stakeholders. She managed qualitative research projects to discover, document, and advocate for best practices in aging in the United States. Currently Jean works in communications and survey research for Vital Research in Los Angeles, CA. She obtained her undergraduate degree in business from Lehman College and holds a master’s degree in aging services management from the University of Southern California Leonard Davis School of Gerontology.

About the Authors

xvii

Fig. 1.1 Rectangularization of the global aging pyramid from 1970 to 2060 2

Fig. 1.2 Global distribution of population 65 and over in 2015 and 2050. Source: U.S.  Census Bureau, 2013, 2014a, 2014b; International Data Base, U.S. population estimates, and U.S. population projections 3

Fig. 1.3 Potential support ratios by region, 2015, 2030, and 2050. Source: UN Department of Economic and Social Affairs 4

Fig. 3.1 Growth in demand for LTSS. Source: Bipartisan Policy Center 20 Fig. 4.1 Green House at Penfield 36 Fig. 4.2 Penfield Green House Great Room 36 Fig. 4.3 Mr. H’s binder 40 Fig. 4.4 St. John’s to traditional skilled nursing regional comparison 42 Fig. 5.1 Palliative care gap 70 Fig. 8.1 CaringKind entrance welcome 121 Fig. 8.2 MedicAlert® bracelet and necklace 128 Fig. 9.1 Results of HomeMeds PLUS Pilot Program. Source: Partners

in Care Foundation 147 Fig. 10.1 AdvantAge Initiative. Age-friendly Measures 176

List of Figures

1© The Author(s) 2019 J. Galiana, W. A. Haseltine, Aging Well, https://doi.org/10.1007/978-981-13-2164-1_1

1 Demographics

The commitment of ACCESS Health International to elder care and optimal aging is fueled by the global change in demographics. The popu- lation over 60 is expected to double to 22 percent, reaching 2.1 billion from 2000 to 2050.1 The demographic shift is attributed to increased life span, lower mortality rates, declining immigration rates, and lower fertil- ity rates. Figure 1.1 is an example of the rectangularization process from 1970 to 2060.

The 100-year shift that began in 1950 is only 17  years past its mid- point.2 By 2060, the pyramid will resemble a dome shape. Some predict that it will morph into the shape of a rectangle3 because, in many coun- tries, the oldest old (85+) population is growing the fastest.4 The global population of those 85–99 is projected to increase by 151 percent from 2005 to 2050, while the population of those 100+ is expected to increase by more than 400 percent5 (Table 1.1).

The demographic shift is occurring at varying rates throughout the world (Fig. 1.2). The United Nations reported that, in 2015, almost 25 percent of the world’s population 60 and over lived in China and that only four other countries account for another 25 percent including the

2

United States, Japan, India, and the Russian Federation.6 The projected growth rate for the over 60 population also varies from country to coun- try, but is expected to continue to grow globally until 2060.

Potential Support Ratio

One result of the demographic shift is that there will be substantially more older people who need care and fewer younger people to provide the care. This care conundrum is reflected in the potential support ratio— the number of workers (age 15–65) to the number of retirees (65+). The potential support ratio has been declining substantially from 2000 to 2050 (Fig. 1.3).

With the shrinking potential support ratio, who will care for the grow- ing number of older adults? Immigration is one answer, but the overarch- ing response should be that healthcare and social support systems become

Fig. 1.1 Rectangularization of the global aging pyramid from 1970 to 2060

Table 1.1 Projected global population increase by age group 2005–2050

Age Percent increase (%)

0–64 21 65+ 104 85+ 151 100+ 400

Source: National Institute of Aging

J. Galiana and W. A. Haseltine

3

Fig. 1.2 Global distribution of population 65 and over in 2015 and 2050. Source: U.S. Census Bureau, 2013, 2014a, 2014b; International Data Base, U.S. population estimates, and U.S. population projections

Demographics

4

more efficient to meet the significant needs of this cohort. Informal caregivers make invaluable contributions, but they cannot meet the com- plex care needs of the growing older population. This care gap is further magnified when considering the rates of comorbidity and cognitive and functional limitations of the older population.

We will begin with some facts about healthcare in the United States and then describe solutions to the challenges we have laid out.

Notes

1. World Health Organization (2015). Global strategy and action plan. 2. Bongaarts, J. (2009). Human population growth and the demographic

transition. Philosophical transactions of the Royal Society of London, 364(1532), 2895–2990.

3. (2014). The next America. America’s morphing age pyramid. Pew Research Center. http://www.pewresearch.org/next-america/age-pyramid/. Accessed March 2016.

Fig. 1.3 Potential support ratios by region, 2015, 2030, and 2050. Source: UN Department of Economic and Social Affairs

J. Galiana and W. A. Haseltine

5

4. National Institute on Aging. Why population aging matters: A global per- spective. Trend 3: rising numbers of the oldest old. https://www.nia.nih. gov/publication/why-population-aging-matters-global- perspective/trend- 3-rising-numbers-oldest-old. Accessed January 10, 2016.

5. Ibid. 6. United Nations, Department of Economic and Social Affairs, Population

Division (2015). World Population Ageing 2015 (ST/ESA/SER.A/390).

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/ by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the chapter’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copy- right holder.

Demographics

7© The Author(s) 2019 J. Galiana, W. A. Haseltine, Aging Well, https://doi.org/10.1007/978-981-13-2164-1_2

2 Healthcare in the United States

United States Health Spending and Outcomes

The health spending of the United States is the highest among the OECD countries. It was 2.5 times greater than the OECD average in 2013.1 Health spending accounted for 16.4 percent of the gross domestic prod- uct in 20132 and, in 2020, it is projected to represent 20 percent.3 By 2040 it is estimated that one third of all spending in the United States will be on healthcare.4,5 Despite all of the spending, the health of Americans lags behind. This is, in large part, a result of America divesting from prevention and health promotion programs. Another contributing factor to such poor health outcomes is that the United States does not invest enough in building robust systems of primary care.6 Although the United States spends close to the same amount as other Western coun- tries on healthcare and social supports combined, the United States spends proportionately less on social services and more on healthcare to treat people after they become ill7 from what are often preventable dis- eases. Adults in the United States are more likely than adults in other developed nations to forgo necessary healthcare because they cannot afford the cost.8 From 2010 to 2012, 54 percent of people with chronic

8

illness reported that cost was a barrier for them to access care. The patients surveyed reported that they skipped medications, treatments, and doctor visits because they could not afford the cost.9 Life expectancy is shorter in the United States than most OECD countries. As of 2013 life expectancy in the United States was 78.8, while the OECD average was 80.5.10 In 2014 the Commonwealth Fund ranked the United States healthcare last among 11 countries.11,12 The measures included access, equity, quality, efficiency, and healthy lives. Because of these findings, the government and many health systems in the United States are creating new care mod- els to address the issues of healthcare access, quality (including patient satisfaction), and cost. Many of these innovations are designed to serve older adults because the older cohort interacts with the healthcare system more than others.

Our ultimate goal, after all, is not a good death, but a good life to the very end. (Atul Gawande, Being Mortal: Medicine and What Matters in the End)

Optimal Aging

In the United States and internationally, there is a continuing focus on community supports and inclusive societies that allow older adults to remain active and engaged. This focus includes age-friendly cities, inclu- sive housing, and employment opportunities. Most of the improvement in healthcare and inclusive environments will positively affect those with dementia, but providers and city planners are also committed to imple- menting dementia-specific care and support measures.

Geriatric Workforce Shortage

Geriatricians are a critical factor of high-quality care for older adults. The United States is already struggling with the ability to care for the older population with the high rates of dementia and other chronic illnesses and is lacking in a workforce that with appropriate training.13 According to the American Geriatrics Society, as of 2015, the United States was

J. Galiana and W. A. Haseltine

9

short of 9500 geriatricians.14 This shortage threatens to grow as the popu- lation ages. The World Health Organization cites that to meet the need of the growing older population, all healthcare providers must be educated in gerontology and geriatrics.15 Some suggest that having more geriatri- cians in the hospital setting could reduce costs.16 This is important because 25 percent of Medicare spending is attributable to inpatient hos- pital care.17 Geriatricians are trained to understand and diagnose cogni- tive problems and functional challenges with activities of daily living. They also are knowledgeable about how drugs act differently in the aging body and are adept at polypharmacy management. Additionally, geriatri- cians are trained to manage multiple comorbidities and understand that health management is often the primary focus rather than cure.

Prevalence of Chronic Disease

Longevity and lifestyle choices such as smoking, alcohol, and obesity have contributed to people developing more chronic illnesses. The occur- rence of multiple chronic conditions increases with age,18 which com- pounds the burden of caring for the growing aging population. Almost one half of older adults in America are living with both chronic condi- tions and functional limitations.19 Eighty percent have at least one chronic condition, and 50 percent have at least two.20 Approximately 75 percent of Americans 65 and older are living with multiple chronic conditions21 and 20 percent are living with five or more chronic condi- tions.22 The oldest old population (80 and older) is growing most rap- idly23,24 and has the highest rates of comorbidity.

The number of people living with dementia is projected to increase by more than 200 percent, from 44 million in 2014 to 135 million by 2050.25 One in nine people 65 and older have dementia. The statistics, however, do not accurately represent the prevalence of dementia because an esti- mated 50 to 90 percent of dementia cases go undiagnosed.26,27 The global average rate of undiagnosed cases of dementia is 75 percent.28 The rates of undiagnosed dementia vary from country to country. The highest rates are found in the low- and middle-income countries.29 It is nearly impossible to separate elder care from dementia care after the age of 75 because that

Healthcare in the United States

10

population represents 81 percent of the cases of dementia.30 As we men- tioned, the oldest old is the population that is growing the fastest. Thirty- two percent of that cohort have received a diagnosis of dementia.31

It is more expensive to meet the complex care needs of people with multiple chronic conditions. Many will also need supportive help because those with multiple chronic conditions experience higher levels of poor functional status.32,33 Older adults who are living with five or more chronic illnesses have, on average, 50 prescriptions and 14 different phy- sicians and make 37 office visits annually.34 Those with multiple chronic conditions account for 71 percent of the total healthcare spending in the United States.35 The fee for service individuals with multiple chronic con- ditions, who are beneficiaries of the government-sponsored Medicare, accounts for 93 percent of the total Medicare spending.36 The unsustain- ability of medical costs is an incentive for the Centers for Medicare and Medicaid to support more efficient, less costly, and better quality systems of care for the sickest people. The financial burden is also borne by people living with multiple chronic conditions through out of pocket costs and the high price of prescription medications.

Meeting the healthcare and social needs of the older population is a world- wide public health challenge. To properly and sustainably meet the needs of older adults, providers must challenge fragmented and complex care and social support systems and implement coordinated, person- centered care across a variety of care settings and providers. Providers must also foster chronic disease self-management programs and other forms of patient engagement. Two important concepts that we address throughout the book that se

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