Can an “Ideal” Long-term Care System Exist within a Context of Disparities?

August 3, 2014 at 8:08 pm Leave a comment

On July 8, 2014 I testified before the California State Senate Select Committee on Aging and Long-Term Care. The title of the session was “California’s Service Delivery for Older Adults: Envisioning the Ideal.” Instead of providing theoretical and quite frankly, unachievable ideas about how to create the “ideal” long-term care system, I focused my remarks on the need for legislators to remain aware of the diversity of the state’s population and to invest in preventative health services.

Here is my testimony to Committee Chair Senator Carol Liu (D-La Cañada, Flintridge) and the Committee:

Good morning. Thank you for the opportunity to share my ideas about how to achieve the ideal long term care system. I have to admit that don’t know whether a truly ideal long-term care system will ever exist. There are quite a few moving parts, not the least of which are the needs of the consumers. However, there are certain essential characteristics that should be present in an ideal system. And we’ve heard about a few of these characteristics today. It’s not simply the sheer number of older adults and persons with disabilities that compound the need for a comprehensive system of long-term care. It’s the constellation of these persons.

One of the factors that adds a particular level of complexity to the long-term care dilemma is the racial and ethnic diversity of older adults in California. Older adults of color are not just one of the moving parts in the long-term care system, they are a moving target. As their numbers increase, so too will the number of multiple, complex chronic conditions and co-occurring disorders, the rates Alzheimer’s disease and other dementias, and the complex social needs.
So, my approach to discussing an “ideal” long-term care system is to talk about the current gaps in older adult services and programs that seniors are experiencing now. In other words, I am suggesting that we also focus on “prevention” as another potential solution to the long-term care crisis in California.

Just two months ago, Advocates for African American Elders completed our Community Survey that identified the service needs of African American seniors in Los Angeles County. We began collecting data on November 21, 2013. We asked African American seniors about their access, utilization, need, quality, and satisfaction with older adult services in their communities. We also asked them about their social and economic conditions, health and computer literacy, and knowledge about important healthcare policies and programs, such as the Affordable Care Act and the Coordinated Care Initiative.

As you can see from the Table of Contents, the report is fairly extensive and the findings too plentiful to cover in the time allowed. However, I would like to highlight a few that are relevant for our conversation today. A total of 550 African American seniors throughout LA County participated in our study. Findings indicate that many African American seniors are healthy, connected, engaged and receiving services that meet their needs. However, findings also reveal service needs and gaps for many African American seniors. Moreover, results revealed low computer and health literacy levels across age groups and educational levels. There was also a lack of knowledge of important healthcare initiatives and of available services and programs for seniors in their neighborhoods. The most disadvantaged groups tended to be seniors with low levels of education, those of advanced years, those who lived alone and those with poor physical and mental health.

We made a number of recommendations based on the findings about how to increase access to services and programs for African American seniors and how to improve outreach, education and engagement strategies to increase the level of knowledge about important healthcare policies and available services and programs in their communities. I should note that 81.5% of African American seniors surveyed had never heard of the Coordinated Care Initiative. We also made recommendations about how to improve the quality and increase the quantity of services and programs to better meet the needs of African American seniors as they defined them. 27% of African American seniors were not aware of programs for seniors in their neighborhood, and only 52% were currently participating in them. 35% indicated that there were services missing from their neighborhood that they needed, including In-home Supportive Services and Adult Day Care.

We recommended strategies for increasing the health and computer literacy of African American seniors, as finding clearly documented a technology divide that places African American seniors of all ages and education levels at a disadvantage. Almost 44% of African American seniors did not know how to use a computer and 43% did not have access to the internet in their home or anyplace else. This has huge implications for access to health care information and one’s ability to manage their health conditions.

Twenty-four percent of African American seniors were not happy with the quality of services in their neighborhoods and 91% indicated that more needs to be done to provide quality services to African American seniors.

In our recommendations, we identified particular policies, such as the California Homes and Jobs Act, the Supplemental Security Income Restoration Act and the Positive Aging Act, that are needed to improve the economic and living conditions of African American seniors and increase their access to quality mental health services in their communities. Housing and income were identified as barriers to access to services by African American seniors in our study. In addition, those who rated their mental health as “fair” or “poor” were disadvantaged across a number of domains.

And finally, we stressed the need for advocacy at the federal level to support programs that strengthen the aging workforce and improve quality of care for African American seniors and all older adults, such as Titles V, VII and VIII, which provide funding for Geriatrics Health Professions Education and Training programs.
Since the number of older adults of color in nursing homes is increasing faster than their rate in the population overall, it is important to address the workforce shortage but to also ensure that those providing the services are culturally competent and have the skills to do so. This includes competency to address the physical, mental, cognitive, behavioral and social needs of older adults.

In 2012, more than half a million direct-care workers provided an estimated 70-80% of the paid hands-on care for older adults and those living with disabilities or other chronic conditions; 376,000 of which were independent providers employed in the In-Home Supportive Services program. The demand for direct care workers is great and will increase exponentially over the next 15 years. By 2030, 3.5 million additional health care professionals and direct-care workers will be needed nationwide. California will also experience a shortage, as the growth projections for the eldercare workforce will significantly exceed that of all other occupations.
While the demand for direct care workers steadily increases, the supply will dwindle. Nationally, between 2010 and 2030, women aged 25 to 44 (the typical direct care worker) will increase by only 7%, creating a large care gap.

Locally, LA County will be experiencing a demographic shift that will radically decrease the supply of workers. Over the next two decades, Los Angeles County will gain 867,000 older adults and lose 630,000 people younger than 25 years old. So it seem as though we will have a workforce issue for some time to come.

The Affordable Care Act extends coverage to millions of previously uninsured Americans. But, coverage does not necessarily equal care. By next year, the U.S. could have nearly 63,000 fewer doctors than needed, and that number could double by 2025. With the shortage of physicians, it is expected that the most vulnerable patients will have access problems. These patients will most often be the Medicaid population because Medicaid reimbursement rates are so low.

So, let’s put these numbers in perspective. Currently, there are 4.41 million older adults in California. In 2011, there were 739 certified geriatricians. That works out to approximately one geriatrician for every 6,000 older adult in California. We need to train 2,813 geriatricians between now and 2030 just to provide the minimum level of care.

Currently 80% of care is provided informally by friends and family members.
In 2009, more than 4,000,000 family members provided care to an older adult in California, which equates to approximately $47 billion in unpaid contributions. 46% of family caregivers performed medical and nursing tasks for care recipients with multiple chronic physical and cognitive conditions. Based on the funding made available to support family caregivers in 2013, each caregiver would have received $3.75 for the year. In 2010, the family caregiver ratio was 7.7 to 1. This ratio reflects the number of potential caregivers aged 45-64 for every person in the high-risk years of 80-plus. In 2030, the ratio will be 4.4 to 1. And in 2050, it will be 2.7 to 1. Until we can better support family caregivers, while also improving our system of long-term care, families will continue to struggle to pay for long-term care services and supports, often impoverishing themselves financially and emotionally to get the services that they need.

Clearly, much needs to be done to address the shortfall in the eldercare workforce in California and nationwide. In the meantime, current older adult services and programs are not meeting the needs of some consumers. So, what does this mean for long-term care? Here is a likely scenario: A low income senior with multiple and complex chronic conditions is admitted to the hospital and instead of returning home, transitions to a low quality nursing home and remains there until his or her death.

There are disparities in nursing home care – both in who is more likely to transition to one as well as the quality of care they will receive. While the number of whites in nursing homes is declining, the rates for African Americans, Asians and Latino seniors are increasing by as much as 55%. A recent study of 11,500 nursing homes found that those with a high proportion of African American residents had lower costs, but also had lower revenues, tighter operating margins, quality-of-care deficiencies and many deficiency citations.

While the ACA does not directly address the racial disparities in the long-term care sector or the financing of long-term care, the law might help ensure that people have better access to preventative care. It is the direct benefit of prevention, high quality and accessible older adult services that can potentially limit the duration of nursing home stays. Better continuity of care earlier in the life course could reduce costs and complications as seniors age and enter a nursing home, which unfortunately, is the most likely long-term care option for many African Americans and many other older adults who rely on public insurance.

Is there an “ideal” long-term system of care? Perhaps. However, given the number of challenges, we have quite a way to go before achieving anything close to an ideal. We might even need another “baby boom” to meet the future demand for and eldercare workforce. So, it seems that reducing the number of older adults enrolled in nursing homes, as well as reducing the duration of their stay will not only lower the cost of long-term care but it just might increase the quality of life for the most vulnerable seniors by allowing them to age in their homes and in their communities.
Findings from our Community Survey suggest that we have a bit more work to do to support our most vulnerable older adults in the community. Why not start improving our long-term care system by improving the access and quality of services for seniors in under-resourced communities to potentially limit the number of preventable and expensive hospitalizations and inadequate support in transitioning from a nursing home back into the community.

How do we maintain our most vulnerable seniors in their homes and in their communities for as long as we possibly can? The answer to that question is the semblance of an ideal long-term care system. And that is what we should be aiming for.

To your health,


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