How State and Local Agencies on Aging Help Older Adults: Susan DeMarois, Greg Olsen, and Lindsey Yourman

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we are delighted to welcome Susan DeMarois, who is Director of the California Department of Aging. Welcome to the GeriPal Podcast, Susan.

Susan: Happy to be here. Thank you.

Alex: And from the other side of the country, we’re delighted to welcome Greg Olsen, who is Director of the New York State Office for the Aging. Welcome to the GeriPal Podcast, Greg.

Greg: Thanks a lot. I’m really excited for the conversation today.

Alex: And we are delight to welcome Lindsey Yourman, who is a geriatrician, she’s a longtime friend and mentee, and is now a peer and is a key component of the ePrognosis working group and helped originate the ideas that led to ePrognosis and she’s now San Diego County’s Chief Geriatrics Officer. Welcome to GeriPal, Lindsey.

Eric: Welcome, Lindsey.

Lindsey: Thank you so much. You’re very kind, Alex.

Alex: We’ve got a lot to talk about…what states are doing and cities are doing to support older adults in the community. And including Lindsey, at some point, I want to hear what the heck a chief geriatric officer does for a county. But before we go into that, somebody here has a song request for Alex.

Susan: That’s me. I asked Alex to play U2’s A Beautiful Day.

Eric: And why, Susan?

Susan: It is my anthem. When you live in California, it’s usually a beautiful day, but also I thought for a while there with older adults, it was described as the silver tsunami. And if I leave this audience with one thing, never ever say that, please don’t compare the aging of older adults in our nation to a disaster. And so, I think it’s a beautiful day that we’re putting a spotlight today on older adults. And in our state, one in four people will soon be 60 or older, so it’s a real asset to our state and nation. That’s why I picked A Beautiful Day.

Eric: Wonderful, Susan.

Alex: That was terrific framing and also hopefully mix up for that phrase making into one of our podcasts. Thank you so much for raising that terrific point. Here’s a little bit of the song.

(Singing).

Eric: Great song suggestion, Susan.

Lindsey: Yes.

Susan: Nice.

Greg: Well done.

Eric: I’d like to start off with both asking Susan and Greg the same question. You are both running state departments on aging, is that right? Are both, I guess different names. Is that fair to say? State departments on aging in general, is that the right word?

Greg: Yeah.

Eric: Greg, how did you get interested in this and in particular this role as the director?

Greg: Yeah, great question. We’re actually designated state units on aging that are designated by our governors. I got into this 31 years ago. I’m a geriatrically trained social worker and it was my grandmother. I was working with abused children at the time, and I watched my grandmother really devolve at the end of her life, didn’t have the support she needed to stay in her home and community, had to spend down and impoverish herself into Medicaid and I thought that there had to be a better way.

I’ve also been very connected with older people, meaning that what I’ve been culturally taught to believe through cartoons, movies, media, television, et cetera, didn’t match my own reality in terms of the value of older people. Started as a direct case manager, worked in a variety of different places including the state legislature and I’ve been with the state office now since 2006.

Eric: And Susan?

Susan: I got my start working for a member of Congress doing constituent casework and a lot of the casework was supporting older adults with VA, Social Security, Medicare, immigration casework. And from there, I went to work on a statewide ballot initiative. Talking about palliative care here on this podcast, in our state, gosh, this was in the early ’90s, physician assisted death was on the ballot. At that time, I was working on the opposition because my view was it was a false choice for people until they had a full array of services, including palliative care that was really not hospice and palliative care weren’t very well known or available in the early ’90s. And so-

Eric: A lot of care was just a tiny, tiny baby by that back then.

Susan: Yeah, I don’t think the word even surfaced. I’ve been on a quest to build those services and support so that people can make true, informed decisions for themselves and their families.

Eric: Great, thank you both. I wonder if you can give our audience a sense. I did a geriatrics fellowship, a wonderful geriatrics fellowship residency. I had some idea, I’ve heard of areas of aging before, not a hundred percent sure about state, was state units on aging, is that the correct term, Greg?

Greg: That’s the statutory term. And then, we all call ourselves something different.

Eric: Something different.

Alex: And you were in New York, right, Eric?

Eric: I did residency in New York, so I have both. I’ve been in both of your territories. And then, I know about things that I think areas on aging do, area agencies, aging, do Meals on Wheels and things like that. But, can you maybe give us either of a little history lesson for us? How did this all develop and does every state have these units?

Greg: Susan, you or me?

Susan: Go for it, Greg.

Greg: Okay. I think it’s a little known fact that the Older Americans Act, which is kind of our mothership, was passed at the same time as Medicare and Medicaid in 1965. It was designed to really balance what Medicaid at the time was to provide nursing homes and Medicare is obviously health insurance. But, what you need is a community-based game there. Acute care is called acute care for a reason. It’s short, it’s episodic, and then where do you go? You go back home.

The idea was to create a robust community-based infrastructure that could help older adults succeed in their homes and communities, whether they were healthy, how to keep them healthy or they were at imminent risk of emergency room visits, hospitalizations, or nursing home placements. Equally as important, is if you wind up in an ED or being hospitalized or wind up in rehab, eventually you’re going to be discharged back home.

And so, we are really the ones that are doing the heavy lift. The long-term care is being actually provided in the community at a much higher rate than what the formal system provides. I think the problem is, and this is something Susan and I deal with every day, we’re on the discretional side of the ledger, which means we have a fixed amount of money that we receive from the Older Americans Act and we have to budget for that for the entire year.

Whereas, things like Medicaid and Medicare, once you’re eligible, you can receive that service, generally speaking. And so, our goal is really to resource the things that we do so you can prevent higher levels of care and Medicaid spend down. And we’ve been proven to do that for over 50 years.

Eric: Does every state have a State Department of Aging? Is that a requirement?

Greg: Yeah.

Susan: Yeah.

Eric: How does area agencies on aging, how does that fit into all of this, Susan?

Susan: State units on aging oversee a network of AAAs, they’re called. In California, we have a network of 33. They cover 58 counties. If you go state to state, they’re all organized differently. They might be called something else, but the framework is the same in every state. Ours are a combination in our state of county run like Dr. Yourman’s is a great example in San Diego. We also have Joint Powers agreements where there might be a collection of counties that ban together. And then, we have nonprofits that are community-based organizations.

All of them offer the same array of services, really emphasizing social determinants of health and preventive services like falls prevention, chronic disease, self-management, caregiver training. And then as you mentioned, senior nutrition is a big part of it where providers like Meals on Wheels, maybe a contractor, but also many of our AAAs run their own nutrition services so you get a combination of in-house and contracted services.

Eric: Let me get this straight, things like Meals on Wheels, that’s through the AAAs, areas in aging, and areas in aging are through these state units on aging, which is all-

Greg: I’m going to, Eric, and you wouldn’t know this, so this is not a knock on you.

Eric: Let me clear, I do not know this.

Alex: I don’t either.

Eric: Which is part of the problem. Right? There is this opaqueness that even a geriatrician who’s been practiced for nearly 20 years is still confused.

Greg: The language Susan use is really important. It’s the nutrition program. We operate the largest nutrition program in the country. Meals on Wheels is a brand like Dunkin’ Donuts is to coffee. We’re organized the same way. In New York, we have very few Meals on Wheels programs. They are a combination of either direct provided by our 59 area agencies or they’re done by contract.

It’s really the nutrition program, which is inclusive of congregate meals. It could be in housing, it could be a standalone senior center, home delivered meals, nutrition counseling and nutrition education done by registered dieticians.

Eric: And then, let me ask another question is, so the state units, what the states are doing in aging in addition to the AAAs, what else does the state department do or state unit do?

Susan: They do a lot.

Eric: Well, it starts-

Susan: Well, oh, I’ll start with in our state it’s about 50/50 state funded and federal Older Americans Act funded. We’ve really grown this space in California and one of our signature activities is the master plan for aging. Our governor, Gavin Newsom, embarked on this in when he took office four years ago, an executive order to develop a master plan for aging that is across all departments and agencies. This includes transportation, driver’s license, parks, volunteerism, housing, and of course health and human services. That would be an example of something we’re very actively engaged in California in addition to the older Americans Act. Greg.

Greg: To build upon that, so Susan and I are required to submit a plan to the feds. We do it every four years. Ours is due next month, and that is going to show how we’re going to meet federal priorities, but it’s only a piece of what we do. We then, from our four-year plan, we require our counties to also submit a plan on all of the services we provide, how they’re going to spend the money, who they’re going to serve, how they’re going to target resources to those hardest to serve diversity, equity, inclusion, rural areas, things of that nature. We also have a network of 1,200 community-based organizations and partners.

That’s just the older Americans Act part. We’re a little bit different. The least amount of money that I get is from the feds. The second largest amount is from the state. The counties are the largest payer in New York state for these services. Why? It’s because this job Susan had, your constituents are the ones you see every day, all politics are local and they put in, we, In addition to having match requirements for federal and state, they put in what we call overmatch, which is an additional.

To Susan’s point. Older people don’t live in the Offices for the Aging. They touch every single system. I have 24,500 veterans on our caseload, 14,000 individuals with diagnosed mental health issue, 8,500 with an alcohol and substance abuse. I won’t even get into problem gambling. We have 350,000 grandparents taking care of grandkids. And so, whether you’re doing master plan on aging or age-friendly communities, if you’re not pulling all the pieces of state agencies, local agencies and the public-private partnerships together, then you’re serving people siloed and not holistically. That’s when they fall through the cracks and that’s when they’re not able to age successfully in place so it is an all hands-on deck approach.

Eric: And then, Lindsey, how does your role fit into all of this? Chief Geriatric Officer, what is that?

Lindsey: That’s a good question. And to some extent, the chief geriatric officer role is something that we’re still defining and that’s evolving. To our knowledge, in San Diego, our county is the first county to have a chief geriatric officer. I think to some extent, the county doesn’t necessarily know what they don’t know about geriatrics, just like I don’t necessarily know what I don’t know about the county and local government and national government and state government. But bottom line, it’s really trying to work across our different departments.

Not just with our aging and independent services, but also with our behavioral health services, with our public health services, with our medical care services, to really have everyone see older people as part of their work. I think it can be tempting to kind of silo it to, oh, that’s just aging and independent services. They deal with that. But, it’s actually every service we’re providing really should be taking into account the unique needs of older people. And so, I’m trying to help have a more unified effort in that way in our county by interfacing with all the departments and asking questions from a geriatrician perspective. That helps.

Eric: Are there other chief geriatric officers in other counties that you know of?

Alex: She said, no, for California,

Eric: No, but elsewhere?

Lindsey: Not that we know of.

Susan: And isn’t that crazy that Lindsey is the first and we’re fast approaching in our state, well, where we’ll have between probably close to 11 million Californians, 60 plus, and that this is the first dedicated chief geriatric officer?

Eric: Well, let me ask you this, because Alex, how clear are you so far in this structure?

Alex: I think I’m seeing sort of the, I don’t know if it’s a branching tree or a sort of org chart in my mind, and it seems to be a tremendous amount of variation by state. I imagine there are some states that, poorly funded offices or, and other states that have more robust offices.

Eric: Well, I guess the question then, go ahead, Greg.

Greg: Oh, very much so. I was talking to one of my colleagues in a fairly large state who had four full-time staff at the state unit.

Eric: Wow.

Greg: There’s one state that doesn’t have a-

Eric: How many do you have, Greg? Just for comparison.

Greg: We have 138, which is-

Eric: Wow.

Greg: It’s fairly good size, but like I said, the beauty of the way we’re structured, it’s top down, bottom up at the same time. Grassroots oriented, so we’re all rowing in the same direction. We can’t succeed without our local partners and vice versa. There’s states where, like I said, the state unit is the AAA.

Eric: I got another question then, so how important, if at all, is it that providers know about these structures? I go to the gas station, I just get my gas and I leave. I don’t really care what their organizational structure looks like. I just want my gas. If you’re a provider in the community, how important is it to know all of these, like the state, the AAAs, and where and how should they interact with this system?

Greg: It’s not. There’s too many things that folks have to offer for people to remember. When I public speak and talk about the 25 core services you’ll find everywhere in the state, that’s really not important. What’s important is that you have a place to go, a trusted resource to start. One of the beauties of Susan’s and our network, and I think I can speak for her, is we’re not selling a product and we’re not selling a service. We’re selling objectivity, information, independence and choice. And that’s critical.

For example, I’m coming out of the hospital, the hospital discharge planner may not know all the services available, so they’re going to say Meals on Wheels, or you might need home care, right?

Eric: Yeah.

Greg: If you call up one of those entities, good chance are you’re going to walk away with one of those services. And that’s not necessarily bad. But, if we’re able to look at somebody holistically, and I’ve got a veteran that has never connected with the Department of Veteran Services in New York State and is eligible for maybe 115 federal, state and local veterans benefits and services, that’s the interconnectedness.

I see somebody like Lindsey being extraordinarily important because I think what we both said is this is about connecting the dots. The growing older isn’t the problem, it’s the way we’ve organized our caring economy. And that’s what needs to change is how you start first at the front end in the community, how you leverage the assets and resources that are across various systems so that you can solve the problem or address the issues then before they get to a point where you’re at a point of no return. Because, I think the general public has no idea what all the state and local agencies do to support older adults and their families in general.

It’s that first place that you start where it may not be the AAAs job, but we’ve organized where they have to have the partnerships and they know who the players are and they know who to make a referral to. And that referral can be done in real time, a soft handoff.

Susan: And so, I couldn’t agree more with Greg that we, all of that should be invisible to a consumer. And that’s something we’re putting a lot of resources towards is to really flatten things so that navigation, so brand name and awareness and navigation are easy and people just know where to get started. And then, the system responds in turn.

Eric: Which is, so let’s say I am a provider, a healthcare provider taking, let’s say a nurse practitioner working in an older, a clinic that’s mainly caring for older adults. I have a 76 year old who’s not doing well at home, not getting a lot of services, and we want to try to, they’re not getting enough nutrition. You’re worried about weight loss, you’re worried about how things are going at home. What should that person do with the structures that are available right now?

Greg: You came from New York, let’s say you’re in Westchester County. I would hope a referral would go to what’s called an ADRC, and it’s called an Aging and Disability Resource Center. I think most states have them. Ours is a $35 million systems change that includes a variety of organizations. But, that’s kind of the front door, right? Because again, we’re a crisis-driven network. I like what Lindsey said earlier. I say this all the time, “You don’t know what you don’t know until you need to know it.” You don’t need to know about property tax relief until you buy a house. You don’t need to know about TAP and Pell until your kid goes to college. Most people don’t know about these services until they need them. And that’s just kind of the way that it is.

But, I would hope, and this is a lot what we’re working with, with really the embracing of this new term, social determinants of health, which we’ve all been doing for decades, to really integrate models and systems that brings social services and clinical services together so that referral can be made, we can do a comprehensive assessment and then let the individual, and if they’re lucky enough to have a family member or caregiver know what’s out there and what choices they have.

And then, they ultimately have the responsibility because they live their own lives to accept or decline or to take the risk in terms of their own care. But, these things need to be coordinated. Then you add a layer of technology over it, which is a huge bonus. There’s so many great tech tools out there now that older adults are using and can use to really wrap around the social services and the clinical services.

Alex: I want to pick up on this thread and talk-

Lindsey: I really-

Alex: Oh, Lindsey, jump in there. Go for it.

Lindsey: Yeah, no, I really appreciate what Greg is saying. And just going back to that patient, I’ll tell you, before I started this role, I would have probably looked at the handout box in our clinic and been like, oh, okay. Here’s a Meals on Wheels handout and here’s a fall prevention handout, and we don’t have a social worker. We just kind of start to amass these handouts and I would give them to the patient. And now I realize, and I’m kind of embarrassed that really what I should have been doing was calling our county 911 or referring the patient to call our aging and independent services.

Eric: Wait, county 911?

Lindsey: Our county 211. Oops. Well, that got people’s attention. Okay, 211 is actually for our county.

Eric: Whoa, it’s an urgent issue.

Lindsey: Not every county necessarily has that. Not everyone necessarily has that central number for their whole county. But, the point is, is that I am now learning that there were so many resources and services that I did not know about that my patients did not ultimately know about because I was really just, I only was aware of a spattering and-

Eric: I know Alex wants-

Lindsey: And I think that’s even, yeah.

Eric: I know Alex wants to ask a question, but we mentioned another thing, ADR. Susan, what the heck is that? That’s another acronym we haven’t talked about yet.

Susan: Yes, so this is sort of the glue, the Aging and Disability Resource connections, so working with AAAs Independent Living Centers, really helping in four core areas to really help people with benefit options, counseling and navigation in the network. Really, to be a bridge between whether it’s a health plan on the healthcare side, Greg mentioned a hospital discharge, which is so common. That’s when a lot of people first discover our network, unfortunately at that late stage. Trained staff that can really help provide options and alternatives.

Again, as Greg said, where the individual chooses what works best for them. But working, California is a big managed care state, and so there’s a lot of, one thing that’s exciting is closed loop referrals where we can work with the physician’s office or the health plan and we can do follow-up and say, “Here’s what was provided.” And then, the health plan can say, “Can you follow-up on this?” And we can offer things, someone presents with a nutritional need, but we can say, ask about, “Do you need grab bars in your shower? Would you be a candidate for adult daycare? Do you have a caregiver in the house who might need?” People aren’t always seeking the services because they don’t know that they’re available.

Eric: And to get into, so to get that evaluation, what needs to be done to get that evaluation for the… Is it the provider that calls? Is it the patient? Either, or?

Susan: Either.

Greg: No, so-

Eric: Yeah.

Greg: For us, and again, I started my career doing this and the beauty again, and I can only speak for New York, we’re in the home. This is not stuff that’s being done over the phone. I would go into somebody’s home where I could do a visual check. Are there fall and injury risk? Is there food in the refrigerator? I can spend some time, my caseload was 90 people. I knew them, I developed a relationship with them. Take some time to get trust, to get real information.

You assess in a whole variety of different ways. Like we assess for social isolation, anxiety, depression, alcohol abuse, we do a tech check. I became the first state in the country to offer free for our case managers, the National Association of Home Builders Certified Aging and Place certification, which provides enhanced skills that you can provide to the individual and family on modifications within the built environment so they don’t fall and break your hip and wind up having to leave.

Having that visual is really important. As a managed care state also, our care managers in managed care for Medicaid could be 300 miles away. They’re never in the home. It’s somebody different every month, and you never develop that relationship. It’s people don’t want to talk about their needs or the things they can’t do. They’re afraid of losing their independence. Our network helps to maintain that independence.

60% of all medical costs have nothing to do with your health diagnosis. It has to do with genetics, 30%, 10% your diagnosis, the other 60% is your built-in environment, educational status, income and your personal choices. Do I have access to good food? Do I exercise, do I smoke? Things like that. The name of the game for this country in terms of saving money and approving health outcomes and actually talking about quality of life, not quantity of life, is to beef up what Susan, Lindsey and I do across the country.

Alex: Yeah, that’s great. I’d love to pick up on this thread and sort of segue way into talking about social determinants of health and hear from all three of you, maybe starting at the local level with Lindsey and then Susan and Greg. I’m going to quote, so there’s an article in JAMA Internal Medicine recently by Madeline Sterling who’s in New York at Weill Cornell obtaining and paying for home care, navigating patients through the complex terrain of home care in the US. And it starts with this quote from a caregiver. “I don’t think I can manage all of this care anymore.” And this is so common.

And Ken Covinsky writes, who’s a frequent guest and host on this podcast, great perspective, “US Medicine does an awful job of helping older persons with disability obtain the assistance they need to maintain independence. We can pay for high tech ineffective procedures, but not help with basic needs. It’s a disgrace.” And then he, as a follow-up tweet in this thread, “Hypothesis, Social Security has done more to improve the health of US older persons since its implementation in 1935 than all of the technological advancements in healthcare.” And I want to just sort of push, segue way into the social determinants of health aspect.

We had a podcast recently with Margot Kushel, who studies homelessness, is at San Francisco General. I see Susan nodding her head, you must know her well. Homelessness, a huge issue in California, I’m sure it is in New York as well. Aging, homelessness, just a profound issue, so many newly homeless. To what extent, and I heard you mention Susan, when the California master plan on aging, housing as being one of the key elements. And I wonder what each of you are doing in your own areas. I’m sure this is an issue in San Diego as well to address social determinants of health. And maybe starting with you, Lindsey, at the county level.

Lindsey: Yeah, so I feel like working in the county has taught me that even more, just the importance of social determinants of health. Just to speak briefly of the experience of a clinician is oftentimes I think I felt in my clinic or in other settings that I couldn’t, I didn’t really have the tools to really help the patient with what I thought they really needed the most. I might feel like loneliness was really the big thing that was impacting their health or food insecurity or whatnot. And I would go to my geriatrician toolbox or just medical toolbox and be like, oh wow, that’s not really, this pill is not really going to help with what is really impacting this person’s health.

When I got to the county, I did a listening tour and I’ve been on it for the last six months just asking every person that I meet, “What do you feel are the most pressing needs of older people?” And I was really ready to just jump into age-friendly clinical health systems as my top initiative. The response I got was about 75% of people that I interviewed asking that question said affordable housing and shelter.

I was floored by that and I have kind of broadened my scope from age-friendly clinical health systems, just thinking about age-friendly public health systems. And one thing that would be great to hear, Susan is much more expert in this than I am, but I have become really excited about this new program in California called CalAIM. I’m sure there are similar ones in New York or similar initiatives, but it’s really this major push for the way that we pay for health, so to have a program like Medicaid actually put money into social determinants of health. I think that’s a great idea. It makes so much sense to me because it’s really all about what helps someone in the end. If the pills and interventions and things aren’t really getting people what they want, then let’s recalibrate a little bit. But Susan, I’d love to hear your thoughts and responses to that.

Susan: Sure, so housing is health, that much we know. And thanks for bringing up Dr. Margot Kushel, she’s doing phenomenal work, not just in California but nationally to raise this serious, the crisis of older adult homelessness. And we’re really proud in our state that the number one goal in our master plan for aging is housing for all stages and ages. I mean, when we put that out that people were like, housing isn’t Medicare. People think of Medicare as the flagship program for older adults.

Really putting a lot of focus in our stakeholders in our state are calling for an end to older adult homelessness and the profile is slightly different. There are traditional reasons why older adults are homeless, and many of them, they’ve been longstanding, they’ve been unhoused. But, for a majority, it’s a first time event. It’s a healthcare crisis, it’s lack of tenant protections, death of a spouse.

We’ve also talked to a lot of older adults who have been living with a parent. The caregiver, the caregiving parent who is 80 or 90 passes away and then the 50 or 60 year old adult child loses their housing. A whole confluence of factors that we’re looking to address. In our state. We have an interagency council on homelessness by our Secretary of Housing and our Secretary of Health and Human Services. And I’m proud to sit on that council representing older adults and was added to that group.

In terms of the area agencies on aging, we are partnering with our transforming Medi-Cal, our Medicaid agency where we do have CMS has been a fantastic partner in the maximum allowable opportunities for housing assistance, rental assistance, temporary payments to keep people housed and to help place people after a hospitalization into housing.

Eric: Well, it’s interesting that our healthcare system, traditionally Medicare too, is willing to pay tens of thousands, sometimes hundreds of thousands of dollars on a drug, thousands of dollars on MRIs. I mean, we’ve had multiple talks about the new amyloid antibody drugs, 25-50,000 never misses a chance to talk about that.

Lindsey: Eric never misses a chance to take a dig on with Aducanumab or whatnot.

Eric: But, if somebody doesn’t have a house to live in or a place to live, probably has a much bigger impact on their health than some of these medications,

Lindsey: Oh, yeah. The number needed to treat with these social determinants of health interventions, I feel so much lower and the lag time to benefit so much shorter than a lot of the medications and interventions we do. Sorry.

Eric: Susan, Lindsey also mentioned CalAIM. Can you just briefly, what is that?

Susan: Sure, so that’s our statewide Medicaid waiver that is transforming our Medi-Cal program over a 10 year horizon. We’re in about year two right now. It was approved by CMS last year, but key to this is enhanced care management. This is reaching the highest utilizers with a wraparound suite of services.

Also, funding 14 community supports also in lieu of services. This would be like home modifications, medically tailored meals, caregiver respite, 14 services and supports that community-based organizations around the state are offering up and they’re building capacity investing in community-based organizations.

And then, related to that as a whole behavioral health continuum when that’s a key to housing also would be behavioral health and substance use disorder, so they’re working in tandem. That’s something we’re really encouraging our community-based providers and AAAs to really align with CalAIM and bridge that divide between the physician’s office, hospitals and to make themselves available as a local resource.

Alex: Yeah, I feel like there’s a ground 12 support for this in California, social determinants of health at the grassroots level. And Greg, you?said you’re all top down and bottom up and you’re hearing, what are you hearing from at the grassroots level, focus on social determinants of health.

Greg: Well, it’s great that state Medicaid programs are starting to look at, this is something that Medicare Advantage plans have been able to do for a number of years, but it’s their choice to do so. I understand from states, our state, California, why we’re focused so much in on Medicaid and high utilization and cost and the way to try to influence that away.

These services that everybody is embracing called Social Determinants of Health, again, are not new. These are things that have been, we’ve been providing forever. And I just want to put a question out there that you can walk and chew gum at the same time when we focus on Medicaid and we should, I think you can improve care, improve quality and lower cost when you do things right. But, the goal is to prevent people from spending down to Medicaid from… to begin with.

And that’s what I’m talking about is you could still provide the same SDOH services and a non-Medicaid framework then Medicaid. Most of the people in New York are not on Medicaid and they don’t need to be on Medicaid and they can live for years in their homes and communities with a comprehensive array of services.

I’ll give you a quick example, and I’m talking fast because I don’t want to take too much of your time. What CMS says, and CMS oversees Medicare and Medicaid at the national level is the most expensive. Utilizers costs about $400 billion a year to serve, have two chronic conditions and two limitations in some functional capacity, need help bathing, dressing, personal care, going to the bathroom, that type of thing.

My average client is an 83 year old low income female that has four to 10 chronic conditions and about seven limitations in their daily activities and I can keep them in their homes for five to seven years for $7,000 a year. They’re older and frailer than a nursing home client is. And then, all the other things that Susan and Lindsey were talking about. Support for a caregiver. We have 4 million caregivers that you pull them out of the mix, you pay another $39 billion. We used to think that what family, friends and neighbors do in providing uncompensated care to somebody was a wraparound around the formal system. It’s the opposite. The formal system is a wraparound on what families, friends, and neighbors have been doing for generations and are doing now.

Eric: That’s brilliant, Greg. I can also sense from all of you, the passion that you have for this and just I can imagine the frustration that you see with some of the priorities potentially that our system has, especially the formal system around keeping people in their homes. I think when you think about where we are in the near future, what are you most worried about right now around the care of older adults in the community? Greg, I’m going to turn to you first.

Greg: I’m actually quite optimistic because what these conversations allow you to do, you were talking about being a geriatrician and doing your rounds, you’re talking about physicians’ offices. The reason they don’t know what we and other community-based organizations, town and municipalities, faith-based org, they don’t know what they don’t know. The opportunities, whether it be through Medicaid, through waivers, through Medicare Advantage, through other payers, is the opportunity to provide and test integrated care models so that when somebody comes through the system and a physician or a nurse practitioner in a community practice or somebody, a discharge planner in a hospital, that you have that knowledge base where you can do those cross-referrals and do them in a electronic way that are HIPAA compliant.

How amazing would it be for an emergency room physician to get an electronic transfer of the data that we have on the client, who they are, who’s at home, what medications they’re taking, what services are being provided, or when that person’s being discharged, they have that discharge plan come to one of our case managers so that we actually, we can connect the dots. That’s how people don’t fall through the cracks. That’s how you provide quality care. That’s how the plans HIDA scores. These are these scores that show their quality.

They’re looking for partnerships like this. And what I hear all the time is we didn’t know you existed. And so, my job is our county offices are not good at making the case, doing the elevator speech, walking into a CEO’s office and saying what it is they do. What they’re really good at is providing the service. It’s my job to make that connection, sell what we do, and then contract together so we can expand.

Eric: Let me ask you this, Greg, before I move on. I am a healthcare provider in New York. I’m listening to this podcast. I’m interested, I want to learn more about resources that I can refer people to. What’s the one place I should go to?

Greg: Give me a call. New York State Office for Aging. We have a fantastic association partner and her and I are really, we’re talking to a lot-

Eric: Seriously, I am a, let’s say nurse practitioner in a community clinic. I call Greg.

Greg: Yep.

Eric: Okay.

Greg: We’ll connect you with our local resources. Yeah.

Eric: That’s amazing.

Greg: It’s really about connecting dots. I don’t think that… People are in this caring economy because they do care, but you don’t know what you don’t know. If you’re open to, again, Susan and I have to leverage other resources because we’re not resourced at the federal level enough to do our job. We have to be open and partner with everybody because we’re not experts in everything. We’re experts in what we do. But then, you tap the experts that are experts in other things and when you bring those things together, good things can happen.

Eric: Susan, I’m a nurse practitioner now in rural California, and I’m looking, I’m listening to the podcast. I want to know where should I find out about the resources that I have available to my older adults?

Susan: Thank you for working in rural Northern California, nurse practitioner. You will call 1-800-510-2020 and that’s where you’ll get started and we’ll patch you through to your local area agency on aging. That’s where you’ll get started. I want to go to your other question being asset-based, but I think there’s a lot of attention on the care economy right now. There have been some fabulous national articles. I think there’s broad agreement about people being able to live independently at home for as long as possible and to move away from a more institutional bias.

But, there is a workforce crisis happening in every rung of the career ladder right now and that is in part influenced by the changing demographics in our nation as people are leaving the workforce and not being replenished as birth rates decline. One thing that I think is really important is raising awareness about how people should plan in their individual lives, how communities should be planning, how states should be planning, and how our nation should be planning.

Something that breaks my heart over and over and over again is when somebody believes that Medicare will take care of, they say, “Well-

Greg: Everything.

Susan: “…I want to live independently. I want to stay in my home as long as possible.” And they have the false belief that Medicare will pay for home care, will pay for assisted living, and they discover very late in life that is not the case. And so, Greg alluded to it, this sort of missing middle or forgotten middle, a portion, a large portion of our population that is not eligible for Medicaid and cannot pay privately for long or much to remain at home.

Eric: Well, yeah. I’m going to leave the parting thought to Lindsey. Lindsey, what are you most worried about or eager to see?

Lindsey: I thank you for that.

Eric: Thank you for putting me on the hot seat, you mean. [laughter]

Lindsey: Yeah, thank you for putting me on the hot seat. I feel like I know locally, at least, at our county level, and I believe at the state level and hopefully likely national level as well, there’s a lot of energy around equity right now and diversity, belonging, inclusion. And, I really want people to start seeing ageism as a fundamental part of that. So not just us that are involved in the aging space, but everyone. I don’t hear that mentioned a lot and I think a lot of the reason that we have some of the challenges we have in building capacity for to leverage the strengths and to support our aging population is because of decades of ageism that led to inattention to unique needs and values of older people.

I’m hoping too, that our geriatrician and palliative care community, that we’re just going to lean into this. Because, really we, over the last couple decades, just like Greg and Susan and our community-based partners, we really have, as a specialty, recognize the importance of social determinants and environment. And we’ve always had that holistic approach and so good for us. I’m going to give us a pat on the back. We haven’t necessarily become the most lucrative specialties in the field, but if we can all lean into this, this is what we’re good at, and contact your local area agency on aging, and start making those connections and be the leaders in this space. I think that there’s a lot of opportunity there

Eric: For a beautiful new day.

Lindsey: Yes.

Eric: I got to transition to Alex, now.

Alex: (Singing).

Eric: Greg, Susan, Lindsey, thank you for joining on the podcast.

Greg: Thanks for having us.

Lindsey: Thank you, as well.

Susan: Thank you. Great job, Alex.

Alex: Thanks.

Eric: All of our listeners, thank you for your continued support.