Aging Forward Series: Equality + Aging
Equality+Aging: Innovations and Future Opportunities
Over the next decade, how can we create truly inclusive solutions for aging people in low-resource settings?” This question was the topic of Aging+Equality, the second installment of our Aging Forward series, held on March 26, 2014. The series consists of online conversations with experts about the future of aging, part of the Health Horizons team’s yearlong exploration of aging.
In this session, Ruth Finkelstein, formerly of the New York Academy of Medicine and currently of the Columbia Aging Center, and Susan Poor, of On Lok Lifeways, weighed in on where they see the future happening today and discussed innovative solutions for providing quality care and services under resource constraints in the coming decade.
The conversation began with an exploration of a 2011 IFTF forecast scenario from the map, Ecosystems of Well-Being in 4 Futures: Alternative Future Scenarios in 2021. Panelists were ask to respond to the “constraint” scenario from the map, which depicts a well-being landscape in a decade characterized by resource shortages and policy and grassroots responses focused on using restraint, sharing, and limits and quotas to create health and well-being.
“This scenario of scarcity and constraint is the current lives of the bottom to half of the population now,” Ruth responded out. “We really can’t project the future responsibility without projecting forward the growing income inequality for every aspect of health and life.”
She asserted that health, well-being, and aging/longevity are inexorably linked to income, citing a recent New York Times article on research that indicates that, as incomes have diverged in between the U.S.’s richest counties and its poorest, the life expectancy of their residents have as well.
“People's health isn’t created [exclusively] by health systems,” Ruth continued. “Building the strength of communities … is literally a health intervention.”
She mentioned the Healthy Bodegas Initiative, that seeks to bring healthy food to the ubiquitous convenience stores of New York, as an example of such an intervention, pointing out that looking more broadly and holistically at the social determinants of health allowed for solutions that provide benefits for multiple stakeholders at once.
“In places where you can’t get healthy food easily… you can see intuitively that older adults would be more affected... a huge long bus or car trip to get food is more inconvenient if not impossible,” she said. “Just as it’s difficult for a mom with five kids under the age of six.”
She asserted that, while these efforts are heartening, “broader policy solutions are needed. “Cutting food-stamps limiting access to other supplemental food is moving in the wrong direction.”
Susan added that, “health systems will deliver what they’re reimbursed for. And there is starting to be some attention given to how things that people have access to outside a doctor’s office contributes to their health and well-being… Whether you can get enough food, get to your doctor’s appointments, go to church, see your friends–the research is starting to show is how important those elements are in keeping someone healthy and building a support system that allows them to stay in their homes and communities as long as possible… But that is in its infancy in terms of being considered a ‘covered benefit.’”
She mentioned non-profits coming together, each with their own set of services, coming together as Managed Service Organizations, to arrange long term services and supports for communities, (earlier in the discussion). “[If they can prove effective at improving outcomes], they can get reimbursed by a payer for those services. If an ACO or health maintenance organization saw the value in those non-medical services… that be another source of revenue for non-profits that are doing a lot under constrained budgets and are very concerned about their own futures.
Susan assumes a future of continued or further constraint, in which “Medicare and Medicaid will continue to exist, but will not be expanded.” She expressed concerns for people who fall just above the threshold for qualifying for benefits.
“Their well-being is just as much at risk, but the policy mood is not to come to the rescue of those people.”
She sees some potential though, that grassroots efforts could close some of these gaps. She cited the hospice movement and village movement as examples of grassroots innovation that scaled and feels other movements could make similar gains.
“Share the Care is a model, where a friend will help me gather around my friends and colleagues who are willing to help support me while I’m going through a recovery period. That’s something that is small, replicable, you can do it on a local basis, you can do it within an organization – maybe that’s how these ideas become diffuse – people can fit them into their own lives and communities without a lot of hassle.”
Ruth spoke about ways in which older adults are, themselves, often an untapped resource in communities.
“I remember a focus group that I was doing in the South Bronx where someone said in ‘a family with a grandmother is rich... This is another adult in the home who either can be working or can help with raising the children and doing the cooking and errands and… it helped me make the connection to our concept of the dependency ratio. The idea that people who are working for money are on one side of that ratio and people who aren’t working for money are on the other side of the ratio is devaluing domestic work, volunteer work, community work, and community-building work.”
This theme of older adults being recognized as an asset and not a burden came up later in the program as well, in response to an audience question about workplace programs.
“There’s an awards program sponsored by the Alfred P. Sloan Foundation, the AgeSmart employer awards, for employers who recognize the value of a multigenerational workface. There are four generations of people working side-by-side now, which is a historical first other than the family farm.”
She mentioned a range of policies and practices that are AgeSmart, including flexible hours, the ability to work from home and mentorship arrangements.
“The best of these are mutual. When a worker helps the other, the older helps the younger with customer service and interacting with real, live human beings and the younger helps the older with technology issues and that is a mutual mentorship relationship – others kinds of practices are to recognize the training needs and different learning styles for all generations of workers.”
Susan added that older adults have unique opportunities to meet some caregiving needs.
“People can be trained as certified ‘senior advisors’ and they can help with the problem-solving and planning ahead that seniors need to do and be ambassadors to health providers.”
Ruth mentioned “Coming of Age” as a model that provides seniors with guidance to navigate new paid and unpaid community work opportunities, but that doesn’t pigeon-hole them into roles traditionally associated with older adults. “There’s a stereotype that if you’re retired you want to volunteer and you love children.”
Susan added that these opportunities exist regardless of socioeconomic status.
“People in lower paid positions have tremendous skills to offer,” she said.
“My life experience… working with communities that have been characterized as disadvantaged or minority… has been that when you listen to people talking about their lives in their voices, within the context of their communities,” added said. “You find a framework of strength and resiliency and rational response to the situation that a wider social context has placed them in.”
Cooperation in Times of Crisis
When the subject of natural disasters arose in the conversation, Susan and Ruth both mentioned that such events bring out a spirit of cooperation between people of different generations, but often dissipates afterwards.
“[I was in a working group on disasters and older adults] and we talked explicitly about how can we build, make, or reinforce structures and systems and ways of communicating and interacting without there being a disaster,” Ruth said. “One of the operationalizable things that came out of this it the proposal of ‘resilience hubs’—information hubs that would be available for communities at all times, capacitated to act in further ways in times of crisis. There are little mini disasters, power outages and snow storms, that [spaces like this could be activated for, that could also build community connection and resilience].”
Susan spoke to the importance of the role of third spaces to the health and well-being of older adults, citing the MatherLifeways Café as an innovation that meets seniors where they are already.
“It provides people with a place to hang out and it also offers classes and there’s a social worker in the corner if you want to talk with them. Third space [can play a part] in normalizing aging,” she said.
The Community Living Campaign in San Francisco, she said, also understands the importance of these spaces. The organization does advocacy work, but also provides a gathering space for learning and teaching.
“It’s not all problem based, it’s ‘come here to meet these people and learn and contribute what you know,’” she said. “It’s a much broader approach than just ‘you have a problem that’s what you're here for.’ That’s part of a philosophy that needs to grow and reach people who feel like what’s out there is not for them.”
Libraries, Ruth said, can provide a similar function, if utilized properly.
“We’re trying to promote the idea that whatever your business is, whatever service you provide, use an age-friendly lens,” she said. “The presumption is that [libraries] are there to serve children, but if you look at who is actually using them, older adults are using computers and technology there. Lots of them are competent to do so and some people need assistance.”
She said that in her discussions of older adult usage of the library, the question came up of whether or not to filter explicit content.
“The re-infantilization of old people is offensive; old people don’t need [content filters] and should look at whatever they are interested in looking at.”
Another potential site of intervention that was discussed was leveraging what Susan called “signal detectors.”
“If mail carriers see the mail pile up outside someone’s home, if a checkout person and notices that a regular customer is getting confused… they need to have a place to go with that information,” Susan said. “We need to grow the thinking around that so that it becomes accepted practice within a community, without invading people’s privacy.”
Ruth cited a partnership between the Weinberg Center for Elder Abuse Prevention at the Hebrew Home in the Bronx and the building workers’ union that teaches doormen, porters and other apartment workers how to notice and report signs of elder abuse.
“Much of the signal detection is based in the service sector. We’ve been advocating for banks or other businesses to accept some responsibility,” Ruth added. “If my credit card fraud detection department can call me up for deviating from my usual [spending patterns], if there’s an algorithm for that, can’t there be a way to bring big data into the early detection of signals.”
Hope for the Future
The discussion concluded with both Ruth and Susan sharing what they saw today that made them hopeful.
Susan cited increasing recognition of the need for holistic solutions to health and well-being that extend beyond the clinic
“One of the benefits of the OnLok model is that it brings [disparate elements of care] together so well… It’s got a great interdisciplinary team that says, ‘this person needs things beyond another medical procedure.’ Recognition of health and wellbeing not being totally defined as medical care is a critically important piece.”
“The broadening embrace of creating communities for all ages, across all the diversity of communities by planners an urban planners and architects [gives me hope],” Ruth said. “This is very future-oriented, because these are the people who are creating places as they are going to be and the places that don’t yet exist—and they are doing it through a much broader lens than the last generation did.”
Ruth is the Senior Vice President for Policy and Planning at NYAM, where she directs policy initiatives to promote healthy aging, to improve population health by preventing disease, and to reduce health disparities. She currently directs the Age-friendly New York City initiative (a joint project with the Mayor’s Office and the City Council) and is the Director of the World Health Organization’s Collaborating Centre on Aging, Globalization and Urbanization.
Susan is the Director of Innovation for On Lok. Her areas of expertise include the Village model and enhancing the continuum of services and support that enables older adults to age in their own homes and neighborhoods. She is currently Co-Chair of the San Francisco Long Term Care Coordinating Council, and is the author of numerous publications about elder care.
- The Aging City on Toward A 21st Century City For All, by Ruth Finkelstein and Tom Kamber
- Connected to the Community: Current Aging-in-Place Choicies, by Susan Poor
- Progress Towards Improving Health: An Update on Altarum's Mission-Driven Research, by Katelyn Videto
- Enough to Make You Sick? Something is Killing America's Urban Poor, by Helen Epstein