The National Population Projections released by the U.S. Census Bureau project that by 2034, there will be 77.0 million people age 65 years and older, or one-and-a half times as many as were reported in 2016 (49.2 million). For the first time, adults will outnumber the nation’s children under the age of 18. By 2030, 1 in every 5 U.S. residents will be of retirement age.
As the country prepares for this demographic milestone, community health centers will be challenged to care for greater numbers of older adults, with more complex and pressing health care needs. Data from the UDS show that health centers are already responding to this demographic shift. In 2018, older adults accounted for 9.6% of those served by community health centers, or 2.6 million people. [HRSA UDS]. Reflecting this shift, Medicare is an increasingly important payer for health centers, with the number of health center Medicare patients doubling from 2005-2014. In 2018, 2.7 million health center patients, or 9.7%, were covered by Medicare and an additional 1 million (3.7%) were Medicare/Medicaid dual-eligible. [HRSA UDS].
To get a bird’s-eye view of how several health centers are meeting new demands for care, we reached out to colleagues in California, Vermont and Illinois known for elder-focused care. While each has unique programs and faces local challenges, each has found a way to forge connections with elders in their communities and to offer older patients high-quality, empathic care. [Ed: With so much going on at health centers as demographics and approaches change, the next article in this series will look specifically at PACE, or Program of All-Inclusive Care for the Elderly.]
LifeLong Medical Care (Berkley, CA)
LifeLong Medical Care was focused from the outset on addressing the unmet need for health services in Berkeley’s senior community. Dr. Marty Lynch, who joined Lifelong in 1980, is the center’s Executive Director and co-founder of NACHCs Sub-committee on Healthy Aging. He explained that the health center was founded by a group of Gray Panthers, senior advocates who realized that the area’s growing low-income aging population did not have access to necessary medical services and decided to develop a place where older adults could receive support and quality health care. The Over 60 Health Center was there for the “folks who weren’t always welcome in the normal private practice offices. Folks who were poor maybe they didn’t speak English, maybe were African American whatever it might be and they didn’t fit in and the doctors didn’t want to see them.”
From the very beginning, Lifelong had an integrated approach to care, adapting as the needs of the community have changed. Care for older people is available across the health center’s network, and includes a range of medical, mental health and case management programs. Lifelong continues to run The Over 60 Health Center, a geriatric-specific program where older patients receive care from a team that includes primary care providers, nurses, social workers and specialists. An Adult Day Center provides social activities along with daytime nursing care and therapeutic activities. Complementing the health-center based programs are street outreach for the homeless and primary care at home for people who are not able to leave their homes. The Senior Network and Activity Program (SNAP), a program funded by the Contra Costa Mental Health Department, provides senior residents of public housing in West Contra Costa County with social and recreational activities.
Increasingly, Lifelong has been faced with meeting the needs of those who are homeless. With the cost of housing on the rise, the area’s homeless population has expanded, and an increasing number of those facing homelessness in the inner Oakland Bay and San Francisco are over age 55. But age aside, says Lynch, “There’s a firm amount of research that shows that a 55-plus-year-old homeless person has the same health and chronic issues as a 75-year-old person who lives in a house. There’s at least a 20-year pick-up on the types of problems people have.” The health center cares for many homeless individuals who may not yet qualify for Medicare, but have complex needs similar to those of much older adults.
Together with community partners, LifeLong has a Supportive Housing Program (SHP) that helps improve the quality of life for adults experiencing homelessness. “We all believe that housing is health care. It’s very hard to accomplish good primary care if a person is on the streets or in a shelter.” The health center brings health and social services to subsidized affordable housing so that tenants who have a history of homelessness can attain housing stability and improve their quality of life. Services are provided to approximately 600 tenants, at 13 different housing sites, as well to those residing in scattered housing elsewhere in Alameda County.
Dr. Lynch remarked that “the elder work that we started with transitioned to homelessness, supportive housing, severe mental health and behavioral health work. It made it a lot less scary because we were already dealing with people who had serious functional problems as well as medical problems, so it felt like the most natural thing in the world to deal with other populations who also had complex problems.” This commitment to meeting people where they are ensures that older adults, and all patients of the health center, receive high-quality attention and care.
Howard Brown Health (Chicago, IL)
The seeds for Howard Brown Health were planted in 1974, when four medical students who were members of the Chicago Gay Medical Students Association began an informal, volunteer clinic to provide safe, confidential care to Chicago’s gay men and lesbians. The first clinic board took shape in 1976, and the clinic was named the Howard Brown Memorial Clinic, in tribute to Dr. Howard J. Brown. A trailblazing gay rights activist, Brown was the founder of the National Gay Task Force (now the National Gay and Lesbian Task Force), and had served as New York City Commissioner of Health and the city’s first Health Services Administrator.
I reached out to Kelly Rice, the Program Manager for Intensive Community Care Services, to learn about the health center’s signature programs for LGBTQ and vulnerable older adults. She explained, “The most recent data I’ve heard is that is 80% of folks go back in the closet when they need aging-related services. Members of the community may not know we exist, and we want them to know about us so that even if you don’t feel comfortable being open about who you are where you live, you know that you can at least come to us and we are here.” To help address head-on the discrimination and disparities known to many LGBTQ elders, Howard Brown Health developed Nurse’s Health Education About LGBT Elders, or HEALE, a cultural competency curriculum for nurses and other health care professionals. HEALE, funded by HRSA and developed in partnership with Rush University’s Geriatric Workforce Enhancement Program of Illinois (GWEP-I) addresses topics such as An Introduction to LGBTQ Elders, Health Disparities and Barriers to Care, Sex and Sexuality in for LGBTQ Older Adults, Transgender and Gender Non-conforming Elders HIV and Aging, and Financial and Legal Barriers to Care.
Educating providers is complemented by evaluating needs. To be sure that the health center remains responsive to the needs of the diverse LGBTQ community, Howard Brown conducted an LGBTQ aging needs assessment in 2017 to get an in-depth, insider view of the needs of older adults, and the challenges and gaps they identified. The comprehensive assessment included focus groups, interviews, and more than 300 surveys, which identified the need for more chronic disease support and management, and mental health care services. In addition, the survey revealed a need for more research focused specifically on older LGBTQ adults. Not surprisingly, in a community where many older gay men had lost partners and friends to HIV/ AIDS, was the desire for more social interaction to combat isolation and loneliness.
To increase outreach and encourage community connections, Howard Brown has worked hard to build networking relationships with aging service programs in the area. Howard Brown also provides frequent evidence-based health workshops at churches and other community-based locations.
Finally, Howard Brown is attentive to the physical aspects of care and adjustments that may be needed to serve all people. Ms. Rice added, “When providing care to the elderly it’s important for health centers to make sure that their buildings are accessible, that people can read the forms. Are all your forms in a ten-point font? You know, a lot of older adults have issues with small fonts, bright screens or bright paper, so do you have different ways to accommodate different needs? Consider your marketing and outreach, too. Are you only presenting youth in the images that you are sharing in your marketing materials?” People need to see themselves in the marketing materials, and be able to access the physical facilities for care to be effective.
While clearly a leader in the field, Howard Brown continues to grow and innovate. Ms. Rice is excited about the upcoming launch of the health center’s aging service advisory board, which will be comprised equally of Howard Brown staff and patients. This will serve to both engage patients, and help ensure that the health center is best equipped to meet the needs of its older LGBTQ adults.
Community Health Centers of Burlington (Burlington, VT)
The People’s Free Clinic opened in 1971, a tiny storefront in Burlington’s Old North End. Announcing “a new kind of health care,” the People’s Free Clinic founders envisioned a mission that would make a resonating statement: every person – regardless of age, race, class, or gender – deserves good medical care regardless of their ability to pay.
Staffed entirely by volunteers, including two local physicians, the small clinic saw 50 people per week by the end of the following year. Soon, the clinic would strengthen its commitment to care in the local community, and become the Community Health Centers of Burlington (CHCB). CHCB was officially awarded the status of a Healthcare for the Homeless Program grantee in 1989, ensuring completely free access to health care for individuals and families experiencing homelessness, and today remains the only organization in Vermont with this designation. It subsequently was designated Vermont’s second Federally Qualified Health Center.
Today, the health center strives to make services accessible to all, including the area’s seniors. Kim Anderson, the health center’s Director of Development and Communications said, “Societally, I think elders are often a forgotten population, not necessarily ignored, just forgotten. I think our role at CHCB is to find the people falling through the cracks – it is our job as a health center to make that connection and have people feel heard; as much as they might not be loud, our older Vermonters are an entire population worthy of extra care.”
Through a partnership with a community physician, CHCB offers a Doctor-At-Home Program, to visit elderly patients in their home or place of residence. This serves two purposes: It provides care to those who may not otherwise be able to get to the health center; and it allows the physician to connect with patients when they are feeling less vulnerable. Last year, CHCB piloted a unique home-visit psychiatry program. While the funding has run out, an unexpected benefit developed: “For a lot of these folks there was a physical barrier to getting out, but there was also a mental barrier. Now, many of the patients come to the health center for their care. Our goal is to provide this quality of care and also help you access it.” Additionally, the Community Health Pharmacy offers convenient mail delivery, ensuring access to prescriptions for homebound patients.
The Burlington area is home to many elderly people for whom English is not their primary language. They are part of a larger community of nearly 8,000 refugees from all over the world who have resettled in Vermont over the course of the last 30 years. In the 1990s, the majority of refugees resettled were from Bosnia and Vietnam, while in the last decade, the newcomers have been from Bhutan, the Democratic Republic of Congo and Somalia [USCRI Vermont]. Noted Ms. Anderson: “While CHCB offers many resources, we need to be sure that people are aware of them so that they can then use them. A focus of ours is making sure New Americans are aware of the range of services they can access at CHCB.” She highlighted that language and cultural barriers can be especially challenging for elderly patients; health center staff work to identify these particular needs to ensure proper care: “Whether a provider is visiting a patient at home or in the office, they are consistently delivering holistic care.”
Examples of elder-focused care abound, and challenges remain. One such challenge – and a significant one – is recruiting clinicians and staff who are trained to meet the needs of ever- older patients with complex needs. Still, health centers have the opportunity to build on their local, community-based strengths while learning from colleagues nationally on how to effectively meet new needs as people age. Dr. Lynch said: “don’t make perfect the enemy of the good. There will always be challenges, but community health centers are uniquely positioned to make practical changes that will best serve their elder population.”
Photo: CHCB At-Home Physician, Dr. Karen Sokol, with one of her patients. Photo courtesy of Community Health Centers of Burlington