Saturday, February 28, 2015

Advocacy

To advocate for aging services, Coalition of Agencies Serving the Elderly (CASE) urged members to attend monthly meetings of San Francisco Commission on Aging, which oversees the budget for Department of Aging and Adult Services (DAAS).  CASE represents 37 agencies and their 20,000+ elderly constituents in San Francisco 
At February 4 Commission meeting, seated from left to right, in photo above, are Commissioners Samer Itani (dentist), Katie Loo, President Edna James (nurse/health educator/gerontologist and nonprofit OMI Community Action Organization President), Kaushik Roy (nonprofit Shanti Project Executive Director), Neil Sims (executive search firm partner), and DAAS Executive Director Anne Hinton. 
Public comment by CASE Secretary Valorie Villela (also 30th Street Senior Center Director), a tree hugger who suggested less printing of agenda which is sent out to regular attendees. 
Anne and Edna congratulated DAAS Employee of Month, who received a desk clock in appreciation.  
Municipal Transportation Agency Board member (and DAAS Manager) Tom Nolan reported last month’s approval of free Muni for low-and moderate-income (up to $67,950 for single person) seniors (age 65+) and persons with disabilities (PWD), effective March 1, 2015...thanks to grassroots advocacyTom reported 20,000 seniors and PWD had already applied, and anticipated 25,000 to sign-up.  He said Muni is for everyone, but especially those who need it most.   
Marie Jobling reported Community Living Campaign launched Tech Council (public-private partnership to expand technology access) the previous day, and Long-Term Care Coordinating Council will hold tenth year celebration this year. 
CASE Co-Chair Michelle Alcedo (also Openhouse Programs Director) presented CASE advocacy platform requesting funding to: 1) increase staffing for community services, 2) increase staffing for Aging and Disability Resource Centers (ADRC, which has lacked Tagalog speaking staff since July 2014 though Tagalog has been certified as third language for City communications), and 3) pay more “equitable” salaries for case management positions because nonprofit agencies struggle to recruit and retain talent when County salaries are “much higher.”  In addition, CASE seeks to extend free Muni to include group van and ADA transportation and 4% cost of doing business increase for FY 2015-16. 
DAAS Program Support Analyst Monte Cimino requested authorization for additional funds to Mental Health Association of San Francisco (MHASF) for expanding hoarding support services to non-English speakers. Commissioners responded with ayes.
DAAS Nutritionist Linda Lau had longest presentation requesting authorization of $5 million in add-backs for nutrition, including three new meal sites and expansion of Choosing Healthy and Appetizing Meal Plan Solutions for Seniors (CHAMPSS, which is healthier than CalFresh Fast Food Restaurant Meals Program).
  
“Good end-of-life”
 
Katy Butler, journalist and author of Knocking on Heaven’s Door: The Path to a Better Way of Death (2013), was speaker at this month’s meeting of San Francisco Bay Area Network for End-of-Life Care (SFEOL), co-chaired by Nate Hinerman. Now a Dean at Golden Gate University, Nate was my former SFSU Professor who taught Death and Dying in Contemporary Society.

Katy discussed the contrasting experiences of her parents’ final years: medical technology interventions to keep her dying father alive for “five terrible years,” and her mother’s determination for a better death so she decided to stop eating and drinking after a second heart attack brought her to a hospice wing. (The legal status of such "voluntarily stopping eating and drinking" by advance directive is untested.) She said it takes moral courage to say it’s the end-of-life, which she recognized in her father’s “benchmark” statements:
  • “I don’t know who I am anymore” (lost capacities)
  • “I am not going to get better” (progressive illness)
  • “I’m living too long”
According to Katy, “bad (painful) deaths” are so common because doctors don’t know how to talk to us, insurance pays for the wrong things (cure v. care), and treatments don’t stop until someone just says no (because medicine’s default is to offer all reimbursable treatments). 
Katy recommended Dr. Angelo Volandes’ The Conversation: A Revolutionary Plan for End-of-Life Care (2015), for patients, family members and doctors to honestly discuss the following:
·         What kinds of things are important to you in your life?
·         If you were not able to do the activities you enjoy, are there any medical treatments that would be too much?
·         What fears do you have about getting sick or medical care?
·         Do you have any spiritual, religious, philosophical, or cultural beliefs that guide you when you make medical decisions?

Katy’s presentation reminded me of The New York Times' recent Opinionator piece, “Dying Shouldn’t Be So Brutal,” in which Dr. Ira Byock proposed Safe Dying Act with these components: 1) train “young” (new?) doctors to assess and treat pain, listen to patients’ concerns and collaborate with patients and families in making treatment decisions, 2) require nursing home companies to double staffing of nurses and aides, and hours of care for each resident, 3) set minimum standards for palliative care teams within every hospital, 4) routinely publish meaningful quality ratings for hospitals, nursing homes, assisted living, home health and hospice programs for people to use in choosing care, and 5) repeal the Medicare statute that forces incurably ill people to forgo disease treatments in order to receive hospice care.

Also on my reading list is Atul Gawande’s Being Mortal: Medicine and What Matters in the End (2014), which was excerpted in Slate and featured in this month’s PBS Frontline

Community of Voices
At this month's CASE meeting held at Project Open Hand, Community Music Center (CMC) Program Director Sylvia Sherman spoke about her organization’s partnership with UCSF School of Nursing’s Institute for Health and Aging and DAAS, to form Community of Voices research involving a dozen senior choirs throughout San Francisco.  Funded by a five-year grant from National Institute on Aging, this study is in its third year to demonstrate health benefits (lung capacity, balance, coordination, memory, moods) on seniors (age 60+) who participate in a community choir.  Check out video, Can Singing in a Choir Improve the Health of Older Adults? 
  
Caregiving
Another reason to thumbs-up “like” Kevin Winge even more: he’s got his priorities in order, resigning as Project Open Hand (POH) Executive Director to return to his home state of Minnesota to provide care to his sisters who are critically ill.  I liked Kevin’s memoir, Never Give Up: Vignettes from Sub-Saharan Africa in the Age of AIDS (2006, reminded me of my own experience as Global Service Corps volunteer in Tanzania), his monumental decision to remove the soda vending machine (ostensibly to cut unnecessary electricity costs), expansion of POH meals to include clients with ten additional diseases (beyond traditionally served clients with HIV/AIDS and cancer), Food=Medicine Pilot Study with UCSF, expansion of senior congregate meal sites, etc. Kevin will be missed more than the in-house production of peanut butter and beloved macaroni and cheese, which he also removed from POH menu.

Let’s Kick ASS (AIDS Survivor Syndrome) hosted Who Is Going to Care For Us As We Age? A Discussion on Options for Long-Term Care, at LGBT Conference Center with elder law attorney Daniel Redman and NEXT Village Director Jacqueline Zimmer (JZ) Jones.  Daniel provided an overview of the continuum of care (in-home, assisted living, continuing care retirement communities, skilled nursing) from low-income (SSI/Medi-Cal/IHSS) to private pay options, and San Francisco's proposed LGBT Long-Term Care Facility Residents' Bill of Rights. JZ shared the benefits of joining NEXT Village, which serves residents in San Francisco's north east, and tips for LGBT community to start a village of neighbors helping one another so all can successfully age in community.  

Dementia care
 
Preparing for the Changing Horizon: Dementia Awareness and Caregiving for LGBT Older Adults from Diverse Communities included roundtable discussion with keynote presenters David Coon and Karen Fredriksen-Goldsen (author of The Aging and Health Report: Disparities and Resilience among LGBT Older Adults), two caregivers and Michelle Alcedo of Openhouse.  LGBT older adults are more likely to live alone and depend on “families of choice” for caregiving, yet such friends or non-families of origin as caregivers lack legal recognition by the health care system.    
Alzheimer’s Association Director of Diversity Edie Yau moderated panel discussion on Sharing Lessons Learned: Integrating Cultural Values, Beliefs and Practices into Dementia Care of LGBT Older Adults, with Geoffrey Kerchner (Alzheimer's researcher), Lou Bordisso (retired therapist with early-onset Alzheimer's), and two caregivers.  LGBT seniors may fear disclosing their sexual orientation/gender identity and not access services out of fear of discrimination, and few providers have received training to celebrate (not just tolerate) LGBT. Alzheimer’s Association has LGBT Caregiver Concerns brochure and Family Caregiver Alliance has LGBT Caregiving: FAQs.

At AgeSong Guru Project’s Biomedical Convention, psychiatrist and Pacific Institute board member Richard Patel welcomed psychologist (retired) Richard Taylor and geriatrician Allen Power for a discussion about wisdom in changes associated with aging and forgetting.

Richard Taylor, author of Alzheimer’s From the Inside Out (2006), has been sharing his experience since receiving his diagnosis of dementia ten years ago.  He described the disengagement process, and finding the “disease” answers in the medical model do not help.  Rather than being defined by deficits to be fixed, it takes time to find out what he can do and the brain is always trying to figure out, Who am I? What’s going on? Why am I here? He repeats because he wants answers that he can’t hold in his short-term memory.  To understand “problem behavior” (negative label) is to understand who the person is, including unique ways of expression, rather than project needs to quiet behavior with psychotropic drugs.  Richard's call to action is: "Stand up! Speak up! Do not victimize yourself with your own silence.  How will anyone really know what it's like to live with dementia?"  He encouraged us to sign-up for his newsletter at http://www.richardtaylorphd.com/. (Another resource is Dementia Alliance International, established in 2014 and the first international group of, by and for the people with dementia engaged in advocacy to eradicate stigma, isolation and discrimination.) 

Allen Power, author of Dementia Beyond Disease: Enhancing Well-Being (2014), discussed 7 domains of well-being: 1) identity, 2) connections, 3) security, 4) autonomy, 5) meaning, 6) growth and 7) joy.  He cautioned that if you view someone as less than a complete person, then you give less care; and that too much focus is on finding a cure for dementia rather than promoting well-being.
 
Singalong at AgeSong’s Forget Me Not CafĂ©: music + cognition.
SFSU gerontology classmate Brittany plays flute at AgeSong’s University campus during Guru Launch Gala.
Psychotherapist Nader Shabahangi, founder of AgeSong and Pacific Institute, moderated discussion of the AgeSong Guru Project, a one-year initiative to “focus on comprehensive care partnerships with elders to understand need-driven behaviors and minimize risky use of psychotropic medication.” 

AgeSong Care Planning Liaison and Pacific Institute Clinical Psychology Ph.D. student Stephanie Rothman’s interest in “what matters in life” led to working with elders, whom she finds more authentic.  She described her disillusionment while attending last year’s Alzheimer’s Association International Conference in Copenhagen that was akin to a pharmaceutical convention.  Instead of drug treatment to make persons with dementia more like us inside, Stephanie seeks depathologizing dementia and psychosocial treatment to see the real person from his/her perspective: we learn from feistiness because we are better off when needs are expressed and supported.

Richard said humanity increases with dementia because you become more of who you are when pretense fades away and you get in touch with your needs for esteem, love and belonging, which you are more willing to express as you get older; forgetfulness gets you closer to humanity because you stay in the present moment to understand now instead of past; instead of looking back at "who I was," now time is spent working on "who I am."  Allen echoed those thoughts about getting to the essence when one is more honest and transparent with fewer agendas, and advocated for an abling perspective so people feel allowed to be.

After the panel discussion, I met Eveline Wu, GCFP, who co-authored the UCSF study on Preventing Loss of Independence through Exercise (PLIE) for Older Adults with Dementia, a non-drug intervention that focuses on training procedural memory for basic functional movements, while increasing mindful body awareness and facilitating social connection.

Hospital discharge
 
At Hospital to Home: A Community Forum on Hospital Discharge, held at 30th Street Senior Center's dining room, DAAS Director Anne Hinton provided an overview of San Francisco’s Long-Term Care Integration Strategic Plan.
 
Senior and Disability Action (SDA) Executive Director Sarah Lehman moderated the panel of speakers:
  • Carrie Wong, DAAS Director of Care Transition Operations, explained San Francisco Transitional Care Program (SFTCP) provides services (transportation including medication pick-up, 14 days of meals, 6 hours of homecare) for 4 to 6 weeks, at no cost to eligible San Francisco residents with Medicare Parts A and B who are referred by one of eight partnering hospitals to prevent unnecessary readmissions.  
  • Donna Willmott, SDA Consumer Advocate, reminded us that Medicare covers the first 20 days in an approved skilled nursing facility, only if one first has at least three full days of "inpatient" Part A hospital care. However, hospitals are placing more patients under “observation status” to protect themselves against new policies that penalize hospitals for unnecessary admissions.  Therefore, Medicare patients should ask whether they are considered inpatients or outpatients each day they are in the hospital as status can change.  More tips in SDA’s June 2013 newsletter
  • Marcia Peterzell, Community Living Campaign Connector, discussed Connections for Healthy Aging workshop that covers hospital stay and advocacy.  She distributed Vial of Life kits for us to complete personal identifying information, medical history and information, and emergency contact. 
  • Ken Hornby shared his personal experience and the need for self-advocacy to make sure one is heard to get the help needed.  Medicare has Discharge Planning Checklist.
One attendee shared her experience of having her service dog stay in the hospital with her.  (Some institutions recognize doctor’s orders for pet visits.) There were more providers than consumers at this event, which was scheduled at the same time as Ai-Jen Poo's book tour talk on Women, Leadership, and the Future of Care.

“Old is gold”: telephone community

After taking online classes like Coursera’s Living with Dementia: Impact on Individuals, Caregivers, Communities and Societies, conveniently accessible 24/7 with power point presentations, taking classes via telephone seems so quaint.  But a recent Telegraph article, “Why low-tech living is back” declared, “old is gold” with the popularity of printed books, vinyl records, typewriters, retro-phones, and Polaroid instant photo cameras.
 
Staying Engaged for a Lifetime gerontologist Hope Levy introduced Susan Lee Lindeman, Program Manager of Senior Center Without Walls, a “statewide telephone community” serving about 300 older adults age 60+ in California.  SFSU gerontology alum Terry Englehart founded this award-winning nonprofit in 2004 to connect homebound, isolated seniors via telephone in activities such as bingo, improvisation, armchair travel, singalongs, health presentations, book clubs, support groups, etc.  To participate or volunteer, call 877-797-7299.