Live simply

“Live simply, so others may simply live.” – Mahatma Gandhi

“For we have brought nothing into the world, and neither can we carry anything out.  So having sustenance and covering, we will be content with these things.“—1 Timothy 6:7-8

“Really having not enough is horrible: persistent hunger and cold make you unwell and stressed. Having just enough, plus a little more, is absolutely lovely. Having even more than that, just because it’s the cultural norm, starts to make you unwell and stressed all over again …”—Annie Raser-Rowland, co-author of The Art of Frugal Hedonism: A Guide to Spending Less while Enjoying Everything More (Finding Pleasure in the Free Things in Life) 

Seniors on fixed income live simply, out of necessity or practicality. My clients who live in Single-Room Occupancy (SRO) housing simply lack physical space to accumulate lots of material stuff! Some tell me they wish to maintain their SRO tenancy (though their limited mobility and lack of building elevator makes them homebound) because their community of neighbors is their social safety net. To live simply, it helps to be content with what one has, and to be resourceful by embracing permaculture: whole-systems approach to sustainable living based on ethics (earth care, people care and fair share) and principles (observe and interact to design solutions that suit our particular situation, integrate rather than segregate so relationships develop and support each other, creatively use and respond to change, etc.).  

Housing

Pictured above, left to right: Steven Wallace, Margot Kushel, Cathy Davis, Cristina Flores, Wendy Max (moderator and Director of UCSF Institute for Health & Aging)

UCSF Institute for Health & Aging and the Dorothy P. Rice Center for Health Economics hosted a stimulating discussion on Economic Security and Housing Among Older Adults:

• Keynote speaker Steven Wallace, Professor at UCLA Fielding School of Public Health, provided a wealth of data showing shortcomings of Federal Poverty Level (FPL) (failure to keep up with costs like housing and healthcare, The Hidden Poor: Over Three-Quarters of a Million Older Californians Overlooked by Official Poverty Line), and need for Elder Economic Security Standard (EESS) Index to adjust for local (county) costs of living and actual costs of basic necessities (food, housing, transportation, healthcare); Affordable Housing: A Key Lever to Community Health for Older Americans. Example: 2017 FPL of $1,005 per month is not enough to cover HUD fair market rent of $2,411 per month for 1-bedroom in San Francisco! He discussed innovations like Santa Monica’s rental assistance (compare San Francisco's rental subsidy program cuts), improving SSI/Social Security (avoid chained-CPI), and linking housing assistance to health care funding.  
• Cristina Flores, Assistant Professor at UCSF Department of Social and Behavioral Sciences, talked about how long-term care (LTC), when one can no longer remain at home, threatens economic security due to its cost outpacing inflation since 2013.
• Cathy Davis, Executive Director of Bayview Hunters Point Multipurpose Senior Services, talked about barriers to access affordable senior housing, based on her experience with George W. Davis Senior Residence, which opened June 2016: waiting list (pre-application process), lack of computer knowledge (SF Housing Authority required online applications), misunderstanding (offers v. information), lack of advocacy, language and cultural barriers, varying income guidelines, missing window of opportunity to apply (October 2015), complexity and bureaucracy. 

• Margot Kushel, UCSF Professor of Medicine, talked about homeless older adults age 50+ who often have geriatric conditions usually found in people who are 20 to 30 years older, and hard to have home care when they don't have a home.  Based on her research of homeless seniors in Oakland, 44% were never homeless until their 50s, and 80% were African-American. Their homelessness was not only due to mental illness or substance abuse; instead, they had low-wage, non-union employment, severe rent burden, job loss, poor access to healthcare, spouse/parent died, etc.–stressors that give rise to hypertension, and 1/3 had problems with executive function so they would be challenged following housing application procedures. Dr. Kushel advocated Housing First adapted for seniors; since 60% of homeless seniors are engaged with family members, address barriers to allow the latter to house former; and more Medicaid LTC spending on home and community-based services. (Dr. Kushel's work to date is featured in "Why Grandpa is Homeless,"published in January/February 2017 issue of Pacific Standard magazine.)

After retiring from federal service, including serving as Director of National Center for Health Statistics, Dorothy Rice joined the faculty at UCSF Institute for Health & Aging.  Professor Emerita Rice, now 94 years old, resides in a senior community.

In my work with homebound seniors, mostly low-income and marginalized in Tenderloin and South of Market Area, some clients have experienced abrupt termination or denial of support services that impact their ability to continue living safely in housing. Several (now former) clients became homeless from evictions due to nonpayment of rent after they were dropped by their representative payees (due to staff layoffs) and were not able to pay rent on their own.  For my frail clients who are dual eligible beneficiaries and could benefit from coordinated care, I referred to On Lok Lifeways Program of All-Inclusive Care for Elderly (PACE) only to learn that they do not qualify because they are not considered “able to live safely in the community” due to their dual diagnoses.

  

Home care

Many of my homebound clients receive home care assistance to remain safely in their homes through In-Home Supportive Services (IHSS), which is covered by Medicaid.  Jill Nielsen, Deputy Director of Programs at San Francisco Department of Aging and Adult Services (DAAS), provided the following statistics at IHSS in San Francisco Symposium:

• 22,000 IHSS consumers
• 19,000 IHSS providers
• 1,320 consumers in contract mode (Homebridge)

Symposium featured following panel of agency directors:

• Megan Elliott of DAAS IHSS oversees 200 employees who receive 400+ referrals per month; IHSS social workers, who have caseload of 350+ each, see consumers at initial application and annually thereafter to determine services and hours needed (detailed in “notices of action”); 90% of consumers use family and friends as independent provider (IP mode); use IHSS Public Authority registry to find provider; less than 5% use Homebridge homecare agency; few use combination IP + Homebridge; Independent Provider Assistance Center (IPAC) enrolls providers and processes their timesheets
• Kelly Dearman of SF IHSS Public Authority provides registry of 250 screened IPs, offers health and dental benefits
• Mark Burns of Homebridge (formerly called Consortium) has about 60 program staff to train/place 400+ home care providers for 1,350 consumers who must be referred by DAAS social worker. 

They discussed the “crisis” of provider retention. IHSS might curtail referrals to Homebridge, by starting waitlist.  Each month, Homebridge recruits 100 providers, "lucky” if 60 show up for training, 20-25 complete 2.5 weeks of paid training, 20 providers from prior trainings are terminated (more than 50% fired for no-show or abandonment), so there is usually net gain of 2-5 providers. Homebridge's home care workers are paid $13/hour minimum wage (v. private agencies pay $19/hour), so Burns advocates a career ladder to attract and retain more workers.  (Burns’ talk about job abandonment reminded me of “A Separation,” an Iranian film portraying the demands of caring work: a caregiver who places her own health at risk and temporarily abandons her job caring for a man with Alzheimer’s to visit a hospital.)

Home design

Rhoda Goldman Plaza hosted this month’s Case Management Society of America (CMSA) dinner meeting. 

Architect Susanne Stadler and Social Worker Donna Schempp presented Aging at Home 360: An Interdisciplinary Approach to Aging in One’s Home.  They showed a 5-minute video, “A Day in the Life,” featuring 4 older adults talking about the role of their home (affordable senior housing, co-op, private home, and Section 8 housing). Susi said who we are depends on our environment, which should support and adapt to our needs and abilities. We should ask: Can my home grow with me? Can I continue to grow in my home?

We need a home base to stay connected and engaged with community, yet the majority of homes do not support all ages and abilities.  As a result, one can become a prisoner at home.  Enter Stadler & Associates offering the power of design with social services to re-imagine aging at home beyond the basics of safety: food, fitness and social connections keep one going and engaged.  

Their collaborative approach has 4 elements:

• Architectural design: spaces are functional & beautiful
• Tools/technology: interactions are healthy, intuitive & delightful
• Health/human connection: promote optimal health, function & support
• Mental health/emotional perspectives: develop understanding, coping strategies & support

 Some of their findings:

• Most significant barrier to change is one’s emotional attachment to the way one has lived for a long time
• A participatory process through conversations is key in overcoming emotional barriers (“telling one’s story”)
• One of the biggest barriers to simplifying life is getting rid of books and personal papers
• It is hard to make changes on your own – one needs partnership of family/friends/neighbors

Their Aging at Home 360 assessment costs $2,000, which they are working to make more accessible by creating a DIY workbook for a workshop. 

Audience included movers and shakers of aging in place advocacy: SFPL health librarian Janet Tom, Aging Commission President Edna James, Community Technology Network Kami Griffiths (who recently launched Tech Allies to bring tech training to homebound seniors), Meals on Wheels social workers Amy and Lois, DAAS Nutritionist Linda Lau, and Sutter Health social worker Vladimir.

Caring for someone with dementia

UCSF Memory and Aging Center presented Caregiving & Dementia workshop at Armstrong Place Senior Housing.  Serggio Lanata, MD, presented on “Dementia 101: Learn the Basics and Understand the Disease.”  After describing the clinical syndromes (typical, posterior, logopenic, frontal) associated with Alzheimer’s disease and urging cognitive assessment, he advised preventive measures like keeping physically and mentally active, adding “the worst thing to do is to stay home and watch TV.”
Yikes, most of my homebound clients are doing this “worst thing”—except during my home visits when I ask them to at least turn down TV volume (as well as to refrain from smoking and drinking alcohol)! And many affordable senior housing and centers have activity calendars that promote a culture of TV watching, along with greed (bingo, casino trips). 

Sarah Dulaney, RN, Nurse Coordinator for Care Ecosystem study, presented tips on “How to be a Caregiver” of someone with dementia: 

• Structure and daily routine to help person preserve the ability to do things—providing more time, support and supervision as person loses ability to organize, plan and initiate activities
• Simplify the environment by removing clutter, organizing objects by task, using visual cues (label objects, color contrast)
• Though Reisberg’s theory of retrogenesis suggests that the cognitive level of a person with Alzheimer’s disease develops in reverse order of how the brain develops from birth, don’t treat the adult with dementia as a child 
• Keep instructions simple and respectful (offer simple choices, break task down to simpler steps, be patient and give time to be successful, etc.)
• Use DICE (Describe context, Investigate, Create plan, Evaluate)  approach to respond to challenging behaviors
• Go with the flow or try to enter the reality of the person with dementia
• Self-care!

Listening to your favorite music is better than watching TV! Music therapist Ruth MacGregor re-enacted the response of her elderly client, with dementia, listening to The Platters’ song, “Remember When”: changing flat affect to engagement, tapping feet, lifting hand to shake rattle, opening up position, etc.  She explained selecting favorite music from era of a client’s teen years to 30s seems to have the most impact. 

End of Life 

UC Berkeley Extension hosted End of Life Option Act:  Clinical and Legal Implications with the legal overview presented by Sara Hooper of UCSF/UC Hastings Consortium on Law, Science & Health Policy, and the clinical perspective by Lael Duncan of Coalition for Compassionate Care of California. Under the Act, aid-in-dying is not “suicide” but underlying disease is listed as cause of death.  Presenters said it’s hard to predict how many California residents will avail themselves of the Act due to our demographics and culture that are very different from other aid-in-dying states (that are mostly white).

This month KALW 91.7FM Host JoAnn Mar launched her 4-part The End of Life Radio Project covering Advance Care Planning, Palliative Care, Advance Directives, and Physician-Assisted Dying.  Five years ago (before I entered the gerontology field), I executed an Advance Directive choosing no life support treatment (preferring to keep things simple, to live/die naturally). Since then, I’ve learned from my senior clients, many who return home after hospital discharge and adapt to their changed quality of life because they’re tethered to an oxygen tank, exhausted from dialysis 3x a week, recovering from major surgery, etc.  Clients say they are grateful for what they have, another chance to savor the gift of life … so you just never know until life happens to you, and I may be reconsidering a few life support options. 

Keep it simple thoughts

53-year-old pop artist Cary Leibowitz got his own solo exhibit at Contemporary Jewish Museum.  His works also will be on view at Muni bus shelters—similar to last year’s poster art from Susan O’Malley’s Advice from My 80-Year-Old Self. 

“if U try reaLLy hard and stiLL faiL U deseRve aLL tHE sympathy U can get”  

“U CAN’T B Dead aLL the TimE”

“it’s not humility or humbleness it’s regret”

“HEY! I’M NOT DEPRESSED ANYMORE"

"IT’S A BEAUTIFUL DAY AND YOU’RE HERE HOORAY!"
These umbrellas cheered me up during this rainy January.