Transitions

It was a nursing home that 92-year-old Anna Mae Blessing feared so much that she shot her son to death and attempted to shoot her son’s live-in girlfriend last summer because they “were trying to get me put into a nursing home,” according to her taped confession released recently after she died in jail hospice.  Media reports continued to confuse assisted living facility (ALF) with nursing home.

Source: Consumer Advocates for RCFE Reform 

This confusion (or use of “alternative facts”?) is understandable as ALFs admit frail older people with complex medical conditions – a trend that was reported more than a decade ago.  With ALF residents appearing more like nursing home residents, some ALFs have “medicalized” their original hospitality/social model with the addition of nurses on staff or on call, and requiring residents with “higher needs” to hire their own private caregivers. 

During my stint in an ALF, staff carried walkie talkies mostly to report falls, biohazards or other emergencies to “Health Services” staffed by certified nurse assistants (CNA).  (City College of San Francisco offers CNA training that can be completed in one semester, and free to City residents.)   I also carried a sheet that listed residents and their room numbers so I could report, “STAT, (location of incident), (room # to identify unnamed resident) needs assistance,” then wait for a CNA to “copy” and show up at the requested location.  Since ALFs generally do not employ nurses or other health care professionals, ALF staff must call 911 and wait for an ambulance or paramedics to arrive. 

Tranquil community space in Congregation L’Dor VaDor at San Francisco Campus for Jewish Living (SFCJL, formerly Hebrew Home for Aged Disabled dba Jewish Home, until name changed in 2017).  While welcoming to all, the facility’s Jewish identity remains intact—unlike other non-profit senior living facilities that were renamed to remove their religious affiliation: American Baptist Homes of the West renamed HumanGood (2017), Episcopal Senior Communities renamed Covia (2018), and Northern California Presbyterian Homes and Services renamed Sequoia Living (2019).

Because a nursing home’s medical model tends to reinforce the culture of chronicity, philosopher Harry Moody suggested the practice of conscious aging (belief in “higher order of meaning or spiritual growth”) to accept physical decline and adapt by recognizing the primacy of spiritual virtues that endure.  SFCJL Rabbi Sheldon Marder always said the right words at the right time, providing reassurance (especially after the Tree of Life and Poway synagogue shootings) and spiritual support, and encouraging contemplation during his weekly Jewish Art and Literature class. 

In a nursing home, I felt greater peace of mind and safety for residents because I could easily find nursing staff to request assistance and use actual names of residents (who were not just a room number) while respecting privacy, so walkie talkies were not used; the level of care was what you would expect from a medical model, so I found better management of residents’ more complex health conditions that could be addressed by an in-house interdisciplinary team (including registered nurses, CNAs, geriatricians, geriatric psychiatrists, psychiatric physician assistant, social workers, etc.).  In fact, I was happy to see several former ALF residents receiving skilled nursing care during their rehab stay following hospital discharge. 

According to the National Center for Health Statistics on Long-Term Care Services in the United States (2013), average nursing hours per resident day (hprd) were 3.83, and average social work hprd were 0.08 (or 4.8 minutes).  To facilitate more person-centered care, it would be worthwhile to consider increasing social services staffing requirements because current federal regulation, 42 CFR §483.15(g), under Nursing Home Reform Act (OBRA 1987), provides for one full-time social worker for a nursing home with more than 120 beds.  Social work intervention can help residents cultivate meaningful relationships to create a more home-like environment where they feel supported and a sense of belonging.  To further balance the deficit-oriented medical model (treating symptoms v. caring for whole person), people can document their own comprehensive, strengths-based biopsychosocial assessment, and offer it to staff upon admission.

Jewish Home’s former main entrance (photo above taken in 2013) was demolished to make way for expansion to add assisted living and community center to its current skilled nursing and rehabilitation center and acute geriatric psychiatry hospital.  Last year, I returned to Jewish Home (renamed SFCJL) 5 years after I organized a Healthier Living-Chronic Disease Self-Management Program (CDSMP) workshop series there, thanks to my SFSU gerontology instructor Dr. C, who was Chief Nursing Officer at the time.  Workshop participants included several centenarians, who died since then, but I was thrilled to see several nonagenarian participants 5 years older and living quite well with nursing assistance!  

As a gerontology student, my focus was home- and community-based services (HCBS), and I never considered working in long-term care (LTC) facilities.  Yet, the reality is not everyone is able to “age in place” safely in their homes indefinitely, so I thought it was important as a gerontologist to gain experience in the continuum of care that includes LTC facilities: 3.1% of older people age 65+ reside in nursing homes, based on 2010 U.S. Census. 

Because death is prevalent in LTC facilities, some residents wonder when it will be time for them to go. Listening to the lived experience of residents, who speak with candor and share their vulnerabilities in the comfort of their home, has been the most rewarding aspect of working in LTC facilities.  Sharing time and space for reflection, coming to terms with life by reframing challenges is so profound, and these precious moments could come up at any time.  For example, in response to staff encouraging residents to be as independent as possible, one resident wrote a humorous short story, The Self-Service Nursing Home.  Residents also taught me subjects I never studied (architecture, opera, timpani, Yiddish), as well as resilience in adapting to new realities (losses, getting along with staff and other residents).

Back to community living

Happy 20^th anniversary of June 22, 1999 Olmstead decision, by Justice Ruth Bader Ginsburg, supporting people with mental disabilities to live in least restrictive settings! After a 2-year hiatus, I am transitioning back to my original focus on health promotion including doing what I can so people can age at home and in their communities as they desire, for as long as safely possible.  This return to HCBS means I need to get up-to-date on issues like housing affordability, public benefits, home-delivered meals, hoarding, domestic violence, substance use disorders, etc. particularly as systemic inequities impact the health and ability of older adults to age in community and avoid premature institutionalization. 

Housing affordability

Healthy aging begins at home! In Generation Priced Out: Who Gets to Live in the New Urban America (2018), Tenderloin Housing Clinic Director Randy Shaw blamed baby boomer homeowners who prevent construction of new housing through exclusionary single family home zoning, so that this restricted supply drives up home prices and rents at the expense of YIMBY millennials. Yet this generational conflict dissipates when older adult (including boomer) homeowners desire to downsize and transition to smaller units in a duplex or apartment buildings.  He also described affluent NIMBY groups who oppose low-income senior housing, and noted New York City Councilmember Margaret Chin’s courage to call for all neighborhoods including upscale ones to participate in alleviating the affordable housing crisis while preserving open garden space. In contrast, he noted how self-identified progressive San Francisco Supervisor Norman Yee considered “lack of community support” in his decision not to support proposed low-income senior housing in upscale Forest Hill neighborhood.

At Tenants Protecting Affordable Housing convention, we watched Priced Out: Why You Can’t Afford a Place to Live in San Francisco (2019), a 6-part animated series available for viewing online by People Power Media. Sponsored by Tenderloin People’s Congress (TPC), Housing Rights Committee, Independent Living Resource Center, Senior & Disability Action (SDA), and Central City SRO Collaborative, this event offered workshops on Code Enforcement Outreach Program, SRO tenant's rights, mediation, eviction process, affordable housing, SB 529 Tenant’s Right to Organize, and grassroots tenant organizing. 

In its Vision 2020 list of priorities, TPC identified the need to have at least one or two Pit Stop locations that are staffed and open 24 hours because sanitation is a human right! Just days after the convention, SF Department of Public Works announced its 3-month pilot program for a 24-hour Pit Stop in the Tenderloin this summer.  Hooray, accessible toilets will provide relief for all, including clients who are homebound due to incontinence and people who are homeless.

SDA Housing organizer Tony Robles presented on “deeply affordable” housing (aka Senior Operating Subsidy = SOS), as proposed by SF Board of Supervisors President Norman Yee, for seniors with incomes below 30% of the Area Median Income (AMI), which is $25,850 for a single person.  The median income for a single older adult (mostly on fixed income) is $1,825 per month. Afterwards, a younger Tenderloin SRO resident took the stage to talk about her hunger strike for rent relief, protesting $500 rent representing more than half of her income, so she was calling for a 30% rental cap on master leases with City’s Department of Homelessness and Supportive Housing. 

At “The Al Robles Express” documentary launch on the 10^th anniversary of Al Robles’ death, Tony participated in panel discussion with Manilatown artists about their journey to the Cordillera region of the Philippines in honor of his late Uncle Al, poet and defender of the International Hotel (aka I-Hotel).  Though Al never set foot in the Philippines, his poetry was influenced by the village of his ancestors and Tony brought his Uncle Al’s ashes to rest there.  The documentary showed the resistance of village people from Cordillera who faced displacement by the proposed Chico River Dam project, which was eventually abandoned in the 1980s.  Cut to SF’s Manilatown, where I-Hotel tenants—along with Al Robles who organized a broad coalition of protestors—staged a similar resistance against displacement by urban renewal developers; after the last tenants were evicted in 1977, the land sat vacant for over 25 years until new I-Hotel built for low-income seniors (see documentary, “The Fall of the I-Hotel.”) 

(After Tony saw my blog posting of an I-Hotel SRO exhibit at CHSA 5 years ago, his Manilatown Heritage Foundation Board of Directors, where he serves as President, persuaded CHSA to donate its I-Hotel SRO installation to I-Hotel Manilatown Center.  Now after 7 years at SDA, Tony is taking a sabbatical in North Carolina where he will pursue music and writing.) 

Chinese Culture Center’s exhibit, Present Tense 2019: Task of Remembrance, included Xu Tan’s video, “Memory of a Gardener and Guardian,” featuring 92-year-old SF Chinatown social justice activist Chang Jok Lee, who recounted protesting the eviction of elderly residents from I-Hotel during 1968-1977. 

Public benefits

At Pathways to Justice, a statewide conference hosted every 3 years by State Bar of California and Legal Aid Association of California, I attended Expanding CalFresh to SSI Recipients presented by Trinh Phan from Justice in Aging, Michael Herald from Western Center on Law and Poverty, and Andrew Cheyne from California Association of Food Banks.  Effective June 1, 2019, a recipient of SSI can apply for CalFresh (in-person at County office, telephone, or online at https://ssi.getcalfresh.org/) and get up to $192 per month in food assistance, without reduction to SSI grant amount.  If the SSI recipient lives with others who already receive CalFresh, SSI recipient is automatically added at next reporting deadline; and if this addition results in CalFresh loss, then “mixed” households can receive Supplemental or Transitional Nutrition Benefit (new state-funded programs).  Seniors age 60+ represent more than half of over 1.2 million low-income Californians who receive SSI.

Home-delivered meals

Nourishing the Whole Person at Meals on Wheels San Francisco (MOWSF): Last month’s 32nd Annual Star Chefs & Vintners Gala raised a record-breaking $3.3 million, representing 22% of MOWSF's $15 million annual budget.  As MOWSF celebrates its 50^th anniversary next year, it launched a capital campaign to support the growing numbers of older adults who wish to age in their own homes—with meals and safety checks, nutrition counseling, social work home visits, friendly visitor volunteers, etc. MOWSF will break ground for construction of its new and larger kitchen (35,000 square feet!) next month, with move-in expected in Fall 2020, so I decided to join this month’s kitchen tour for these “before” photos.

After donning food safety hairnets, we began tour of 7,000 square feet kitchen.  MOWSF Chief Program Officer David Linnell said 2.1 million meals for 4,700 clients were prepared last year by 36 kitchen staff.  All professional staff because insurance cost would triple if volunteers are used in kitchen. (Sign-up for other MOWSF volunteer opportunities at https://www.mowsf.org/volunteer/!) Soup is made from scratch to control sodium content, and this pair of 40 gallon Tucs kettles will be replaced by a 200 gallon kettle in the new kitchen!

Next year, MOWSF plans to switch to compostable food containers made of sugar cane pulp from Indonesia. 

MOWSF’s Bayview building was a former greenhouse, which may have attracted Golden Gate Gardening author Pam Peirce (seated to left in photo above) to the tour + lunch with MOWSF CEO Ashley McCumber.  In 2007, Ashley became MOWSF’s CEO as he contemplated his own aging without children and who would be there to take care of him? He discussed factors contributing to the “vast unmet need of seniors” and expansion to serve younger adults with disabilities and Navigation Centers (which provide temporary room and board to unhoused San Franciscans as they work with case managers to secure housing): demographics (aging Baby Boomers), living longer, SF’s high cost of living, families moving out of SF so seniors left behind without support, limited access to alternatives in the continuum of care (assisted living, nursing home, affordable senior housing).  MOWSF exists to feed and provide support services so people are visible and safe at home.  He highlighted ways to get involved in MOWSF initiatives like Adopt-a-Building (connecting millennials to SRO clients), home-delivered groceries (serving 500 clients per week), Friendly Visitors, and supporting clients with pets (supply food, walk dog).

Hoarding

As a former MOWSF social worker, my home visits to clients included home safety checks.  Clutter was a common issue with clients living in SROs with limited space, and I often referred these clients seeking help to Mental Health Association of San Francisco (MHASF), which has effective peer support and recovery programs.  (Clients with more serious hoarding cases were referred to Adult Protective Services, which has categorized nearly half of its cases due to self-neglect, including hoarding.)   MHASF hosted a very engaging PROPEL Peer Convening for Sparking Joy/Collecting Behaviors at CounterPulse.   

Susie DuBois, MFT, presented Does This Spark Joy? A Closer Look at the Marie Kondo Method for People All Along the Clutter Scale, a witty and critical perspective on the best-selling book, The Life-Changing Magic of Tidying Up (2014).  After reviewing Konmari (living in present, having gratitude for things, being mindful of what’s truly important), Susie concluded this method can be successful for people with lower levels of clutter; people with space, time, ability, energy, health and resources to sort, discard and get stuff out; and people who need a little nudge or structure for them to be motivated and successful at decluttering. 

Clutter is disorganized collecting, and hoarding is a psychiatric disorder that impacts about 3-5% of the population.  According to DSM-5, hoarding symptoms appear almost 3x more prevalent in older adults age 55+ compared with younger adults. 

What if too much stuff, too little space (like SRO)? Susie recommended:

·       Get help, find support, learn more about collecting behaviors: MHASF offers free peer-led support groups for people overwhelmed by too much stuff

·       Address safety and health issues 1^st!

·       Reduce acquiring: for example, Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding (2013), by Drs. Tolin, Frost, and Steketee, can be borrowed from SFPL 

·       Address co-occurring disorders: collecting behaviors can be symptom of obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), depression, bipolar disorder, autism spectrum disorder (ASD), obsessive compulsive personality disorder (OCPD), post traumatic stress disorder (PTSD), and schizophrenia.

·       Identify your motivation and define your goals

·       Start with things that are easiest to discard

MHASF Peer Coach Robyn McGrath shared motivating advice from her favorite self-help books in Getting Things Done: Tips for Decluttering on Your Own:

·       David Allen’s Getting Things Done: The Art of Stress-free Productivity (2015) – 2-minute rule: do now, or file for later/add to project; Robyn called this a “variation of OHIO: Only Handle It Once, but better”) 

·       Dana White’s How to Manage Your Home without Losing Your Mind: Dealing with Your House’s Dirty Little Secrets (2016) – visibility rule: don’t start with your closet because you can’t see progress but might create visible clutter; instead, visible progress has lasting effects that make you feel good, start with 5-minute clean-up because less is more 

·       Marie Kondo’s The Life-Changing Magic of Tidying Up (2014) – start with easy stuff, like clothes which are easy to obtain and replace 

·       Jen Sincero’s You are a Badass: How to Stop Doubting Your Greatness and Start Living an Awesome Life (2013) – take bold action, get crystal clear on what you desire, then take “hell-bent, joyful, passion-fueled action” and repeat 

No mention of The Gentle Art of Swedish Death Cleaning: How to Free Yourself and Your Family from a Lifetime of Clutter (2018) by Margareta Magnusson, who is “80 to 100 years old,” and asks “Will I ever need this?” and “Will anyone I know be happier if I save this?” 

Julie Rosenthal, MSW, Director of Social Services at Bar Association of San Francisco’s Justice and Diversity Center, covered A Holistic Approach to Eviction Prevention for Clients with Hoarding and Cluttering Challenges, by facilitating audience participation of their lived experience with “deep cleaning.” 

Domestic violence

In a youth-focused society, child and domestic abuse get more attention, while elder abuse is almost an invisible problem despite increased violence and financial abuse against older adults.  This year’s World Elder Abuse Awareness Day (WEAAD) panel focused on Rights and Resources for Older Victims of Domestic Violence in San Francisco:  Mary Twomey, Elder Justice consultant; Beverly Upton, Executive Director of SF Domestic Violence Consortium; Melissa McNair, Victim Witness Advocate at SF District Attorney Victim Services; and Ali Riker, Director of Programs at SF Sheriff’s Office.  Mary provided statistics: 1 out of 10 older adults are abused in their lifetime; 20% of abusers are intimate partners, split equally between men (mostly physical) and women (mostly neglect). Beverly talked about isolation, fear, threatened eviction, immigration and accumulated trauma issues that are amplified as a senior; then described partners in Consortium with specific cultural/linguistic capabilities to connect with diverse older victims.

Panel did not include older survivors, but check out videos at Lifting Up the Voices of Older Survivors. 

Substance use 

Rising rates of elder abuse have been linked to rising opioid addictions, and aging Baby Boomers are dying from accidental overdoses at a higher rate than 18- to 45-year-olds, mostly involving prescription opioid painkillers. Yet, when drug overdose deaths occur, it is usually not clear if the death is accidental or “silent suicide.” 

“Life expectancy, perhaps the broadest measure of a nation’s health, has fallen for three straight years, in part because of the rise in drug overdoses and suicides. That’s the first three-year drop since 1915 to 1918.” – Cynthia Koons, “Latest Suicide Data Show the Depth of U.S. Mental Health Crisis,” Bloomberg (June 20, 2019)  

Organizations like Program of All-Inclusive Care for the Elderly (PACE) and LTC facilities generally do not accept people with substance use disorders (SUDs) because they are not set up as addiction treatment centers or detox units (e.g., facility lacks clinician licensed to prescribe buprenorphine).  Last year, the first skilled nursing facility with addiction services opened in Allegheny County. 

Opioid crisis is being treated like the public health crisis it is (white privilege?) rather than war on drugs.  Last year, U.S. Senate Special Committee on Aging held a hearing, Preventing and Treating Opioid Misuse Among Older Americans, and bipartisan Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act became law. 

Last month’s SF Bay Area Integrated Behavioral Health (IBH) Symposium focused on Opioid Use Disorder (OUD) at East Bay Community Foundation.  Maxwell Davis, Director of CalSWEC IBH Program, introduced Beth Rutkowski, MPH, Director of Training at UCLA Integrated Substance Abuse Program, who explained why integration is so important:

·       Adults with serious mental illness (SMI) die 25 years earlier, largely as a result of treatable medical conditions

·       Adults with SUDs die 26 years earlier, due to physical health problems related to their long-term substance use

We watched video, “Treating Addiction in Primary Care at Marin Health and Wellness.” 

Addiction is a chronic disease of brain affecting reward, motivation, memory and related circuitry. (In above photos based on imaging technology to measure metabolism or glucose uptake in brain and heart, bright yellow/red colors represent high functioning, and blue/purple colors represent disease.)  Opioids are highly addictive, and brain cells can become dependent on exogenous opioids so that users require regular dosing in order to function.  Initially, opioids cause euphoria, then slow down thinking and reaction time.

The presentation’s messaging was similar to Nova documentary, Addiction (2018), and last month’s UCSF Osher Mini Medical School series, Everybody Hurts: How We Understand and Treat Pain and Addiction: 

·       Addiction is chronic, treatable medical condition versus moral failing

·       Evidence-based treatments include FDA-approved medication-assisted treatment (MAT, such as methadone dosings at clinic approved by SAMHSA; prescribed buprenorphine, or combined with naloxone to make suboxone injection), and distribution of naloxone (Narcan spray) to reverse effects of opioid overdose

To critically examine our assumptions and biases around OUD and MAT, we considered language to reduce stigma (e.g., DSM-5 replaced stigmatizing language like “abuse” and “dependence” with opioid “use disorder”). To promote recovery, we use affirming language to inspire hope and capital resources (social, physical, human, cultural). 

HIV Education Prevention Project of Alameda County (HEPPAC) distributed Naloxone kits with 2 Narcan sprays + SCARE ME instructions for naloxone injection, so looked up “how to use Narcan spray.”  When calling 911, important to give location and say “the person is unconscious and not breathing”—no need to say any drugs involved until ambulance arrives.

Despite the fact that there are not adequate services available for voluntary treatment, SF has approved implementation of Senate Bill 1045, under a 5-year pilot program that would require people with SMI + SUD to be placed under court-ordered conservatorship after eight 5150s (72-hour emergency psychiatric holds) in a 12-month period.   The intention appears to remove “visible mental illness” (i.e., homeless) from the streets, without addressing the underlying problem of access to mental health services and housing, especially since the bill provides no funding for both. (SF General Hospital has only 22 acute care beds in its inpatient psychiatric unit, and a national psychiatrist shortage leaving 1 of 4 psychiatrist positions chronically vacant.)  Instead, the Voluntary Services First Coalition (includes SDA and other senior advocacy organizations) favor restoring $40 million in budget cuts since 2008 for mental health services to address access problem. 

At last month’s Drug Policy Alliance’s Coercive Treatment – Moving Beyond “For Your Own Good” conference, Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction (2016), provided a historical review of “illegal” drugs based on racism (opium/Chinese, cocaine/Black, marijuana/Mexican) and not science (tobacco smoking and alcohol cause more deaths); oppressive treatments based on Synanon cult (forcing people who need help with addiction to feel powerless and humiliated in group encounters, denying access to outside world and punishing them); Walden House and Delancey Street in SF “copied” Synanon drug rehab model. 

Strict abstinence rehab programs based on the 12-step Alcoholics Anonymous (AA) model are not supported by evidence.  One-size-fits-all is not the solution, especially when treating older adults. 

Instead, Maia advocated for harm reduction which is evidence-based: kindness and compassion works in addiction recovery to help people because “taking away everything including the only thing that makes you feel okay in the world, and then say now you’re cured” – this will not fix a traumatized, often mentally ill population; for example, Maia who is on autism spectrum took drugs to feel socially comfortable. 

Spectrum of Coercion – Manifestations of Coercive Treatment for People Who Use Drugs panel: Denise Tomasini-Joshi of Open Society Foundations said drug courts and other punitive drug policies  do not acknowledge realities of trauma, poverty, homelessness and mental health needs of people who use drugs, as well as the scarcity of treatment services and housing options. She noted Portugal’s drug decriminalization and investment in a health-based harm reduction model since 2001 has seen an increase in the number of people in treatment for drug addiction. (SF District Attorney George Gascon traveled to Portugal to study whether decriminalization might work in the City.)  

Jennifer Friedenbach of Coalition of Homelessness criticized expansion of conservatorship to coerce treatment under SB 1045 because this would displace people in line for voluntary treatment.  Northeastern Law Professor Leo Beletsky  asked whether people fail treatments or treatments fail people as jail/prison cannot be therapeutic; he recommended changing the narrative. 

Drivers of Coercion – Vulnerable Populations, Stigmatization, and Economics panel: Attorney Talila Lewis noted coercive treatment was an oxymoron; putting people in poorhouse/asylum to label “others” as idiots, insane, senile and elderly; and people who show resistance are labeled as insane or criminal.

Beyond Coercion-Where Do We Go from Here? panel recognized need to reduce barriers to treatment, but not use coercion as tool to increase access.  Sera Davidow of Western Mass Recovery Learning Community criticized “fake choices” (forcing hospitalization after one chooses not to go voluntarily), diagnoses that lack scientific validity (like schizophrenia given to blacks in 1960s civil rights movement by an oppressive system), and language of internalized oppression. Instead, she suggested a trauma-informed approach: ask what happened to you (abuse, loss of power), instead of what is wrong with you – the latter is “misguided, a way of masking/distracting from societal ills.”  She was skeptical about evidence-base, which depends on who has money and social capital, at the expense of actual support that many find useful.

Patt Denning, founder of Center for Harm Reduction Therapy, talked about value of listening to people based on her work as therapist, so she does not blame the client.  While working at SF Department of Public Health (DPH)’s Castro Mental Health Center, she referred white gay men using drugs and alcohol for treatment.  She discontinued making referrals after hearing complaints and then visiting Walden House (where she was appalled seeing clients standing in corners with dunce hats, being humiliated like told to take cotton out of ears and put into mouth) and 50 AA meetings (which she “found scary as recovering Catholic” yet 95% of treatment in U.S. is based on this 12-step mutual support fellowship, Christian values and meant to be anonymous and voluntary).  She decided to make up her own treatment programs, and eventually “tired of DPH bureaucracy” so she set up her own non-profit practice. 

Leah Warner, NP with SF Homeless Outreach Project’s Street Medicine team since 2014 when NP could not get special waiver until law changed in 2016, allowing NP to complete training to prescribe buprenorphine; she said challenge is people who are homeless with SUDs face many barriers to access primary care including MAT, so she meets them where they are to provide low-barrier, life-saving buprenorphine to prevent overdose. 

Attorney Wilda White spoke of need to expand treatment beyond “beds and meds” as she related how drugs forced on her brother diagnosed with schizophrenia had harmful side effects: tardive dyskinesia from anti-psychotics, thyroid removed from lithium, diabetes from Zyprexa.

For a perspective on mass incarceration, historian John Martini moderated Alcatraz alumni panel discussion at Hilton’s Cityscape Lounge.  Former Alcatraz 1259 inmate Bill Baker said boredom was the “real story” while locked up in 6x9 isolation cell, no rehab as he repeated his crimes and lived most of his life in prisons.  Former prison guard described typical workday routine as redundant only interrupted when a fight or attempted escape occurred.  Also heard from former Alcatraz island residents whose parents worked in prison, and they were mostly oblivious to prison life.

From 46^th floor of Hilton Union Square, enjoyed view of Civic Center and Tenderloin District where I am returning to work in this community.

Pursuing meaning and purpose

“It’s the American idea: Get rich, then do nothing.  Sit on a beach.  Go out for an expensive dinner.  Go to Las Vegas.  But those kinds of pursuits turn people into narcissists and thrill addicts… They don’t prioritize the good of the community, they don’t fight for social causes, and they aren’t pursuing a life of meaning and purpose.  As a result, they often end up isolated and depressed…. Meaning is connection, relationships, contribution, and service.” –Esther Wojcicki, author of How to Raise Successful People: Simple Lessons for Radical Results (2019), using Trust, Respect, Independence, Collaboration, and Kindness = TRICK

In my previous career in employee benefits, I worked with employers and employees in the workplace to meet their goals for financial retirement security.   Now I work primarily with older people who have “earned” their retirement with freedom of time to pursue (fill-in-the-blank).  According to Erik Erikson’s stages of psychosocial development, following an adulthood of generativity (v. stagnation) for care, mature people seek ego integrity (v. despair) for wisdom.

At this month’s SF Aging and Adult Services Commission meeting, Department of Aging and Adult Services (DAAS) Executive Director Shireen McSpadden recognized Linda Lau, RD, MPH, for her 35.5 years of service, DAAS’ longest-serving employee!  As Lead Nutritionist, Linda developed with community partners and oversaw the City’s wide-ranging nutrition programs to meet older adults where they are (home-delivered meals and groceries, congregate meal sites offering 9 different cuisines to please diverse palates, CHAMPPS restaurant meals) and evidence-based health promotion programs (Healthier Living-CDSMP, Diabetes Empowerment Education, Always Active, Fall Prevention, Tai Chi for Arthritis and Fall Prevention).

Commissioner’s best line about Linda: “amazing that you could work for the City for 35 years and not look older than 30!”  Yes, Linda walks the talk: always active and modeling healthier living while fundraising (Walk to End Alzheimer’s, 24-Hour Cancer Dance-a-thon), bicycling everywhere, growing her own food (and sharing fruits in the office), encouraging innovation while maintaining high standards to truly make a difference. Hard to imagine DAAS without Linda, but now it’s her turn to benefit from her legacy of award-winning nutrition and health promotion programs!

Linda was my preceptor during my nutrition internship at DAAS nearly 8 years ago, and I continued to benefit from her deep expertise and guidance.  During my gerontology internship at Administration for Community Living 5 years ago, I consulted with Linda to assist American Samoa Territorial Administration on Aging in launching its own senior congregate meals program, which was modeled after Linda’s trailblazing work to provide more culturally appropriate Polynesian fare at Samoan Community Development Center.  This project with American Samoa was thought to be mission impossible after attempts over 20 years, but mission accomplished within 6 months, our eternal gratitude to Linda!

Personally, Linda has helped me so much with her inspiration, sense of social justice, and amazing recommendation letters that got me into graduate school 2x as well as scholarships, and many employment opportunities.  When I told Linda about my plans to return to work in the community, she announced her retirement from DAAS with plans to be more politically active…so looking forward to collaborating more for positive change and healthy aging in community!

At Linda’s retirement party held in atrium outside DAAS office, Linda danced with her hubby Alan.  When Linda officially retires from DAAS at fiscal year end June 30, she has plans for traveling, more dancing and time with her family.  She will continue to pursue meaning and purpose: participation in SF Food Security Task Force, as trainer for Diabetes and Tai Chi programs, and community activism focused on equity and inclusion. 

Standing on the shoulders of giants at Linda’s retirement party, Catherine Wong, RD at SF Chinatown Public Health (also co-author of cookbook with Martin Yan!) and Lisa Yamashiro, RD, Coordinator at City College of SF Nutrition Program, which graduated its 19^th class this summer! Lisa required students (yours truly) to document our learning journey during our nutrition internships, which later inspired me to start this blog to document my learning journey in gerontology.

As a foodie, I connect food with anything.  Most enduring is how food connects to gerontology, which makes sense because centenarians like to credit food (and sleep) for their longevity (following summary from Marc Agronin’s book, The End of Old Age):

·       Jeanne Louise Calment (French) who lived to 122: port wine and chocolate

·       Hendrikje van Andel-Schipper (Dutch) lived to 115: raw herring and orange juice

·       Misao Okawa (Japanese) lived to 117: sushi and sleep

·       Emma Morano (Italian) lived to 117: raw eggs and brandy, and sleep

·       Susannah Mushatt Jones (American) lived to 116: bacon, scrambled eggs, grits, and sleep

And there we have recipes for healthier living 😊. Bon appetit!