Home-ful

This is a home-ful time for unhoused clients who have been staying at shelter-in-place (SIP) hotels during this pandemic.  Through Project Roomkey, in response to San Francisco’s SIP order due to community spread of COVID-19 last year, the City began leasing 2,600 hotel rooms to temporarily house homeless people, prioritizing those age 60+ with chronic health conditions, who are most vulnerable to COVID-19, and got most older adults off the streets. 

Guests who moved into SIP hotels on or before Nov. 15, 2020, are eligible to participate in SF COVID-19 Command Center’s rehousing program, which will offer three housing options.  Most of my clients prefer to remain in the City, close to their providers (yours truly), but some say they will refuse Tenderloin and Bayview-Hunters Point to avoid drugs and violence.  While waiting for an elevator at a SIP hotel, one SIP hotel guest excitedly told me that she was moving out to Tracy (over 60 miles south of SF) to start a new life.

This rehousing process has picked up pace as federal government reimbursement for SIP hotels will run out Sept. 30, 2021, and the City plans to gradually close SIP hotels between fall 2021 and mid-2022. SF Department of Homelessness and Supportive Housing plans to spend $1 billion to house 6,000 homeless people by July 2022. 

According to a report by Coalition on Homelessness, SF has a “generational opportunity” to cut homelessness in half by using federal, state and local Prop C funds to purchase struggling hotels and convert them into permanent supportive housing, which is quicker and half the cost of newly constructed affordable housing.  

Inside SIP hotel floor with separate hallways leading to case managers, medical staff, and Homebridge caregivers, meeting the needs of SIP hotel guests, who receive three meals per day in subsidized rooms with private bath, laundry service, and three daily check-ins by staff who carry walkie-talkies.  SIP hotel guests also sign in/out of a book in the lobby, and cameras record goings-on in common areas. This surveillance system reminds me of assisted living.

This investment in SIP hotels has transformed lives of unhoused people by providing onsite access to basic needs.

“…beyond the healthcare services, it’s also the simple dignity of housing that has allowed patients to heal. Having a chance to rest, to use the bathroom without having to run from place to place, to have three nutritious meals per day — these basic dignities are prerequisites for managing any health condition.”—Naomi Schoenfeld, NP, quoted by Diane Qi and Rani Mukherjee, “Providing more supportive housing is the best way to heal the homeless: San Francisco must act quickly to acquire more hotels and other sites,” SF Examiner (Apr. 13, 2021) 

No wonder SIP hotel care coordinators offer incentives like food and gift cards to engage comfy guests to get assessed for rehousing, provide documentation (state ID, Social Security card, proof of current income), and sign participation agreements that include fill-in-the-blank for reasonable accommodation/life safety concerns (with verification from health provider). Participants have up to two business days to respond to a housing option.  Rehousing is a limited opportunity: Participants who refuse three times end their eligibility for rehousing. One client seeks to stall the rehousing process, as he wishes to remain at his SIP hotel until closing in order to maintain access to onsite medical care (also supported by his primary care physician).

Another program to transition SIP hotel guests is Flexible Housing Subsidy (FHS) Pool, which places them in private market rate rentals and provides support services.  Under this FHS arrangement, tenants contribute rent based on 30% of their income and the remainder subsidized by nonprofits through 2022, then the City takes over funding. 

Attention Adult Protective Services: Muni commuter holds up sign reading “Stop violence against the elderly in the SIP hotels.” (June 15 was World Elder Abuse Awareness Day.)

During this pandemic, other unhoused people were moved into group shelters and outdoor tent camps, like this “safe sleeping village” fenced outside SF Main Library.  SF Supervisor Rafael Mandelman proposed controversial expansion of temporary safe sleeping sites, with an average cost of $190 per tent, per night! This “shelter for all” policy has been criticized for taking resources from long-term solutions, like permanent supportive housing. Puzzling why SF Department of Homelessness and Supportive Housing recently sought $20 million over next two years to fund 260 tents in six Safe Sleeping Villages, at a cost of over $60K per tent, per year? 

Poster reminder to Share the Sidewalk: Keep it clear, clean, and cool ("look out for one another - especially kids and seniors").

California Gov. Newsom said “what’s happening (tent camps) on our sidewalks is unacceptable.”  Henceforth, he proposed more home-ful plans: spend $12 billion to house homeless people over five years ($7 billion to expand Project Homekey, convert hotels to housing + $1.75 billion to build affordable housing + $3.5 billion on new housing and rental support); and state’s payment of all back rent owed by lower-income people who haven’t been able to pay rent during pandemic. 

Yet the state’s spending on homelessness has been criticized for a lack of centralized system to track spending, and inability to determine duplicative efforts, according to state auditor’s report: Nine state agencies spent $13 billion through 41 programs to address homelessness in the past three years…like too many chefs in the kitchen?! 

“With more than 151,000 Californians who experienced homelessness in 2019, the State has the largest homeless population in the nation, but its approach to addressing homelessness is disjointed. At least nine state agencies administer and oversee 41 different programs that provide funding to mitigate homelessness, yet no single entity oversees the State’s efforts or is responsible for developing a statewide strategic plan.”—Elaine M. Howle, California State Auditor, Homelessness in California: State’s Uncoordinated Approach to Addressing Homelessness Has Hampered the Effectiveness of Its Efforts (Feb. 2021). 

In response to this state audit, California unveiled Homeless Data Integration System (HDIS), the first statewide repository of homelessness data from 44 regional continuums of care; some stats from 2020:

·       161,548 people experienced homelessness on a single night in January 2020

·       In 2020, local providers reported serving 248,130 people experiencing homelessness (36,810 from age 55-64; 14,802 from age 65+)

·       Of the people who were served, 91,626 people (37%) moved into permanent housing throughout 2020

Unhoused clients pay relatively sizeable amounts from their government income for storage space, which is limited when they stay in shelters (typically one backpack, one luggage).  Example: 73-year-old Buffalo Sojourn of Oakland has been “unhoused on and off” for the past 20 years, and spends $480 (out of his $700 government aid check) to pay for monthly storage of his Black Panther Party memorabilia. 

Coalition on Homelessness (COH) issued a report, Stop the Revolving Door: A Street Level Framework for a New System (Sep. 2020), based on pre-pandemic surveys of homeless experts (584 unhoused people in SF) and called for: 

·       Prevention: pass policies to keep housing affordable; expand access to variety of permanent supportive housing options (rental assistance/subsidies).

·       Shelter: majority prefer legal camp with amenities (over existing shelters associated with institutionalization, dependency, stigma, strict curfews that interfere with getting hired/maintaining jobs); demand for both clean and sober shelter; high quality case management (many complained of low-quality).

·       Substance use: need for diverse system that includes methods of harm reduction and abstinence.

·       Mental health: bring mental health services including peer support where homeless people already congregate at drop-ins, shelters and navigation centers; stable housing after treatment is critical to stabilizing mental health.

·       Trans homelessness: need gender-affirming care.

COH report's "revolving door" refers to homeless people churning through SF’s homeless response system without landing permanent housing.  But the report doesn’t address the revolving door of staff who work with the unhoused population (other than briefly mentioning "it is difficult to attract and maintain quality staff" in Shelter section, p. 42), allowing clients to fall through the cracks.  Yet dedicated staff is essential to build stable therapeutic relationships with clients to provide case management, substance use and mental health treatment services.  Sadly, as in long-term care facilities, there appears to be high turnover among staff who work with the unhoused population that can negatively affect operations and client outcomes. And staff turnover existed prior to this year's Great Resignation.  In last year's Performance Audit of SF Department of Homelessness and Supportive Housing (DHSH), SF Budget and Legislative Analyst noted high staff turnover/understaffing, insufficient contract oversight and unspent funds made DHSH unprepared to handle the growing homelessness crisis amid the pandemic.

Home Match, a nonprofit that pairs older adults who have extra home space with people seeking affordable housing, is “good at homeless prevention,” said its Program Director Karen Coppock.    

Tents inside fenced parking lot and outside parklet space keep sidewalk clear.

Encampments opposite outdoor murals.  

Books adorn this Bigbelly trash compactor on streets of Tenderloin, sharing space with tents; Helayne B. reminds us of our humanity: we are like books, full of stories.

Warning sign on traffic light post marks drug-free zone in Tenderloin, yet enforcement is lax.

Tenderloin’s Sierra Madre Apartments fire displaced 60 residents, mostly seniors, a reminder how precarious our housing status is. 

Pacific Bay Inn mural reads, “Spend a night, not your life savings…Best Buy—San Francisco on a Shoestring.”  This 75-unit single room occupancy hotel (each unit with private bath!) was the first building to be master-leased by SF Department of Public Health to service the homeless population. 

UC Hastings Law is constructing 14-story, mixed use complex that includes 600+ units of below-market-rate graduate student housing with occupancy set for June 2023.  Murals painted on building exteriors make art freely accessible to people on the street.

Mural of androgynous face on Mosser Tower Apartments, with balconies that provide perfect pandemic escape!

Alicia McCarthy’s “Untitled” mural on luxury hotel that was former SRO. 

Mural on boarded up Aviary storefront invites viewers into meditating frame of mind. 

Mural of “Misunderstanding” by 13-year-old Marisol, painted in groovy style.

Van Mess (ongoing construction for five years, three years overdue and counting) could use some colorful murals as distraction during slow traffic. 

While moving forward with SF’s reopening, it’s also an opportune time to reflect on how this pandemic has exposed many broken systems and prompted emergency measures to invest in our safety net: food security with Great Plates home-delivered meals (ending next month); Medicare coverage of telehealth; CARES Act coverage of uninsured patients with COVID-19; free COVID-19 testing and vaccination; universal basic income pilot; etc. 

Home-ful measures included eviction moratorium and rental assistance, suspension of homeless sweeps and “poverty tows” (people who live in their cars).  Now there’s consideration of more city-sanctioned spaces for unhoused people to park and live in their vehicles. 

Oldness

“Oldness, it’s everywhere. And if you’re lucky, it can happen to you!”

—Power of Oldness, Australian Human Rights Commission 

At Institute on Aging, Jenny Yen, PsyD, presented ageism awareness training, Hear My Story: See the Invisible.  At 31 years old, she reflected on how age 30 over-the-hill jokes made her feel less competent, internalizing ageism, so she found herself unable to perform her usual exercises.  She discussed sources of ageism from aging models (loss and fragility are inevitable; adaptation to changes via selection, optimization and compensation to maintain self-efficacy; successful aging; positive aging), media portrayals and cultural attitudes (anti-aging). 

When Dr. Yen went over “Why Aging is Tough,” I wondered how much of the physical changes are “tough” due to reactions from other people projecting fears of aging (pain; disconnection from self and other people; loss of function, independence, control, dignity) than one’s own adaptation to gradual changes?

For models, she offered 66-year-old Social Work Professor turned Accidental Icon Lyn Slater, and 98-year-old Iris Apfel, oldest person to be turned into a wrinkle-free Barbie doll and another Accidental Icon. 

Refreshingly, Dr. Yen did not reference #endageismsf, but used Australian Human Rights Commission’s upbeat “Power of Oldness” campaign.  She also used Meaningful Ageing Australia’s “See me, Know me” campaign with its 10 conversational starters to talk about “some” of who you are (likes, interests, beliefs, etc.).  She concluded, “Feel good, and be your authentic self.”

Dementia care

UCSF Mission Bay hosted its Memory and Aging Clinic’s Loving Dementia Care: Learn the Skills You Need.  UCSF resources include Care Ecosystem toolkit and free online Dementia Care Training for Lay Health Workers at http://canvas.instructure.com/enroll/R9B67G

Serggio Lanata, MD, presented Heartbeat of Dementia, discussing cerebral localization (predicting regions of brain damage based on patient’s clinical syndromes).

He also covered how the brain changes with aging, different neurodegenerative diseases of the brain causing dementia, and diagnostic process of person with cognitive impairment (neurological evaluation + neuropsychological testing + investigations + level of independence). 

Alejandra Sanchez-Lopez, MD, on Embracing Cognitive Evaluation, described how cognitive domains affect function and behavior.  She also reviewed tools for cognitive evaluation: screening tools include MMSE, MOCA, Mini-Cog, SLUMS; diagnostic neuropsych testing.  Simple strategies to assess cognition: orientation questions (person, place, time), knowledge of current events, perform task with more than one step, ask them to point to something (can they see it? Can they identify it by name?).

Julio Rojas, MD, on Getting to the Heart of Behaviors, because there is no cure for dementia, so treatment goals are to maintain quality of life, maximize function in daily activities, enhance cognition/mood/behavior, foster safe environment and promote social engagement.  

The vulnerable brain has lowered stress threshold.  Instead of "diagnose and adios," he offered 10 principles of behavioral management of dementia symptoms:

1.   Evaluate for medically treatable causes of symptoms, aka is your patient delirious?

2.   Use structured method to assess and manage behavioral symptoms: DICE = Describe, Investigate, Create, Evaluate 

3.   Non-pharmacological interventions should be implemented before pharmacological treatments: address underlying cause(s), provide cognitive accommodations, avoid triggers, reinforce desirable responses

4.   Savvy caregiver is most important ally, empower caregiver: educate, connect with resources, coach and reassure continuously

5.   Pay attention to communication style and content, tailor to accommodate for existing deficits (e.g. dementia stage)

6.   Use intervention hierarchy: nurse, social worker, OT/PT

7.   Person-centered care strategies should be prioritized because they promote strength of patients and honor their choice and values, stay creative: tailored activities program, validation therapy, reminiscence, music therapy

8.   Become structurally competent provider: know resources

9.   Systems-level and multidisciplinary approaches to coach families should be implemented when possible: care navigators, behavioral nursing clinic, support groups, task forces

10.If behavior poses high risk of harm to self or others, or causes severe disturbance to patient or caregiver, pharmacological approach should be implemented first

Nhat Bui, RN, AGNP-C, on Longitudinal Case of Compassionate Caregiving, discussed intervention strategies at each stage of dementia: education and support, counseling, community-based resources, home-based support resources, facility placement resources, legal and financial planning.

Family Caregiver Panel with Matthew (shared story about APS involvement to increase IHSS hours and adult day health care for mother-in-law dx CAA), Gayle (finding “right” caregiver for partner dx PCA and practicing meditation), and Pam (hiking with dogs and late husband dx Alzheimer’s to focus on what worked and not taking behaviors personally).

Mind-body health

At UCSF Parnassus, psychiatrist Descartes Li, MD, presented Cultural Factors in Psychiatric Care: Focus on Asian Mental Health.  He reviewed Cultural Formulation under DSM-5.  

·       Cultural identity: individual v. collective (family), acculturation (different levels around different issues), communication style (direct v. indirect, verbal v. nonverbal, include kinesics/haptics, proxemics, paralanguage), emotional expressivity (Confucian value of self-restraint), language proficiency (involve interpreters & translators)

·       Explanatory models of illness: idioms of distress (neurasthenia v. depression), cultural syndromes, definition of mental health (Western definition of mentally “healthy” person: ability to express feelings in words; high value on insight, understanding one’s emotions, highly individuated, ability to trust clinician), importance of patient’s perspective

·       Cultural stressors and supports: U.S. secularization (psychologization), community mental health/deinstitutionalization, biomedical paradigm; Chinese Confucianism (family, harmony/interdependence, golden mean, virtue), traditional Chinese (filial piety, “face,” love expressed by providing, self-restraint, humility)

·       Cultural elements of relationship with clinician: relationship to authority, informed consent, transference and conception of “self”

·       Overall assessment: impact of culture on assessment/diagnosis and treatment plan 

In 1980, American psychiatrist and medical anthropologist Arthur Kleinman went to Hunan, China, where he evaluated 100 patients who had been diagnosed with neurasthenia (characterized by fatigue after mental effort in ICD-10, dropped from DSM in 1980) and diagnosed 93% with depression and 71% with anxiety disorders.  Dr. Kleinman figured that older generation Chinese, influenced by Traditional Chinese Medicine and avoiding stigma of mental disorder, might experience mental distress as somatized distress, with physical symptoms such as fatigue (depletion of qi) and sleep disturbance.

Thought experiment: Could a Chinese psychiatrist come to the U.S., evaluate patients with a prior diagnosis of depression, and then re-diagnose them with neurasthenia? Are American psychiatrists misdiagnosing U.S. patients?

Three years later, Dr. Kleinman returned to China:

·       48 patients with “medical” perception, 33% decreased their medical utilization;

·       52 patients with new “psychological” understanding, 70% of patients decreased medical utilization

Oldness prevention?

Oldness does not happen when pedestrians are killed by drivers of motor vehicles.  Earlier this week, an 80-year-old man struck by a car in the Tenderloin became San Francisco’s first pedestrian fatality of the year.  San Francisco’s Vision Zero project is four years away towards its goal of zero traffic deaths by 2024. However, last year’s 29 traffic-related deaths, including 18 pedestrians, represent an increase from the previous two years (23 deaths in 2018, and 20 deaths in 2017).
Oldness also does not happen when people end their lives prematurely by suicide (and medical aid-in-dying).  In the U.S., suicide rates are highest among middle-age white men, with firearms accounting for more than half of all suicide deaths.  According to the Centers for Disease Control and Prevention (CDC), guns kill more Americans than motor vehicles, but CDC is reluctant to link “access to firearms” with suicide – though 60% of gun deaths are the result of suicides, not homicides.  Because 1996 Dickey Amendment prohibits CDC from using its funding to “advocate or promote gun control,” CDC’s suicide prevention message is “safe storage of lethal means” (keep gun locked and separate from ammunitions to decrease impulsive use) instead of “restricting access to guns.”

The suicide rate among veterans is 1.5 times greater than non-veterans, with over 6,000 veterans dying by suicide each year.  Veterans account for 13.5% of all suicide deaths, though just 7.9% of the U.S. population.  While VHA focuses on the growing number of younger veterans who have the highest rate of suicide among veterans, those 55 and older still represent the largest number of suicides.  Almost 70% of veteran suicides involved a gun, compared to about 48% of non-veteran suicides. 

At War Memorial Building, American Foundation for Suicide Prevention (AFSP) and San Francisco VA Health Care System partnered with National Shooting Sports Foundation (NSSF) to present all-day conference, Counseling Veterans at Risk for Suicide: Latest Advances in Preventive Strategies and Safe Storage of Firearms.  

(Left to right, in photo above) Joseph Simonetti, MD, MPH, Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention, VHA); Carolyn Colley, Disabled Air Force Veteran who lost two brothers, both veterans suffering PTSD, to suicide, and blamed "incompetent social worker"; Joy J. Ilem, Disabled American Veterans (DAV); Aimee C. Johnson, LCSW, VHA Office of Mental Health and Suicide Prevention; Matthew A. Miller, PhD, MPH, VHA Office of Mental Health and Suicide Prevention; M. Emmy Betz, MD, MPH, VHA); Jay Zimmerman, BA, CPSC, CRE, CPRP, Certified Peer Support Counselor, James H. Quillen VAMC; Matthew J. Miller, MD, MPH, ScD, Northeastern University; Doreen Marshall, PhD, AFSP; Joseph Bartozzi, NSSF; Megan McCarthy, PhD, AFSP Project 2025 (nationwide initiative to reduce annual suicide rate in U.S. 20% by 2025).

Like CDC, there was no mention of “gun control” but presenters used “lethal means safety.”  The presenter for firearms industry defended 2^nd amendment right to firearms, encouraging audience to reduce bias: “learn about gun owners, go out for a shoot.”  Peer support presenter explained “I shoot for relaxation, blow off steam… losing my hearing, but have fun bonding” with shooting pals. 

Matthew J. Miller stated the presence of firearm access matters in suicide.  His rationale for “means reduction”:  suicide acts are often impulsive for crises often fleeting; method used depends on availability; 90% likelihood of death with firearms; fewer than 10% of survivors go on to die by suicide.  Majority of guns used in suicides come from victims’ home.  People who live in homes with guns are neither depressed nor more suicidal than members of non-gun owning homes.  Availability of method affects suicide rates:  If not able to use preferred method, will not turn to other alternatives.  Population level restrictions on access to commonly used lethal methods of suicide saw profound fall in suicide rates, without any psychosocial intervention, after U.K. detoxed gas used in home ovens and Sri Lanka banned most toxic pesticides.  Israeli Defense Force cut its weekend suicide rate by 40% after requiring that soldiers leave weapons on base during weekend leaves.

Joseph Simonetti stated the presence of a gun in the home is strongly associated with suicide among adults, and U.S. veterans have greater firearm access than non-veterans: 47% of male veterans own a firearm versus 30% of male non-veterans; 24% of female veterans own a firearm versus 12% of female non-veterans. 1 in 3 firearm owners have a household firearm that is unsecured and loaded with ammunition.  Goal 6 of VA’s National Strategy for Preventing Veteran Suicide is to promote efforts to reduce access to lethal means of suicide among veterans with identified suicide risk.  Current efforts focus on Lethal Means Safety (LMS), including firearm safety device distribution program.  He explained messaging language matters: “safety is better than restriction.”  “Safety” means keeping firearms unloaded, secured with locking device, and separate from locked ammunition; removing firearms from home.  He also discussed need to expand suicide risk screening beyond risk groups with mental illness because nearly 30,000 VHA primary care patients died by suicide from 2000-14: 45% had no prior mental health or substance use diagnosis; those without diagnoses more likely to die by firearm injury.  LMS interventions should be different for female veterans, who use firearms for protection and safety (e.g. keeping loaded gun by nightstand), particularly if they've known sexual assault in the military. 

Oldness in museums

In recognition of the 75^th anniversary of the liberation of Auschwitz, War Memorial Veterans Gallery exhibited Violins of Hope: A Journey of Heroism, Healing and Humanity, a collection of over 20 violins once played by Holocaust prisoners and victims, exploring the power of music to heal, unite and protest. This exhibit made me think about TwoSet Violin Youtube duo who make old classical violin music so cool, accessible and relevant, and how can we do the same for Oldness? 

Social policies, based on compassionate ageism, that promote age-segregation do not help to make Oldness cool.  Adam Schachner’s short video, “The Old People Museum,” depicts this commodification and othering of older adults for visitors to observe and learn from Depression-era Old Man who talks about “what you used to be able to buy for a nickel.”  After the museum closes, Death Skeleton absconds with 104-year-old woman from her display case.  The end.

As part of its Soul of a Nation: Art in the Age of Black Power 1963-1983 exhibit, de Young Museum re-created the Black Panthers’ ground-breaking Oakland Community School with its Director (1973-1981) Ericka Huggins (both the first woman and first Black person to be appointed to the Alameda County Board of Education) facilitating a discussion about revolutionary child-centered education focused on serving children of color, each according to their ability and needs.  Critical thinking skills came from teachers and children posing questions and dialoguing for answers.  They were educated in subjects like math, science, language arts, history, current events, physical education (martial arts and yoga for mind-body connection), theater, dance, choir, gardening and environmental studies.  With “each one teach one” philosophy, everyone learned from one another. 

Contemporary Jewish Museum’s Levi Strauss: A History of American Style displayed never-before-exhibited Levi’s leather Cossack jacket worn by Albert Einstein during his early years in the U.S. when he arrived as a 54-year-old refugee from Nazi Germany.  Einstein makes Oldness cool!

Care partners

“When you give something, you’re in much greater control.  But when you receive something, you’re so vulnerable.” – Fred Rogers to Jeanne Marie Laskas, “The Mister Rogers No One Saw,” The New York Times (Nov. 21, 2019)

At this month’s Gerontological Society of America’s Annual Scientific Meeting, the term “care partner” seemed to be used more often, replacing caregiver.  While a caregiver is one who gives care to a recipient who needs assistance, a care partner describes both parties in a caring partnership with shared goals, opportunities to both give (control) and receive (vulnerability).  Care partner also reflects more dynamic roles in person-centered and partnership-centered models of care. 

“Person-centered care involves engaging with people as equal partners in promoting and maintaining their health and assessing their experiences throughout the health system, including communication, trust, respect, and preferences.” –Primary Health Care Performance Initiative 

Partnership-centered care goes beyond person-centered care by promoting a culture of collegiality:

“(Partnership-centred care) approach promotes collaboration between all those involved in an older person’s care. It recognises the values of interdependence and reciprocity, and aims to maximise the wellbeing and dignity of all by creating a positive environment that draws on the best evidence-based practice available.”—Caring for Older People: A Partnership Model, Centre for Innovation and Education in Aged Care (CIEAC), Deakin University 

Caregiver Action Network (CAN), a non-profit organization advocating for more than 90 million Americans who care for loved ones of all ages, selected the annual theme for National Family Caregivers Month, #BeCareCurious: about your loved one’s goals, treatment options, research, the care plan, and insurance coverage.

Language matters because words have meanings that shape culture, attitudes and behavior.  Yet reframing care takes time as there was no rebranding of National Family Caregivers Month to Family Care Partners Month?

As a follow-up to September’s Care Agenda: Expanding CA’s Long-Term Services and Supports (LTSS) for All Town Hall meeting, California Aging and Disability Alliance is circulating a petition for a new social insurance program to help Californians afford LTSS needed to live and age with dignity in our communities. 

According to this month's AARP report, Valuing the Invaluable, the availability of family “caregivers” is unlikely to keep pace with future demand: in 2026, baby boomers begin to turn age 80—when people are most at risk of needing long-term care (LTC); yet the U.S. population aged 45-64, “peak caregiving” years, will increase by only 1% between 2010 and 2030, while the age 80+ population likely to need LTC will increase by a staggering 79%!  

House Ways and Means Committee held a hearing, Caring for Aging Americans, that included powerful testimony from a family “caregiver” faced with raising $84,000 to pay for her mother’s home healthcare, or dropping out of her last year at Yale medical school to provide this care.  Proposed solutions included universal LTC, increased reimbursement rates for nursing homes, stronger enforcement to prevent elder abuse, expanding access to hospice care, addressing LTC access in rural areas, developing workforce, paid family leave, etc.

At Institute on Aging (IOA), Jenny Yen, PsyD, Director of Training for Integrated Behavioral Health, presented on De-escalation Techniques and Strategies.  In her work consulting IOA staff in addressing challenging client behaviors due to dementia and psychiatric issues, she emphasized the need to view and understand people and their behaviors with compassion (=reduce suffering), increase empathy and strengthen relationships.  We all experience suffering (e.g., loneliness, fear, anxiety, stress, unmet need, being misunderstood, underappreciated, etc.) and want to be respected, so approach the person with suffering with a view to help, not punish. 

This training made me reflect on my work in the Tenderloin serving marginalized and diverse older adults, observing conflicts arising from control issues relating to personal space (lack thereof in densely populated congregate places like senior centers and SROs), mental illness (loss of control in anxiety/trauma, confusion in psychosis, trust and safety violations in personality disorders, not knowing how to express complex feelings in grief and loss), cognitive disorders (impulsive, forgetful expressions), and impact of cumulative disadvantages (poverty, discrimination).  Her tips included:

·       Compassionate listening: ask what is their suffering, what is trigger? Be present, give complete attention (no multi-tasking), convey you are following discussion, avoid problem-solving (unless they ask?), be open-minded and curious (no judgment), listen for suffering and triggers (work to remove triggers, create sense of safety), reflect/validate (e.g., “Sounds like you’re going through a tough time.  Tell me more.  What helps you when you are stressed?”)

·       Redirect attention: ask/use “we” language to change topic/activity/environment (be ally, “let’s do together”); offer choices to regain control & opportunity to grow/learn (integrate person’s strengths)

At JCCSF’s 5^th Annual Embracing the Journey End of Life Resource Fair, Dr. Shelly Garone presented two talks on Palliative Care: 

·       The Art of Taking Care of Our Dying Loved Ones – Finding Peace Within Knowledge: where would you prefer to die (90% of Californians want to die at home, only 25% actually do); how would you choose to die (“sudden death” in sleep for 10-15% Americans, cancer 20-25%, organ system failure 20-25%, dementia/frailty 40%); physical & emotional aspects of dying (disengagement from prior joys-life smaller, loss of appetite, onset of skinniness, increasing sleep; delirium, chorea, pain, air hunger/shortness of breath, own un-ease & un-readiness); timing (out of doctor’s control, loved one choose moment most protective, ears last to turn off so say everything want to say)

·       Taking Care of Caregivers – Finding Hope Despite Grief: keep notebook (jot to-do tasks, clinical notes); delegate; get informed; don’t lose your health; take breaks (nobody likes to be watched while they sleep, some too private to die with others present); our bodies die, this doesn’t mean that life is worthless.

SF Supervisor Hillary Ronen delivered keynote at Redefining Crazy: It’s the System, not the People conference hosted by Mental Health Association of San Francisco.  She introduced her proposal for universal Mental Health SF, which emphasizes voluntary engagement and addresses current gaps in “coordinated, managed care fashion”:

·       24/7 service centers (similar to Behavioral Health Access)

·       office of coordinated care (real-time inventory of beds, high quality data, regular/intensive/critical levels of case management with standardized supervision)

·       crisis intervention street team (similar to Mobile Crisis)

·       expansion of services (more beds, cooperative homes)

·       office of private insurance accountability to advocate for access to anyone insured

·       use $400 million budget for behavioral health more wisely, plus additional $100 million funding via taxes.

She explained her proposal evolved from trying to address the homeless crisis, especially after homeless from Super Bowl City near Embarcadero Plaza were cleared to the Mission in 2016, so she fought for a Navigation Center that reduced the number of tents from 260 to 30 in her district.  She declared the major causes of homelessness were economic inequality and displacement, compounded for people with mental illness and substance use disorders; 38% of people discharged from Psychiatric Emergency Services were not connected with follow-up services, due to lack of communication among agencies operating in silos or lack of high quality data regarding availability of beds; and her rejection of SB 1045 housing conservatorship, which targets homeless people with dual diagnosis, whose presence on the streets of San Francisco have increased visibility.  (A week after her keynote, Mental Health SF was revised to limit its scope in a compromise with SF Mayor.)  

Susie DuBois, MFT, presented on the development of a drop-in support group for Family & Friends of People with Hoarding & Collecting Behaviors.  Five years ago, SF Department of Aging & Adult Services provided funding to start support group, which evolved from 6 weeks in 2015 to 14 weeks.  There is a two-hour orientation session for new members; each two-hour session includes 1^st hour didactic on topic in lecture/discussion, 2^nd hour open group sharing & support.  About 5 to 14 participants attend, ranging from age 19 to 75.  The model curriculum includes: 

·       Family and Personal Vulnerabilities: genetic predisposition, executive function deficits; trauma, scarcity, loss; learned about possessions, acquiring, anti-organizing; lack of skill how to discard, maintain; mental health issues

·       Relationship Issues: communication; high conflict/passivity/avoid conflicts (couple); co-dependence/control; lack of connection; power imbalance; blame & responsibility; standoff

·       In-Home Issues: turf wars; loss of control; conflict; clutter-blindness; mutual avoidance/standoff

·       Community and Social Issues: shame & embarrassment; isolation; lack social norms; difficult find support; neighbor & landlord conflict; involving social services; secret keeping

·       Accommodations: OCD scale/symptom severity

Lunch & Learn Q&A with Esme Weijun Wang, author of The New York Times bestselling essay collection, The Collected Schizophrenias (2019).  She discussed the mental health stigma of “schizophrenia terrifies” due to psychosis that results in later discharge from hospitals.  In contrast, people with anxiety, depression or eating disorders are reframed (almost mainstreamed) as having “attention to details” and “empathic concern.”  Schizophrenia is commonly diagnosed during young adulthood, and colleges find it difficult to deal with mental health issues.  As a Yale student struggling with mental illness, she was hospitalized against her will.  She talked about the loss of dignity in involuntary hospital stays, which resembled prisons; her need to access outdoors and fresh air.  Her self-care/wellness plan includes medications, therapy, journaling, dressing well to restore dignity, support system, and "wonderful dog."

Human rights advocate Kirsten Irgens-Moller left SFSU’s MSW program over 30 years ago to co-found Global Exchange and serve as its Executive Director, then returned to complete her MSW degree in 2015, with a field placement that turned into employment at Ombudsman Services of San Mateo County (OSSMC)! OSSMC advocates for the rights of 10,000 residents in LTC facilities in San Mateo, accomplishing 5,000 unannounced visits in the past year.  When Kirsten interviews field ombudsman candidates, she asks “why do you like old people?”  The responses often relate to experiences with a grandparent and love of stories/wisdom.

Senior & Disability Action’s Housing Collaborative celebrated victory of Proposition A, which funds $600 million for affordable housing bond, including $150 million for senior housing! SDA members called 2,500 senior voters to support Proposition A, which passed with 71% of votes.  Gen Fujioka, Policy Director at Chinatown Community Development Corporation (CCDC), which houses 2,379 seniors age 65+, representing 53% of its low-income residents, talked about Senior Operating Subsidy (SOS), need to increase senior housing (currently representing only 12% of housing pipeline) and for public oversight of Mayor’s Office of Housing. 

Jen Low, legislative aide to Board of Supervisors President Norman Yee, talked about plan to construct a 200-unit affordable continuum of care campus at Laguna Honda: senior independent housing, assisted living, and an intergenerational early childcare education center with adult day health center.  She also spoke of need for data to organize for transparency and accountability, such as a comprehensive needs assessment, income levels, wait list for BMR housing, etc.