Reimagine End of Life

Reimagine End of Life (EOL) https://www.letsreimagine.org/ was a weeklong event that “envisions a world in which we are all able to reflect on why we’re here, prepare for a time when we won’t be, and live fully right up until the end.”

Conference founder Brad Wolfe said inspiration to create Reimagine event came from his grandparents’ experience of surviving Auschwitz: “What is so precious about life that, in the face of death, we are inspired to fight for more time?” Partnering with the San Francisco Palliative Care Workgroup, Reimagine offered 150 events that looked at EOL from perspectives of healthcare + social services, arts + entertainment, design + innovation, culture + spirituality.

Psychedelics and Death: New Science, New Understandings was a conversation between Temple Emanu-El Rabbi Sydney Mintz (who said Judaism does death well) and Richard Miller, PhD, clinical psychologist and author of Psychedelic Medicine: The Healing Powers of LSD, MDMA, Psilocybin, and Ayahuasca (2017).  Richard said psychedelics help at EOL to remove cultural fear from death experience; he talked about LSD opening the mind to realization that the world is one breathing organism, all beings are connected, death is sleep without dreaming; his tombstone would state date of birth to blank date of death because “who’s to say”? 

End of Life Project: A Theatrical Exploration of Death, Dying and Suffering was sold-out at Castro Theatre, filled to over 900 people. 

Dramatic readings of scenes from Sophocles’ Philoctetes and The Women of Trachis by David Strathairn, Frances McDormand and Marjolaine Goldsmith.  In both plays, there was a lot of screaming at the audience by actors portraying patients suffering in pain. 

Community Conversation moderated by Bryan Doerries, founder of Theater of War, and featured panelists Eric Poche (Zen Hospice Project), Anne Germanacos (writer and “amateur student of death”), Steve Weitz (JFCS Palliative Care volunteer) and Bonnie Lasky (caregiver for her dying husband).  What kind of EOL experience do we want?

One audience member talked about a dying loved one “covered up with meds” such that the person was no longer there, not awake when death happened.  Is it worse to hear dying people scream in pain or be complicit to silence when dying people can no longer express themselves?

At the end of each Reimagine event, participants received a box of cards inviting us to:

1.   Remember: (fill-in-name) who inspires me to (fill-in-blank).  Included were cards with photos of public figures and their quotes:  “Try to be a rainbow in someone’s cloud” by Maya Angelou (writer and first African-American female cable car conductor), “You gotta give room for people to experiment” by Mayor Ed Lee (who was also an organ donor),  and “You need music, I don’t know why” by Jerry Garcia (Grateful Dead guitarist). 

2.   Prepare: (fill-in-name) is a person I can imagine talking to about helping me carry out my end of life wishes.  Speak up about the things that are important to you (advance health care directive), help family and friends be your advocate (durable medical power of attorney), and for what you want to leave behind (will, after gifting).

3.   Wonder: (fill-in-blank) when I think about end of life. Questions to ponder:  where would you have your last meal? What would it be? Where do you want your remains to go after you die? If you could leave one piece of advice for the next generation, what would it be? What would you do differently if you knew that this was your last day? Year? Who would you spend time with? What would be important to say? Do you think life would be better if we could live forever?  

At Yom HaShoah (Holocaust Remembrance Day on April 11) event, Gloria Hollander Lyon spoke about surviving seven concentration camps during the Holocaust and engaging in Tikkun Olam (repairing or healing the world) by bearing witness and speaking out against prejudice, discrimination and threats to civil liberties.  Six candles (representing 6 million Jews killed) were lit by Holocaust survivors, followed by music (“Eli Eli” sung by Jan Peerce and “Avinu Malkeinu” sung by Barbra Streisand) before a screening of Gloria’s documentary, “When I Was 14: A Survivor Remembers."  For the past 40 years, Gloria has dedicated herself to teaching the lessons of the Holocaust and published her memoir, Mommy, What’s That Number on Your Arm? A-6374. (I attended Gloria’s book release reception nearly 18 months ago, and now it was a privilege to work with her in organizing this moving remembrance program.)

At JCCSF’s 12^th Annual JCCSF Art of Aging Gracefully Resource Fair, Donald Abrams, MD, integrative oncologist at UCSF repeated Cannabis as Medicine presentation, including its use during end of life. 

“Cannabis — also known as marijuana — increases the desire for food, makes foods smell better and taste richer, decreases pain and relaxes and elevates a person’s mood. Subsequent studies have confirmed these effects, in addition to cannabis’ effectiveness in reducing nausea and vomiting.

Patients at the end of their lives can have problems with appetite, nausea, pain, anxiety and sadness…

I see cannabis as an extraordinarily safe drug to be given if needed at the end of life.” –John Morley, MD, “Senior Focus: Should marijuana be legalized for end of life care?” St. Louis Post-Dispatch (Oct. 10, 2013)  

In her new book, Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer (2018), 76-year-old Barbara Ehrenreich (a cancer survivor) writes that she’s given up on preventative care after realizing that she’s “old enough to die” (sounding almost like Ezekiel Emanuel’s “Why I Hope to Die at 75,” article published in The Atlantic almost four years ago):

“Once I realized I was old enough to die, I decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life. I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber, and fats. I exercise—not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me. Ideally, the determination of when one is old enough to die should be a personal decision, based on a judgment of the likely benefits, if any, of medical care and—just as important at a certain age—how we choose to spend the time that remains to us.”—Barbara Ehrenreich, “Why I’m Giving Up on Preventative Care: How Contemporary American Medicine is Testing Us to Death,” Literary Hub (April 9, 2018) 

A recent Stanford University study, published in the Journal of Palliative Medicine, suggests an EOL approach to facilitate better “preference-sensitive” care and informed decision-making is for patients to share their bucket lists with physicians who can discuss the impact (if any) of their medical treatments on their life goals.  Researchers hope their findings will promote more intimate discussions that focus on what patients want to make the most out of life, rather than over-reliance on advance directives that focus on death (though patients should still complete/update their advance directives).  According to VJ Periyakoil, study author and director at Stanford Palliative Care Education and Training Program, regret is the most common emotion seen in patients when they are dying.  She also noted that participants who said religion/spirituality was important were the most likely to have a bucket list, which suggests that faith allows “the ability to imagine something is a proxy for a level of hope even in the face of little evidence.”

Money magazine reported, “A Growing Cult of Millennials Is Obsessed With Early Retirement. This 72-Year-Old is Their Unlikely Inspiration” (April 17, 2018), referring to Vicki Robin, co-author of Your Money, or Your Life (YMoYL). (When I read YMoYL originally published in 1992, it inspired me to maintain my simplified lifestyle and reject consumerism because money=life energy; YMoYL has been revised to emphasize financial interdependence, such as a community building to share resources and support.)  Apparently, millennials are focused on “Financial Independence, Retire Early (FIRE) with more emphasis on the goal of FI than what to do for the rest of their retirement lives before they die?! When older adults retire at age 70, the “biggest challenge is to make your life as meaningful as it was when you were working,” according to Dr. David B. Reuben, Chief of Geriatrics Medicine at UCLA.  Towards the end of life, we may think even more about making a contribution to society based on Erik Erikson's theory. 

Aging in America 2018 conference highlights

This year’s Aging in America (AiA18) conference was held in San Francisco, HQ of host American Society on Aging (ASA) and my hometown!  Yay, I was spared the expenses of airfare and lodging to attend this conference … and I volunteered one day to receive 50% discount on registration!
At AiA18, ASA continued its Call to Action to remain vigilant in our advocacy to improve the quality of life of older adults and their families, as President Trump threatened to veto and then signed on March 23, the 2018 omnibus appropriations bill, which rejected proposals to cut or eliminate older adult programs and even included increases for some.

There were reminders of the demographic shift underway, thanks to the maturing of America’s baby boomer generation: in the next four years, nearly 15 million Americans will turn age 65; by 2030, 73 million (or 1 in 5) Americans will be 65+! And there was acknowledgement of priorities (not listed in any order) to: address the caregiving shortage (trained workforce); consider technology and accessible design (user input, age-friendly, livable) to enable aging in place; do better with less silos and more integration (social services and medical care to address social determinants of health, aging and mental health, welcome CHRONIC Care Act); invest more in home and community based services (HCBS) provided by community based organizations (CBOs)(“health happens at home and in the community”) and strengthen social networks of support (community connector, village); preserve and expand safety net; offer meaningful options to meet growing needs/wants of diverse older adults (rural, solo/orphan, LGBT, etc.); challenge ageism (“reframe” or “disrupt” aging), etc.

General Sessions

Like past ASA conferences during the Opening Session, we heard the usual "We Will Rock You" by Queen.  However, the usual local entertainment was missing – not even San Francisco’s highly acclaimed Community of Voices Senior Choir, Dance Generators, Stagebridge talent, etc.  

ASA Chair Bob Blancato welcomed 3,000 attendees from 50 states and many countries.  AARP sent 88 staff to attend AiA18!  He talked about last year’s collaboration with 8 organizations to Reframe Aging, and the “best bipartisan increases” to Older Americans Act and other aging programs including those targeted for elimination last year. 

ASA Leadership Awards recipients on stage 

Paul Nathanson received ASA Hall of Fame Award in recognition of his 45 years of advocacy for low-income older adults in America, as well as many years of service on ASA Board of Directors.  He was founding Executive Director of National Senior Citizens Law Center (now Justice in Aging). 

Ashby Wolfe, MD, Chief Medical Officer for Region IX of the Centers for Medicare and Medicaid Services (CMS) in SF, presented on CMS Priorities: Putting Patients First, discussing Patients Over Paperwork and new Medicare card. 

Justice in Aging Executive Director Kevin Prindiville talked about defending healthcare and using our voices to: push back on proposals to repeal Affordable Care Act and to add work requirement to Medicaid that would impact older people age 60-64, protect LGBT rights in nursing homes, expand dental care, etc. 

How Technology is Reinventing Aging panel discussion with David Inns (GreatCall CEO), David Rhew (Samsung Electronics Chief Medical Officer), Daniel Herscovici (former Xfinity Home Executive), Lilian Myers (IBM Watson Health Global Leader), Kate Lorig (Self-Management Resource Center Partner) and moderator Ginna Baik (CDW Healthcare Senior Care Practice Leader).  Highlight was watching 5-minute video, Uninvited Guests, by design firm Superflux about an elderly man who lives alone and rebels against smart devices monitoring his every move (calories, steps, sleep, etc.) as they are reported to his helicopter kids who annoy him with check-up calls. 

Kate stole the show with her practical insights (and made up for missing local entertainment): she likes technology as a means to keep in touch with family and friends, wants to remain empowered using technology to make life easier; she does not use tech if there are no instructions unless she goes online to get help.  In response to David Inns' belief that tech is a “game changer to transform aging with predictive analytics from devices to get one’s health trajectory,” Kate replied surveillance might be fine, but problem is one can’t predict do no harm—anxiety and depression from too much data might overwhelm so people don’t want all data and don’t want it in their home.  When Lillian talked about prediction models such as number of toilet flushes to determine if one drinks enough fluids, Kate explained some do not always flush due to drought in Northern California (audience laughter)! David Rhew talked about using tech as an engagement tool to address loneliness epidemic, especially with caregiver shortage, and viewed surveillance with motion sensors (no camera) as non-invasive yet proactive.  Dan talked about access to underserved with affordable Internet Essentials program for low-income older adults, and need to find solution to problem instead of solution looking for a problem.  David Inns said engineering with price needs to be part of design criteria. Kate emphasized design with, not for, older adults, concluding with disability movement's slogan, “Nothing about us, without us!” 

Bob Blancato introduced Spring 2018 issue of Generations on Fundamentals of Community-Based Managed Care: A Field Guide.

The New Wave of Population Health Management: CBOs in the Forefront panel featured:

·       Lance Robertson, Administrator and Assistant Secretary for Aging at Administration for Community Living (ACL), discussed his vision for ACL focusing on 5 pillars: connect people to resources, support families and caregivers, protect rights and prevent abuse, expand employment opportunities, and strengthen aging and disability networks. 

·       Malaz Boustani, Indiana University Professor of Aging Research, talked about need to integrate health and CBO so no one is left behind (100% of population actively managed), while showing slides from Kaiser Family Research on social determinants of health; clinical care determines only 10% of health.

·       Connie Benton Wolfe, Aging & In-Home Services of Northeast Indiana President and CEO, noted 5% of the population with high needs spend over half of medical costs.  She emphasized health happens at home and ROI Simulator developed by Dr. Boustani to demonstrate value of non-medical interventions in potential cost savings.  

Health care spending can be reduced by shifting cost from higher delivery points to lower delivery points (change entry point for health): CBOs, which work directly and intimately with people in home settings, connect them to community services before crises--this reduces emergency visits/inpatient admissions/inpatient length of stay and increases utilization of outpatient services.

AARP Foundation President Lisa Marsh Ryerson delivered “rah-rah” speech, Ending Senior Poverty: Why We Can’t Wait, inspired by Martin Luther King, Jr. saying we need to challenge every form of social injustice though people may be too uncomfortable to talk about poverty and aging; many suffer in silence because they don’t want to be a burden; we need to treat poverty as a disease, instead of individual failing.  She praised last weekend’s March For Our Lives led by youth leaders … (See Teenagers: Saving Our Country So You Don't Have To) 

ASA Public Policy Committee Chair Bill Benson discussed housing (Congress rejected proposal to eliminate HUD, Section 202 support for senior housing construction and rental assistance represents first major investment in six years), Social Services Block Grant (saved by level funding that represents only federal funding for APS, also source of some funding for Meals on Wheels and case management), and SSI (neglected since creation, Paul Nathanson has advocated to modernize).

ASA Board member Paul Downey discussed need to maintain vigilant advocacy, so ASA Board voted to hire a public affairs firm in Washington, DC, to take ASA’s message to Capitol Hill.

San Francisco

At last year’s ASA conference, I skipped sessions with presenters from San Francisco because I wanted to learn what was happening outside of our San Francisco bubble.  At this year’s conference, one couldn’t miss attending the many sessions with San Francisco presenters and learning about best practices.  In fact, San Francisco Department of Aging and Adult Services (DAAS) was honored with two n4a Aging Achievement Awards in 2017 for Cayuga Community Connectors—Every Neighbor a Connection, and IHSS Supplemental Groceries Program!  

ASA Chair’s Lecture – Aging A-Z: Inequality, Power and Resistance (Policy & Advocacy): ASA Chair Bob Blancato with Aging A-Z: Critical Concepts in Gerontology (code FLR40 for 20% discount at https://www.routledge.com) authors Nicholas Di Carlo and Carroll Estes, and Brooke Hollister of UCSF.  

Aging starting with Ableism/Temporarily Able-Bodied ...

Brooke, who was mentored as UCSF doctoral student by Carroll and as Health & Aging Policy Fellow by Bob, discussed issues relating to long-term care (LTC) and long-term services and supports (LTSS) (overburdened informal caregivers; underpaid and trained formal caregivers; lack of regulations; bias toward institutional care; lack of coordination across settings; poor quality of care) and policies (CLASS, LTC Commission; LTSS expansion through Medicaid waivers, duals demo, person-centered care, care coordination, and expanded benefits).

Bob noted that Congressional budget was repudiation of Trump priorities (particularly increased funding) and gave kudos to the power of grassroots advocacy—authentic voices can change policy! His contributions to Aging A-Z: Elder Justice Act (seven year effort to pass, needed because data drives dollars) and White House Conference on Aging (which he participated in 1981, 1995, 2005 and 2015). 

SF LTC Ombudsman Program Director Benson Nadell (standing in line for microphone to ask question), Tony Sarmiento (former Executive Director of Senior Service America, Inc. and a presenter at Charting Your Course in Retirement: A Perfect Storm or a Rainbow?) and SF DAAS Executive Director Shireen McSpadden (who later presented on The Dignity Fund: An Idea Whose Time Had Come). 

DAAS Nutritionist (and awesome internship preceptor!) Linda Lau and Self-Help for Elderly Assistant Director Robert Chan presented Let’s Do CHAMPSS: An Effective Nutrition Program with Restaurants and Cafes (Aging in Community).  Since 2014, older adults in San Francisco have option to dine from RD-approved menus on weekdays at restaurants participating in Choosing Healthy Appetizing Meal Plan Solutions for Seniors (CHAMPSS) -- alternative to dining at congregate lunch sites, which have limited serving times and locations in City’s west side (CHAMPSS sites are Chinese restaurants in Parkside, Outer Sunset, and Excelsior). 

Alzheimer’s Association Family Support Coordinator Rachel Main co-presented with Elder Care Alliance, Movie Moments: A Dementia-Inclusive Event Bridging Film and Community.   

Advocating for Profession of Gerontology: Accrediting Programs and Credentialing Graduates by Donna Schafer, who is involved in both, as Board of Governors member of Accreditation for Gerontology Education Council (AGEC) and as Executive Director of National Association for Professional Gerontologists (NAPG).  According to Donna, newly formed AGEC has received applications from USC and American River College, and more established NAPG (founded in 2005) has 300+ members. 

Brain Fitness Forum: Organizing a Successful Community Event by Shiva Schulz, Adult Programs Manager at Jewish Community Center of San Francisco.  In addition to Brain Fitness (June), Shiva also organizes Embracing the Journey (aka End-of-Life, November), Art of Financial Well-Being (winter), and Art of Aging Gracefully (April) – always great sources of material for my blog!

UCSF doctoral student Jarmin Yeh moderated High-Touch in a Tech City: Regarding People-Place Relationships in Designing a San Francisco for All (Technology, Accessibility & Transportation) with presenters who work to create and sustain age-friendly communities based on placemaking.  

Cathy Spensley, Felton Institute Senior Division Director: Felton received a Metta Fund grant to reach isolated older adults with histories of trauma, through Visitacion Valley Wellness, which brought together African-American and Chinese communities through back-pack giveaway and surveys at food pantries. 

Susi Stadler, At Home With Growing Older Executive Director and Architect, talked about age-friendly design through Aging 360 Workshops to adapt homes to personal needs as one ages. 

Dan Gillette, CITRIS Senior Research Scientist, discussed development of design for all: autocratic, ergonomic, user-centered, universal, inclusive, empathic (Patricia Moore) and co-design (done together).

Anne Hinton, SF Tech Council Co-Chair (also former DAAS Executive Director) talked about the work of SF Tech Council, hosted by Community Living Campaign, to advance digital inclusion for older adults and people with disabilities. 

Marie Jobling, Community Living Campaign (CLC) Executive Director, reminded us of studies showing that for people to age in place, 20% comes from formal services and 80% from informal support (family, friends, neighbors).  She shared lessons learned from Community Connectors who are catalysts for neighborhood projects that turn strangers into neighbors, and neighbors into friends: weaving community is an art (plant seeds of hope in garden parties); poverty takes many forms, but social capital abounds (SF ReServe employment, food delivery networks); technology and social media are changing everything; standing together, we can make a difference; and independence is knowing who you can depend on.  

[We can depend on Marie and her work with CLC in making San Francisco more age-friendly through advocacy, community building, computer training, healthy aging workshops, etc.  As a student, I could always count on CLC as my subject for research papers to earn “A” grades!  Thrilled for CLC’s Cayuga Community Connectors to receive n4a Aging Achievement Award, and DAAS’ funding Community Connector model (connector with friends and neighbors), designed to accommodate low-income seniors.  DAAS has subsidized the Village model (staff with members and volunteers), but will begin to require minimum $120 annual membership from Village members.]

Discussant June Fisher, Aging 2.0 Chief Elder Officer, emphasized the empowerment theme: design with, not for, older adults and respect for autonomy; she also shared her list of A’s for Aging on screen. 

Robin Roth and Dorothy Quock after screening of Forever, Chinatown  (2016 documentary) about octogenarian artist Frank Wong, who spent the past four decades recreating memories of his youth by building intricate miniature dioramas of old San Francisco Chinatown.  He has donated his Chinatown dioramas to Chinese Historical Society of America. 

Robin taught Health and Aging at City College of San Francisco, which inspired me to pursue graduate studies in gerontology.  As Co-Chair of San Francisco Hepatitis C Task Force, Robin presented a session, 1 in 30 Baby Boomers Has Hep C: Learn What You Can Do (which I missed due to my volunteer duty on Monday) and starred in public service announcement video.

Chinatown Pretty Dorothy, dressed in apron made from 100-pound rice sack (fitting as her father worked delivering rice), met Frank while she was a Chinatown Wok Wiz tour guide. 

Legacy Film Festival on Aging (LFFoA) Executive Director Sheila Malkind introduced Dial-A-Ride, a British film with English subtitles for greater accessibility (also shown at last year's LFFoA).  This year's LFFoA will be held September 14-16, 2018, in San Francisco!

Grassroots Palliative Care: Fully Engaging Our Communities with Ken Ross (Elisabeth Kubler-Ross Foundation), Susan Barber (Mission Hospice & Home Care), Nate Hinerman (Golden Gate University), and Redwing Keyssar (Jewish Family & Children’s Services).

Senior Division Director Cathy Spensley and Director of Geriatric Mental Health Ed Fowler, both of Felton Institute, discussed Integrating Mental Health and Aging Services to Create Change (Mental Health) based on their Geriatric Mental Health Model.

Policy & Advocacy

My required Volunteer Orientation and Training began on the first day of the conference at 7:30 am, and lasted only 10 minutes.  I received my assignment as room monitor at Imperial AB, which featured all Policy sessions!  Since I didn’t have to report to my assigned room until 8:30 am, I stopped by a table in the lobby level to pick-up printed materials on caregiving, and was warmly invited to the meeting room…

Wow, hearty protein-rich breakfast at 12^th Annual National Conference of Caregiver Advocates: Engaging Caregivers Across the Lifespan.  

By 8:30 am, I reported to my assigned room, where my role as monitor involved checking conference badges and taking attendance.  Because the registration line to pick-up conference materials (including badges) was so long and registrants didn’t want to be late for 9 am session, I had to write names of registrants without conference badges for Innovation for Impact: What We Have Learned featuring AARP Foundation staff: Paolo Narciso (Income Security), Kim Perry (Food Security), Marc McDonald (Grants), Zac Leverenz (Impact) and Emily Allen (Programs). 

West Health’s Aging and Policy Summit presented survey results about Americans’ Views of Healthcare Costs, Coverage and Policy, based on a national poll conducted by NORC at University of Chicago and West Health Institute:

·       40% skip recommended medical test/treatment because of cost

·       44% don’t go to a doctor when sick/injured because of cost

·       30% had to choose between paying for medical bills or basic necessities like food, heating or housing

·       More people fear medical bills that come with serious illness (40%) than fear illness itself (33%)

·       Support for greater spending on Medicare and Social Security grows with age (no surprise)

Panel proposed 3 solutions:

·       End individual, procedure-oriented fee for service in favor of population-based value metric; HCBS also need to end silo funding based on units of service, which is a variation of fee for service

·       Medicare should negotiate pricing of prescription drugs, including generic v. brand name

·       Increase price transparency

Comments during Q&A:

·       Consumer has burden to use Medicare Plan Finder website for price comparison; only 10% change plans, yet usually lose savings when they keep the same plan.

·       Learn from states: spend money on social services to save money on healthcare

·       Single-payer healthcare is galvanizing sound bites like an easy solution v. value-based payer model

·       Eligibility for LTSS under Medicaid work requirement?  

West Health partnered with SCAN Foundation to launch “We Stand With Seniors” campaign on the specific challenges faced by seniors and their families in accessing high-quality, affordable healthcare, dental care and supportive services.  In the months leading up to the election, the campaign urges candidates running for governor and other statewide offices to develop a concrete plan to provide for healthcare needs of vulnerable seniors.

Integrating Social Services and Home-Based Primary Care for Older Adults (Policy & Advocacy), as alternative to hospital-intensive system, based on presenters’ article, “Integrating Social Services and Home-Based Primary Care for High-Risk Patients,” published in Population Health Management. 

·       Michael Gelder, Center for Research on Health & Aging member, talked about ACA moving from fee for service to pay for value, shifting care closer to patients’ homes while combining traditional medical care and HCBS—these are most pressing for the sickest, highest cost, end-of-life and homebound patients; savings would be realized 5-10 years (versus current emphasis on short-term); financial incentives to integrate social services into primary care include capitation (e.g., Program of All-Inclusive Care (PACE) for Medicare-Medicaid dual eligibles based on adult day health center model, started in San Francisco, now in 29 states, but not scalable as national model because resource intensive and difficult in rural settings).

·       Robyn Golden, Rush University Medical Center VP, discussed the importance of seeing person’s home situation, potential for teamwork and care coordination facilitated by tech surveillance; challenge is “internal medical doctor does not talk to psychiatrist, surgeons don’t talk to anyone”; though it is more effective to meet people where they are in their homes, there is stigma associated with home visits. 

Federal Funding for Aging Programs: What’s Ahead and What We Can Do about It (Policy & Advocacy)

·       Amy Gotwals, n4a Public Policy & External Affairs Chief: turnaround was stunner, bipartisan Budget Act lifted caps to increase non-discretionary domestic (NDD) funding levels! Trump eliminations avoided, programs with most advocacy rewarded—Older Americans Act programs saw big increases! Aging in place requires resources and options so need to educate and fight cuts to vital programs in budget!

·       Lindsey Copeland, Medicare Rights Center Federal Policy Director: threat to Medicaid is threat to Medicare, dual eligibles are vulnerable.  Medicaid important to 6 million low-income seniors + 10 million people with disabilities = 62% of Medicaid spending; 2/3 of seniors in nursing homes rely on Medicaid = LTSS. Need year-round appropriations advocacy! 

ASA Chairs’ Lecture—Provocateurs and Predictions: A Brave New World for Aging with moderator Joanne Handy (Trinity Continuing Care Board Chair) and panelists who provided their insights on disruptors in aging services:

·       Richard Browdie (Benjamin Rose Institute on Aging President & CEO): New ACL Secretary Lance Robertson is “bright light” in Trump Administration; President’s threats to cut aging programs scared a lot and reignited advocacy; trend to medicalize social determinants of health; reframe aging might be a way of “finding new words to make problem go away.”

·       Robyn Golden (Rush University Medical Center VP): poked fun at “digital solution” to social determinants of health; Amazon hired geriatrician, need to cut silos of care; not enough disruption in housing and caregiving; need to change view that kids, not old, represent hope--need to be comfortable talking about future, how can still have meaning in old age to rid stigma/fear.

·       John Feather (Grantmakers in Aging CEO): millennials are not buying cars, so auto industry has transformed to mobility company, creating personal devices for people with disabilities to move; immigration reform to address labor shortage—majority of MDs serving rural communities are foreign born because can’t attract Americans to do this work.

Diversity & Cultures 

Kevin Prindiville, Justice in Aging Executive Director, began session, Fifty and Forgotten: Focus on Wealth and Women in Their Fifties (Diversity & Cultures of Aging), stating that women are disproportionately impacted by poverty (as detailed in the report, Aging, Women and Poverty: We Must Do More) due to systemic causes:  unequal pay (women earn 80 cents on men’s dollar); caregiving (75% of women are caregivers, often underpaid); longevity (women’s life expectancy 81.2 v. men’s 76.4); and higher healthcare costs. 

Jhumpa Bhattacharya, Insight Center for Community Economic Development (CCED) Director of Racial Equity and Strategy, suggested wealth as the broader issue (than income) providing a holistic view of economic security as it is passed down generations, showing how economic injustices of past connect to the present and future.  Women experience a motherhood penalty from time spent out of the labor force or working part-time for caregiving, as there is no paid family leave; men in pre-retirement age (50-64) have 1-1/2 times the wealth of comparable women-- $60,500 v. $38,200, according to Women and Wealth (2015) study by Mariko Chang.  Also, women, especially Black and Latinx, are less likely to have access to the wealth escalator (employee benefits, government benefits, favorable tax breaks to turn income into wealth more quickly).

Anne Price, Insight CCED President, added the impact of wealth stripping (schemes to extract wealth from communities, e.g., payday lending).  Therefore, she concluded need to focus on wealth building/wealth stripping using an intergenerational approach.

Jhumpa noted that millennial women do not fare better, given student loans, gig economy with no benefits, and fewer entering STEM careers than Gen X (possibly due to tech’s frat culture).

Courageous Aging: The Extraordinary Struggle to Maintain an Ordinary Life (Diversity & Cultures of Aging) featured panel discussion on diverse elders: 

·       Daniel Maher (NP, Rush University Senior Care) on Disability: 5% of older people are in LTC facilities, 80% of older people have at least one chronic condition, 13% of older household population with a disability lived in poverty, 13% of older population uses 40% of prescriptions, more than 25% of older people fall each year, but less than half tell their doctor, over 95% of hip fractures are caused by falling (usually by falling sideways).

·       Randella Bluehouse (Executive Director, National Indian Council on Aging)  on American Indians: 2.6 million American Indian/Alaskan Natives (AI/AN) age 55+, who represent 44% of total AI/AN population; diverse group with 573 federally recognized tribes and 229 tribes/villages in Alaska; most live outside tribal areas, face discrimination/hate crimes in border towns; challenges include geographic isolation, poverty, medically underserved, digital divide, lack of phone connectivity, poor infrastructure, access to culturally approriate services.

·       Leland Kiang (Information & Referral Manager, IONA Senior Services) mentioned need to rethink community, such as choir or bingo participation accessible by phone.  (Missed this first presenter due to room monitor outside who initially refused to allow me to enter room, which she claimed to be standing room only; yet after much coaxing, she finally allowed me to open door and I easily found empty chairs in front rows to sit.)

·       Imani Woody (President & CEO, Mary’s House for Older Adults) on Social Issues of LGBT Elders: 3 million LGBT elders (age 55+) in U.S., more likely to be childless (90% LGBT elders have no children v. 20% overall older adult population) and living alone; survived by scanning for clues (countless put in mental institutions because homosexuality was classified as mental disorder until 1973, when it was replaced by sexual orientation disturbance until 1987); by ignoring/avoiding LGBT issues, providers contribute to isolation—indications are Gen Silent that fought hardest to come out is going back into closet to survive as they face housing discrimination, so she wears LGBT Pride Rainbow pin to create visibly welcoming and inclusive environment; aging and social services need to dismantle institutionalized ageism, heterosexism, and classism through policy, marketing and staffing; instead of “disrupt” aging, embrace aging! (audience applause) When she quoted Bette Davis’ “aging ain’t for sissies,” someone called out, “what’s wrong with being a sissy?”

·       Tom Callahan (Director of Senior Living Resources, Archer Law Office) on Economic Issues of LGBTQ Elders: LGBT adults face employment discrimination and earn less than heterosexual counterparts; 41% LGBT struggle financially, spending (Kardashian effect) but not saving money; lesbians’ greatest fear is they will run out of money before they die; gay men’s greatest fear is they will become disabled and dependent on someone else.  His advice was to plan for aging, which will be there sooner or later, and do not be afraid to ask for help.

How to Manage and Promote a Lifelong Learning Program in the Modern World (Lifelong Learning)

·       Linda Maurice (Lifelong Learning Institute Director, Nova Southeastern University) on Reaching the New Generation of Lifelong Learners: Marketing, Advertising, Social Media and Networking.  Ideas for getting word out free: community calendars, social media, word of mouth, networking groups, partnerships, inhouse brochures/flyers, peer incentives.

·       Sandra von Doetinchem (Founder, Silverlearning.org) on Exploring New Target Groups: Lifelong Learning in the Fourth Age. Lifelong learning programs typically target older adults who are female, with higher education/socio-economic background, in their 60s and 70s, healthy, active and mobile; her presentation focused on “others” who are in Fourth Age (age 80+ or 85+) with physiological (multimorbidity, immobility, sense impairments), cognitive/psychological (cognitive decline, prevalence of dementia, loneliness, depression) and social (isolation) risk factors.  Access issues to consider include transportation, programs held in living environment, distance learning (phone, online, TV).

·       Janna Overstreet (Director, Ringling College Lifelong Learning Academy) on Managing Purposefully: mission to build community—8 million over age 50 are socially isolated, staff doing more with less, more faculty/volunteers needed; practice servant leadership—hear what people have to say; active fundraising gives others opportunity to invest in what they believe in and leave legacy. 

With Lifelong Learning Consultant Hope Levy, attended Roundtable, How to Plan Events that are Accessible to All, presented by Irene Stewart, Aging & Disability Services Planner, Seattle Human Services Department. ADA in a nutshell – best conference handouts and practical tips, with emphasis on facilitating “meaningful experience” for attendees.

Journalist Kerry Hannon moderated Solo Aging: 360-Degree Perspective (Aging in Community). 

·       Wendi Burkhardt, Silvernest Founder and CEO, explained that as a 52-year-old with no children, she developed her “Golden Girls 2.0” business idea after her widowed mother faced isolation and invited a friend to move in.  This sparked her to create fee-based online roommate matching service that pairs boomer generation home residents (owners/renters) with prospective housemates of any age.  Her business has 40,000 users, with 70% age 65+ women who live alone.

·       Maria Carney, Northwell Health Geriatric Chief MD, was an internist/geriatrician for 20 years in a hospital, where she increasingly saw patients who were alone and needed to involve a social worker earlier to bring in resources for decision-making and caregiving needs, as treatment plans require identification of a social network.  She shared 10 steps in caring for an elder orphan (anyone can be in this situation): identify all medical issues; identify cognitive and functional abilities; obtain detailed social support information; create manageable & realistic treatment plan; utilize service delivery to home; make safety and injury prevention a priority—address safety & injury issues; address goals of care & advance directives; understand privacy issues (HIPAA); assess decision-making capacity and involve individual as much as possible; determine if guardianship is needed, and if so, seek it.  Dr. Carney said advice was practical, noting likelihood of chronic illness in old age when we will need someone to care for us, and introverts could express their “time alone” orientation.

·       Carol Marak started Elder Orphan Facebook group for people aging alone to exchange resources on issues relating to housing, rides, health and medical decisions, social support to reduce isolation.  She also wanted to build awareness because worlds shrink as people die, so we need to create relationships and find out who will be like family you can trust with your life.

·       Sara Zeff Geber, Life Encore founder and author of Essential Retirement Planning for Solo Agers: A Retirement and Aging Roadmap for Single and Childless Adults (2018), noted that U.S. General Accounting Office predicts by 2020, the number of solo agers (no living children or siblings) will be 1.2 million—almost twice the 1990 figure.  She advised solo agers—while still healthy, able-bodied in their 50s and 60s—to get started building social support, “at least join a village because your world begins to shrink when you no longer drive.”  She also provided a Solo Agers’ Life Plan checklist: have conversations with relatives, close friends, spouse; visit experts (financial advisor, attorney, fiduciary, insurance agent, physician); put it in writing (POA-finances and healthcare, will and/or trust, advance directive for healthcare); and explore options (research online, visit potential communities, talk to people with experience).  As a do-it-yourself type, I thought her checklist applied to anyone.      

·       F. Scott Moody started K4Connect CEO for people with disabilities to live simpler (single application to integrate smart technologies), healthier (activity tracker, blood pressure monitor, telehealth) and happier (connect with video/audio chat).  He said technology is not hard to grasp, problem is poor design like teenage clothing does not fit older people.

Networking + Receptions

Since I have been focused on working with homebound older adults, trying to promote aging in community and prevent institutionalization in a locked facility or nursing home, I miss being out in the community … so took full advantage of the conference’s receptions, especially to reunite with classmates! 

Meet-up with SFSU Gerontology classmates Diane, Mary and Brittany before Opening General Session. 

Meet-up with SFSU Gerontology alumna Hope at Exhibit Hall 

Hope and Sheila at Exhibit Hall

Exhibit Reception featured grilled veggies, pita bread and Mediterranean dips, cheese and crackers.  Similar fare throughout conference receptions, so this is about the only food porn in this blog post! 

Andrew Scharlach chatting with Tony Sarmiento at UC Berkeley Social Welfare exhibit booth. 

SFSU Gerontology alumna Ann Colichidas of Vitality for Life, Sheila and Watson Fellow/filmmaker Devin Reese 

Victor (holding poster, Culturally Adaptive Digital Avatars for Psychosocial and Self-Management Support of High-Risk Elders) and Brittany Wang of Gerijoy with classmate Maggie outside Hilton Union Square.  

SF Senior Center Director Sue Horst and Program Coordinator Crystal Booth; 30^th Street Senior Center Director Valorie Villela (presented on Bullying Elimination Training Program for Staff and Older Adults); and Senior Center without Walls Director Amber Carroll (presented on Without Walls: Programming Over the Phone for Older Adults and Increasing Connection, One Call at a Time).

SFSU classmates Mary and Diane with UCB MSW alum Darrick Lam, CEO of ACC Senior Services (and former ACL Program Specialist who supervised my SFSU Gerontology internship) at SF Senior Center reception for UC Berkeley School of Social Welfare celebration of its 50th Anniversary of MSW Aging Services and upcoming retirement of Professor Andrew Scharlach.   

Family Caregiver Alliance Executive Director Kathy Kelly and ASA Chair Bob Blancato at 10^th Anniversary of Rosalinde Gilbert Innovations in Alzheimer’s Disease Caregiving Legacy Awards reception at Parc 55. 

SFSU Gerontology classmates Mary, Brittany, Lois and Diane at Aging 2.0 reception at Rex Hotel.

Women’s History Month: "Nevertheless, She Persisted"

At age 96, Betty Reid Soskin is the oldest U.S. Park Ranger.  As field representative for California State Assemblywomen, she was actively involved in planning for Rosie the Riveter/WWII Home Front National Historical Park, focusing on the contributions of women to the War effort.  Earlier this month, she was at the SF Main Library to discuss her new book, Sign My Name To Freedom: A Memoir of a Pioneering Life (2018), based on selections from her blog, Cbreaux:

I've suspected for a long time that much of the interest in my work tends to lie in the fact that I'm such a late bloomer.  Though I cannot say that I didn't work -- I'd been a stay-at-home mom for the first half only but after having helped to start our little family business in Berkeley until motherhood took over my life.  Didn't have my first significant formal job until I was almost fifty, and have been working ever since.  That the National Park Service hired me as a permanent park ranger at 85 continues to bring smiles to the faces of the elders who stop in, especially when I playfully suggest that they keep their resumes updated, "you never know when the call will come!"