William A. Vega Provost Professor Executive Director

1. Successful “Aging in Place: How do we attain it?CalSWEC: California Social Work Education CenterSacramento, California, September 19, 2012 William A. Vega Provost Professor Executive Director

2. U.S. Population Over 65 An estimated 39 million in 2008 Projected to reach 72 million by 2030 (Federal Interagency Forum on Aging-Related Statistics, 2010)

3. U.S. Latino Population Over 65 Expected to increase six fold by 2030 Fastest growing ethnic sub-group of elders (Bureau of the Census, 2008; Federal Interagency Forum on Aging-Related Statistics, 2010)

4. “Aging in Place” • The ability to retain an appropriate level of independent living in one’s community and place of residence and personal control over one’s lifestyle

5. Latinos “Aging in Place” • Current practices in human services, public health and health care fail to promote and sustain optimal functioning for Latino elders to “age in place” in low-income communities • Disparities research has shown that inequality produces disproportionate hardships in physical and mental health in later life for Latinos (Vega et al., 2009)

6. Recession Impact Household wealth among Latinos declined more sharply than among either Blacks or Whites between 2005 and 2009. Food insecurity increased to 32.1% compared to 23.8% previous to recession for Latinos Even though Latinos are 16% of the population, 6.1 million children are in poverty, an increase of 36.1%, compared to 4.4 million Black (up 11.7%), and 5.0 million White (up 17.6%) children

7. Three Domains of Effect Quality of Life

8. Factors Threatening Domains • The fundamental challenge facing American society is how to reconcile enduring economic inequality with the need to supply a higher quality of life and improved human services for low-income elders (Orr et al., 2003) • Latinos increasingly live in ethnically segregated, high-risk communities

9. The Best News You Never Heard: Trends in the Leading Causes of Death,Los Angeles County, 1999-2009 Rate (per 100,000) Age-adjusted to year 2000 U.S. standard population

10. Death Rate: Latinos vs All Persons Data based on death certificates

12. Community Context • The role of community in successful “aging in place” for low-income Latinos has received little attention in research • A community that supports “aging in place” provides a safe environment for exercise, recreation, socialization, sufficient access to preventative and health and human services, various means to receive adequate nutrition, and opportunities for personal growth

13. Inequality of Services • Residentially segregated Latino communities exemplify persistent structured inequality in American society (Lawrence, Sutton, Kubisch, Susi, Fulbright-Anderson, 2004) • Is it possible to improve public and private institutions and services, as well as sustain or increase the social capital of low-income communities, without a commensurate improvement in the financial status of residents?

14. L.A.MINORITY AGING SURVEY Purpose: to identify living circumstances and health status of non-institutionalized Latino and African American elders living in disadvantaged neighborhoods in Los Angeles.

15. what changes have happened due to country’s economic situation? someone in family lost a job and has been unable to find another (38%) had to sell something important or use up savings (30%) have been unable to pay bills that were able to pay before (28%) have lost their usual source of income (25%) someone in house lost a job and had to take a lower-paying one (16%) someone had to move in for economic reasons (14%) had to move from own home to live somewhere else (13%)

17. Quality of life components for aging in place... social integration living with others communication with friends and relatives intimate relationship community shared values cooperation and assistance sense of belonging infrastructure transportation safety accessibility sense of control capacity to effect desired change

18. Quality of life components for aging in place... social integration living with others communication with friends and relatives intimate relationship community shared values cooperation and assistance sense of belonging infrastructure transportation safety accessibility sense of control capacity to effect desired change

20. highly similar desire for improvement in all areas asked about: transportation for the elderly (90% “very important”) assistive medical devices (88% “very important”) home health care/nurse (79% “very important”) homemaker services (76% “very important”) in-home delivered meals (65% “very important”)

21. Protective Effects of Social Support • Decades of research has shown that individuals benefit from adequate social support over their entire life course (Umberson, Crosnoe, & Reczek, 2010) • The well-documented salutary effects of social support on emotional well-being may offset the deficits in community resources among some Latinos, especially immigrants

22. Trends in nursing home care (SNFs) • Demand is decreasing for non-Hispanic Whites and increasing for African Americans and Latinos • Availability is increasing for non-Hispanic Whites due to growth of the private sectors providers • Availability is dropping for Latinos and African Americans due to loss of public pay providers and few replacement providers

23. Health and Human Services • Low-income Latinos face major challenges in access to and quality of human services and medical care received, especially for chronic diseases (Beal, Hernandez, & Doty, 2009; Perez, Ang, & Vega, 2009) • The human services system and medical care services systems are poorly integrated and at best tend to provide only short-term patient tracking and management

24. One-Stop Geriatric Services • The Geriatric Day Hospital (GDH) was pioneered in the 20th century by British physicians • The goal is to provide easily accessible services that reach elders where they live, thus fostering independent living by coordinating services of health care professionals with social workers and other community health aides • This approach is intended to provide timely health oversight for patients

25. By the Numbers On nearly 70 percent of their indices, Latinos are receiving substandard care, the worst profile of any U.S. ethnic group (U.S. Department of Health and Human Services [HHS], 2009) Two-thirds of people over 65 who are ineligible for Medicare are Latinos (U.S. Department of Health and Human Services [HHS], 2009)

26. The CLASS Act • Community Living Assistance Services and Support Act (CLASS) Act was the promising legislation of our time to support aging in place • It represented the first thoroughgoing redesign of public policy to address long-term care needs of elders in 50 years • It was dropped from the ACA in Fall 2011 because it was not financially viable as an self supporting program

27. Public Policy and Aging • Community participation is needed to address core determinants of health and well-being of our population, including social determinants directly affecting aging people • National Institutes of Health (NIH) has progressively moved in the direction of community-based research

28. Public Policy and Aging • The ultimate challenge will be to functionally integrate the planning and implementation across three domains that historically have had only coincidental connections • Establishing initiatives that foster community resident participation, and even advocacy, is a basic requirement for effectiveness and successful implementation

29. Health and Sprawl People living in counties marked by sprawling development: Walk less in their leisure time Are more likely to have high blood pressure Have higher body mass indexes Are more likely to be overweight (average 6 pound difference) Ewing R, et al: American Journal of Health Promotion 18(1) Sept/Oct 2003Photo from: http://blog.travelpod.com/travel-photo/arsucasas/1/1267654070/2_rty.jpg/tpod.html

30. CTG Strategy Areas • Five Strategy Areas • Tobacco-free living • Healthy eating and active living • Clinical preventive services • Social and emotional wellness • Healthy and safe environments

31. The California Endowment • Building Healthy Communities • Dedicates nearly 50 percent of its annual giving to a 10-year commitment to 14 high-risk communities across the state of California

32. Strategies for Improving the Physical Environment for Nutrition Source: Public Health Institute

33. Key New Tool –Health Impact Assessment (HIA) HIA is tool for systematically evaluating, synthesizing, and communicating information about potential health impacts for more informed decision-making, especially in other sectors. 33 33

34. Successful “Aging in Place” • The success of the “aging in place” movement will be determined by how successfully policies and programs are implemented • Programs must contend with complex federal, state, county, and city policies and administrative systems

35. The Chain of Effect in health and improving quality of life for low-income disabled seniors Inter-sector planning, organization and financing Macro-system Policy development Model testing and develop- ment, efficacy and effective- ness trials, scaling up Research knowledge Micro-systems Context Processes of elder care Program implementation Design concepts for integrated multi sector community models with practice standards, clinical extended services, upskilled staffing for home assistance, social network and and community stakeholder participation Seniors

36. “Every system is perfectly designed to achieve exactly the results it gets.” - Donald Berwick