HealthyCal.org

By Matt Perry

The day the north tower of the World Trade Centers fell into her office at Lehman Brothers world headquarters, Katy Thomas Fike’s world changed forever.

The night before, as a corporate strategist, she’d been at the global banking giant long past midnight in the midst of another 90-hour week rolling out software as part of a new e-commerce strategy.

In the crazed aftermath of September 11th, Fike fled through the lobby as it became an emergency triage area. Outside, she passed the bodies of suicide jumpers.

During the weeks that followed, Fike spent many hours trying to make sense of the tragedy – and finding her purpose.

“My immediate desire was to talk to people who were alive during World War II, World War I,” says Fike. “I knew talking to someone older would help me digest the world.”

Then her mother sent her the book “Learning from Hannah: Lessons for a Life Worth Living” by revolutionary aging expert Dr. Bill Thomas. Fike spent hours reading and crying while underlining nearly every line, especially this one: “In a human community, the wisdom of the elders grows in direct proportion to the honor and respect accorded to them.”

Fike knew she was heading back toward the life she was meant to lead.

“I just started devouring everything I could find,” she says.

Fike’s admiration for older adults, their wisdom, and unique life experiences was nothing new. At 14, Fike befriended her neighbor Boots, who was diagnosed with end stage cancer. Secretly, Fike sent Boots inspirational quotes and short stories each day with help from the neighborhood mailman. In person, the two women shared great conversations, and Fike felt blessed to have closure around her friend’s eventual death.

After working at Lehman for three more years, in 2004 Fike returned home to Los Angeles to get her doctorate in gerontology at USC. There, she fused her diverse interests in finance, science, and aging to envision a bold future: businesses that used technology to solve the problems of aging.

A complex mix of Type A go-getter and compassionate do-gooder, Fike experienced the isolation of seniors in her own neighborhood, seeing them through their windows eating and watching TV alone. She started a walking group for them, also negotiating a post-walk discount at a local coffee shop.

It was the first time Fike solved an aging problem with an eye towards innovation – in this case, tennis shoes.

Enthralled with the possibilities of technology, Fike decided to pursue this specialty, yet faculty members frequently threw roadblocks her way: “Tell me you’re joking about this,” said one.

Desperate to provide practical solutions, Fike found her patience for academia wearing thin.

“It was very clear that the change I wanted to make in the world – and the people I wanted to meet – wasn’t going to happen there,” she recalls. “I needed to make my academic stuff real.”

So Fike began her own company – Innovate 50 – which consults with businesses targeting adults 50 and over.

At the same time, she joined forces with MBA Stephen Johnston to start Aging 2.0, an innovation network to bridge aging advocates with technology entrepreneurs and design experts, spawning interest from high-profile players like Qualcomm, the Stanford Longevity Center, and AARP.

This January in San Francisco – in a meeting bursting with both intelligence and compassion – Aging 2.0 hosted one in a series of mixers.

Attendees proposed impressively diverse solutions to the problems of aging: financial fraud protection, software for home caregivers, simplified video calling, improved product design, and smoothing the transition from hospitals to long-term care.

This year Aging 2.0 plans an investor conference and incubator to speed products to market.

One of the biggest problems Fike sees is getting past skeptical aging administrators who are both resistant to change and wary of hucksters.

“How do you beta test to your target audience?” she asks. “I think the aging space should be welcoming with open arms these young entrepreneurs who want to bring technology into this space.”

Fike recalls fondly the 300 tech geeks who chased her around a Silicon Valley conference asking “What problems should I solve?”

“We really need to be telling the entrepreneurial community what problems to work on,” says Fike. “We have no idea how technology could really affect seniors’ lives in the fullest extent until we start doing it.”

Fike says the best ideas of all may be hidden away.

“How many great ideas are there in the heads of someone in assisted living?” she wonders.

Ironically, the USC Davis School of Gerontology plans this year to unveil its new Center of Digital Aging, tapping the talents of other schools in computer science, policy, engineering, and design.

Fike will be one of its advisors.

“I was impressed by her enormous compassion, as well her ability to draw from her professional background to create a new path for herself,” says the school’s dean, Dr. Pinchas Cohen. “Katy recognizes the limitless opportunities technology affords older adults.”

Like many others in the wake of 9/11, Fike is thrilled with her new career path.

“I feel so much like it was what I was meant to do.”

Photo: Mrs. Logic/Flickr

By Alexia Underwood
California Health Report

As the US population ages in record numbers, home care workers are becoming part of an increasingly in-demand market. They make an independent life possible for thousands of seniors and people with disabilities, but in the Central Valley and elsewhere across California and the US, they’re barely scraping by themselves.

Many seniors are choosing to stay in their homes for as long as possible, and employing a home care worker – or two – is one way to make this arrangement work. According to a study done by AARP in 2010, more than 90 percent of Americans over 65 would prefer to stay in their homes as they age. This is often referred to as ‘aging in place.’ Melissa Norton of Assured Care, a family-run caregiver agency in Modesto that employs around 30 people, has noticed the growing need in her community for in-home care services. People often choose this route because of the personal attention they receive, and because they are more comfortable in their homes, she said. “They have more of a say of what goes on in their daily lives.”

According to the Bureau of Labor Statistics, the demand for home care workers is swiftly increasing. Home health aides and personal care aides (who do much of the same work but are required to have less training) are among the fastest growing occupations in the nation. The Paraprofessional Healthcare Institute (PHI’s) website states that by 2020, there will be 1.6 million more positions to fill.

Jill McFarlane, 59, employs two home care workers to take care of her 96-year-old father in Turlock. A dairy farmer for more than sixty years, her father recently fell and broke his hip after getting off of a tractor. She lives close by and sees her dad frequently for meals and visits. Though he can’t work anymore, he can still do some of the things he enjoys, and he’s much happier than if he were in a facility, she said. “He says that if he were put in a convalescent home, we would be visiting him in a graveyard now instead of at home.”

But paying for this kind of one-on-one care can be very expensive. Agencies like ResCare, which screen home care workers and offer services ranging from a few hours a week to live-in arrangements, normally charge between $17 and $25 an hour. Medicare will only cover very limited home care help in specific situations, like after a hospital stay. For many seniors and their families, though, hiring in-home help is worth the price.

However, the workers who are allowing our aging population to live out their last years comfortably and independently are among the worst paid in the nation. In California, wages for home care workers fell well below the 2009 federal poverty line, according to PHI. On the national level, home care workers are considered exempt from minimum wage and overtime wage protections, under the Fair Labor Standards Act. President Obama announced his intention to change this law in 2011, but the proposal has stalled. The approximately 2.5 million home care aides in the U.S. are disproportionately women, and many are immigrants or women of color. Almost half receive some type of public assistance, like food stamps or Medicaid.

Typical is the story of a home health aide for an elderly woman in Hughson, a small farming town east of Modesto. The aide, who asked that her name not be used to protect the privacy of her clients, spends her days cooking, cleaning, doing laundry, and helping her client do basic tasks, like walking to the bathroom, bathing, and washing her hair. At night, she reads to her client, gets her medication ready, and helps her take out her teeth. The aide, who is a Certified Nurse’s Assistant (CNA) and has years of experience working as a caregiver in private homes and convalescent homes, gets paid $9 an hour. She works for a caregiving agency, but receives no health insurance or paid holidays. While she enjoys building personal relationships with her clients, the money she earns just isn’t enough for herself and her family. “If it were just me, fine. But I’m supporting two other people. I have two sons who are both living with me,” she said.

Maria Rivera, 36, a former home health aide from Turlock, spent over three years working seven days a week so that she could qualify for health insurance. She divided her time between working at a nursing home and being an in-home caregiver, and made less than $11 an hour at both jobs.

Rivera enjoyed the work, she said. “I like being of service to people who really need it.” But there were plenty of challenges. She had to learn how to not take things to heart, like when one client refused to let her into the house one day over a petty disagreement. “A lot of people have no idea how to care for the elderly. Sometimes it’s like caring for a child, but they know they’re adults and they don’t want to take orders from someone one-third their age,” she said. And the most difficult part, by far, was losing the people she cared for. Watching a recent client’s health deteriorate over time was “devastating.”

There were also other, more day-to-day difficulties – like when the next caregiver from the agency where she worked didn’t show up. “When there’s one person, one caretaker, you can’t take breaks,” she said. “At night, sometimes you’re up every 15 minutes.”

In addition to this, the nursing home work was physically challenging for Rivera, who has congenital scoliosis, and has no cartilage between the discs in her back. In 2005, she had surgery, which required her to put metal rods in her back. One day in March of 2011, after lifting a client at the nursing home, she felt the left rod in her back snap. “I could still move, and walk, but it caused me pain and I couldn’t lift anything,” she said. Finally, in April of the following year, the company’s worker’s compensation fund paid for her to have surgery again and fix the problem.

Now, Rivera is receiving disability payments and living with her parents. Though the demand for home care workers with skills and experience like Rivera will only increase in the coming years, she’s hoping to move on to something more lucrative where there are better opportunities. Her dream career is to be a pharmacist. The median pay for home health aides in 2010 was about $20,000 a year, but pharmacists made over five times that much.

Betty Johnson, pictured in the dining room of the Park Lane Retirement Community in Monterey, is a founder of a support group for widowed people. Photo: Kate Moser/California Health Report

By Kate Moser
California Health Report

When Betty Johnson was widowed for the second time in her life, after her husband’s three-year battle with a rare form of leukemia, she was wracked with grief for a year.

“I knew that feelings can fester,” said Johnson, 92, recalling that period in her life. “I knew that I had to get rid of the choking, suffocating, feeling, the sickening feeling.”

She cried every week of her first year of meeting with a counselor. Throughout her mourning, it was a great help to bare her soul to a trained expert, said Johnson.

A change in the way depression is diagnosed in the bereaved – to be implemented in May by the American Psychiatric Association – could have a particular impact on older people.

After a years-long revision process, the APA is set to publish its revamped Diagnostic and Statistical Manual of Mental Disorders, the first major revision in almost 20 years of the guide to psychiatric diagnoses.

Among the controversial changes to the DSM-5 is its expansion of the diagnosis of depression in people who are newly bereaved. It removes an exception that advised doctors against diagnosing major depression in a patient who has lost a loved one in the past two months, unless that person’s symptoms are severe – if the patient is suicidal, for example.

“What I find is that most older adults I see are dealing with bereavement,” said Martin Skerritt, a licensed clinical social worker at the Community Hospital of the Monterey Peninsula. Skerritt has specialized in care of older people in his 19 years at CHOMP.

Whether it’s a spouse, a friend, a pet or the loss of something as fundamental as eyesight, older people tend to more frequently battle bereavement. Partly because of this, underdiagnosis of depression among older people has been a problem.

While depression affects more than 6 million of the more than 40 million Americans over the age of 65, according to the Geriatric Mental Health Foundation, experts have made a concerted effort to teach the public that it isn’t a normal part of growing old – and that it can be treated.


“Many people, particularly younger but also as we age, see being depressed as a part of aging,” Skerritt said. “It’s not.”

That misconception can be worsened sometimes at the doctor’s office when a patient complains of lack of energy and perhaps vague symptoms. “It can be part of the problem that the clinician may say, ‘Well, you’re 87 years old.’”

Although the new DSM-5 could help address the problem of underdiagnosis of depression among older people, critics worry that it could also now lead to overdiagnosis.

“I personally see bereavement as a very normal part of living, and I don’t like the idea of making it a medical item, especially for seniors, because they probably are faced with bereavement more than any other age group,” said Sheryl Zika, director of wellness and mental health services at Monterey County’s Alliance on Aging. “When you label something depression, you’re making it a disorder. To me, it strips some of the meaning out of the whole process.”

The biggest problem, Zika added, would be if the change to the DSM made it more likely an older person being treated for depression in a physician’s office would be offered antidepressant medication, without expanding access to counseling or psychotherapy.

In her 14 years directing the senior peer counseling program at the Alliance on Aging, Zika has seen seniors struggling with both depression and a host of bereavement issues.

The bereaved can benefit greatly from support for the variety of challenges a fresh loss can create.

“It’s not just that their mood is depressed, but that they have all sorts of life issues they have to work out around that – for example, they have lost a spouse of many years – say it’s a woman who hasn’t been doing the driving, or hasn’t been balancing the checkbook,” Zika said. “In the peer counseling, we’re working with the mood, but we’re also working with what gaps are now in the person’s life – because just giving them medication might help with the mood, but it’s not going to help fill these other gaps in their lives.”

Johnson lost her husband in 1989. In the year after his death, she relied on support from a social worker, Wayne Lavengood, at Community Hospital of the Monterey Peninsula.

“I found that I could hold my crying for once a week until I saw Wayne, and then I went through a whole box of Kleenex,” she said. “Unloading was the key.”

Johnson said she was terribly depressed for about a year, though she was never diagnosed with depression or prescribed anti-depressants.

“Wayne kept saying ‘There’s a light at the end of the tunnel.’”

Things really turned around for Johnson in taking a six-week class for widows that Lavengood helped lead. The group organized speakers to talk to the group about auto repair, traveling alone, health care and finance – any life decision they’d have to face alone without their spouses. After she graduated from the class, she helped to found a Monterey chapter of the support group Widowed Persons Service. Meeting with other widows was instrumental to her healing process.

Lavengood, who’s now retired as the manager of the hospital’s Outpatient Behavioral Health Services, coordinates a class for physicians, nurses and allied health professionals on caring for seniors with chronic conditions through the Monterey Bay Geriatric Resource Center, where he is a board member.

In the class, Lavengood said the physicians are advised to do their best to avoid side effects of antidepressant medication for their elderly patients, because older people tend to be more susceptible to side effects. Much is at stake beyond the discomfort of side effects. Side effect such as dizziness, for example, could lead to a fall – which can be particularly devastating for an older person.

“The challenge to me is to really responsibly differentiate between someone who is depressed and needs medication, and those who might be able to pull it together with help,” Lavengood said. “I would recommend that physicians be very apprehensive about starting a person on a medication just because they’ve lost their husband in the last few months.”

Expanding the number of free grief programs for people would also help, Lavengood said.

Johnson said Lavengood and the group helped jumpstart her life, enabling her to take risks and live fully – from traveling around the world to falling in love again.

“Starting the group was my biggest accomplishment aside from raising my children,” she said.

Leah Bartos
California Health Report

As millions of Californians are projected to gain coverage over the next several years, the independent clinics that have traditionally served the uninsured are in for some big changes. Soon, many more low-income patients are expected to have private insurance, following the roll out of the Affordable Care Act’s signature reforms in 2014.

That’s putting some clinics, like those in the Women’s Health Specialists network, in a quandary. They want to be a part of the system that’s creating a boon of paying patients – but in a way that allows them to hold onto their guiding principles. That will require a balancing act that clinic directors are starting to plan for now, before reforms go into effect full effect in 2014.

For nearly 40 years, Women’s Health Specialists has run its network of nonprofit clinics with a commitment to women’s rights, patient empowerment and education. In 1975, the first of the clinics, then called the Feminist Women’s Health Center, opened in Chico. It was only a couple of years after the landmark Roe v. Wade decision, and abortion services were hard to come by. The health center filled the void.

Women’s Health Specialists now operates half a dozen clinics across Northern California — and for four decades, they’ve done so essentially off the insurance grid, offering services ranging from sexually transmitted disease screenings to mammograms to abortions on a sliding fee scale.

While the clinics have always accepted private insurance, by and large, they’ve been surviving on Medi-Cal and other public funding programs. But now, with changes coming under the Affordable Care Act, independent clinics across California are facing a rare opportunity to join the third-party payer system in a big way.

Shauna Heckert, executive director of Women’s Health Specialists, is fighting for the clinics to be integrated into the new health insurance scheme, as potential subcontractors in existing managed care networks.

Ideally, Heckert said, abortion and birth control would operate as a carve-out service — one where patients would not need pre-authorization from their primary care physician when seeking reproductive health services. Minimizing bureaucratic barriers, she added, is especially important for patients seeking time-sensitive services like abortion.

“We realize that for us to be able to maintain services to women, we’re going to have to play ball with whoever we need to play ball with,” Heckert said of her talks with insurance companies. She acknowledges that it may seem odd for an organization founded on feminist politics, which has traditionally worked outside of networked care, to actively seek an alliance with insurance carriers. “I guess in some worlds they call that strange bedfellows, but it can work.”

Julie Rabinovitz, president and CEO of the California Family Health Council — an organization dedicated to promoting access to sexual and reproductive health care — says that for clinics like Women’s Health Specialists, collaborating with private insurance companies will be imperative.

“For health centers to remain viable and succeed in the future, they’re going to have to,” said Rabinovitz, whose organization helps distribute federal funding to hundreds of clinics in California, including Women’s Health Specialists. She says the clinics can expect to see many of their currently uninsured patients become covered in the near future, which may mean that they can get their services from other providers.

Women’s Health Specialists brings experience in another realm that will be valuable even as more women gain private insurance, she added – issues surrounding patient privacy. Women’s health clinics, Heckert said, are experts when it comes to discretion. Many of the clinics’ patients already go outside their insurance plans in seeking services from Women’s Health Specialists, she said.

For instance, Heckert said, many patients would prefer not to see the same primary care physician that treats their children if they want an STD check or are facing an unwanted pregnancy.

“Women do seek out a different provider for those services, and for good reason,” Heckert said. “These kinds of things are so sensitive, that women have come to rely on independent women’s health providers.”

Other challenges for the potential collaboration with insurance companies will be more ideological than logistical in nature — in particular, navigating the politics of abortion.

“The stigma of abortion has kept most primary care [physicians] from going anywhere near any of the independent clinics that are involved with abortion,” said Cindy Pearson, executive director of the National Women’s Health Network and also on the board of Women’s Health Specialists. She worries that the stigma of abortion may also keep the clinics that provide the procedure from being included in networked care after reform.

Pearson said although abortion is only one of many services these clinics provide — Planned Parenthood, for instance, reports that abortion makes up 3 percent of its services — the political blow-back for offering the procedure can be staggering.

“As long as abortion is opposed by a vocal, aggressive minority, I don’t believe any clinic that provides abortion would be able to re-brand itself as something more palatable,” Pearson said. “Without giving up abortions they would never assuage the critics.”

But this is not discouraging to Heckert. To her, it only proves the need for the specialists to continue to specialize. Since most primary care physicians do not currently provide abortion services, why not avoid duplicating costs and efforts, she says, and let Women’s Health Specialists continue to provide them?

“If things went well, Women’s Health Specialists and other women’s health providers would have a rightful place in the whole health care system,” Heckert said. “I’m not sure that’s going to happen, because sometimes the private insurance companies don’t realize that they need us. The women know they need us, but the health insurance companies don’t.

“If it doesn’t happen well, there will be consequences. There’s only so long a clinic like mine can keep seeing clients without being reimbursed,” she added. “We’re not going to be looking to philanthropy for providing care that should be paid for by insurance companies.”

Also, Rabinovitz points out, not everyone will be covered. As many as 3 to 4 million Californians will remain uninsured through 2019, according to a recent study by the UC Berkeley Labor Center.

That’s one more reason why women’s clinics remain essential, according to Heckert. For Women’s Health Specialists, treating the uninsured is no novelty – and the money from more insured patients will only improve their ability to serve the uninsured.

“We’re already seeing those low-income women. We are very much in touch with what the needs are of women that don’t have health insurance, and never have enough to make their ends meet,” Heckert said.

Hospice of Santa Cruz County gave comprehensive support to Linda Donovan and her late husband Paul during a brief respite in his illness. Paul died in the comfort of his home in 2006. Linda now volunteers as a grief counselor for Hospice.

By Lynn Graebner
California Health Report

Santa Cruz County is home to an intriguing health care mystery: The county spends much less on acute long term care than most of the country.

Santa Cruz’s long term acute care costs for Medicare beneficiaries is a little over 10 percent of the national average, according to preliminary data from the Centers for Medicare & Medicaid Services (CMS).

Long term acute care, or care for patients requiring ongoing medical care but who are not sick enough for a traditional hospital, costs $17 in Santa Cruz County on a per capita basis. The national average is $156 per capita, according to CMS, which is in the process of validating these numbers for communities nationwide.

Given the huge cost discrepancy between the county and the rest of the country, the state’s Medicare quality improvement organization is looking into what Santa Cruz is doing right – and if their practices could be replicated across the U.S.

The organization is collaborating with the Health Improvement Partnership of Santa Cruz County, which has created a study team of health-care providers and community members to get to the bottom of why this county accounts for such a small amount of Medicare long term acute care dollars.

A seemingly obvious answer is the county’s lack of a long term acute care hospital. These hospitals serve patients for 25 days or longer who have had a stroke, cardiac or breathing failure, spinal cord or head injury, a serious infection or other acute or chronic condition.

But some communities without long term acute care hospitals still have higher long term acute care costs than Santa Cruz, said Andrea Silvey, chief quality improvement officer of Health Services Advisory Group Inc. of California the state’s Medicare Quality Improvement Organization.

Patients in those regions are not necessarily getting better care than Santa Cruz residents, Silvey said. If patients were getting insufficient care, they would be landing back in traditional hospitals. That’s not the case in Santa Cruz.

Instead, the region had 30 percent fewer admissions than the national average in 2011. They also had 44 percent fewer readmissions 30 days after patients left the hospital, CMS reported.

One possible reason for the lower costs: The closest long term acute care hospital is an hour away from Santa Cruz, in San Leandro. The distance forces a deliberate decision to move a patient away from family and emotional support, said Dr. Robert Quinn, medical director rehabilitation services at Dominican Hospital in Santa Cruz. He suspects that’s a strong motivator for keeping sick family members at home.

Quinn has a patient in his 40s who is on a ventilator, he said, and his 80-year-old parents care for him. Other patients disabled by a spinal cord injury or stroke may need a ventilator, bowel and bladder care and feeding tubes, he added, but most of them don’t require 24-hour professional help. They need a limited amount of nursing care and physician oversight, but they could remain at home if a family member were able to do around-the-clock care. In-Home Support Services of Santa Cruz County pays family members just above minimum wage to do that, he said.

While few Santa Cruz Medicare beneficiaries are using long term acute care hospitals, they are using hospice and palliative care widely. Hospice is the only Medicare benefit where Santa Cruz surpasses the state and national average cost per Medicare beneficiary, CMS reported.

Hospice is a prime example of the support that exists in the community for families who choose to care for loved ones at home.

Linda Donovan’s family brought in Hospice of Santa Cruz County when her husband, Paul, suffering from cancer, wasn’t responding well to chemotherapy. They enjoyed a brief period when he got much better, and they had close to a normal life again, Donovan said.

Oxygen and medication were delivered, volunteers came to massage Paul and stay with him so Linda could leave the house. A chaplain counseled him, a social worker helped with the
administrative tasks and Linda received grief support. Paul died at home in May of 2006.

“If I didn’t have hospice, I wouldn’t have had that quality time with him,” said Donovan, who now volunteers her time to do grief support work for hospice.

“This community is doing a heroic job with hospice and advance directives,” said Dr. Lawrence deGhetaldi, president of Palo Alto Medical Foundation’s (PAMF) Santa Cruz division. And by intervening early with palliative care, people are living longer, he said.

Palliative care is provided by a team of doctors, nurses and others who work with a patient’s primary doctors to provide an extra layer of support for people with a serious illness.

Sharon Tapper, chief of staff at Dominican Hospital in Santa Cruz, established an out-patient palliative care pilot program in Santa Cruz in 2011. Medicare chose Tapper as an Innovation Adviser in January of 2012 for helping to move palliative care beyond hospital walls and out into the community where patients live.

Many candidates for long term acute care hospitals can live indefinitely. But for some it means a tough decision between getting some aggressive long-term acute care that will improve their quality of life for a brief time or calling in hospice or palliative care to ease pain and suffering for whatever time they have left. And it may be that patients and providers need to understand more about what these specialized hospitals offer to make an informed choice.

Certainly there is room for more education about these hospitals, said Kelli Cole, chief executive officer of Kindred Hospital-San Francisco Bay Area in San Leandro, the closest long term acute care hospital to Santa Cruz.

She wonders if patients are not being offered the opportunity to go to a specialty hospital because their health-care provider may not be knowledgeable about them, or the family may be resistant to the distance, she said.

“Maybe the patient could have longer quality of life if they were to go to a long term acute care hospital,” she said. “I’ve seen so many scenarios where a week into the stay the patient is off the ventilator.”

Cole envisions a time when long term acute care could become out-patient care, enabling more patients to use it.

It’s that type of innovation that Santa Cruz embraces as their changes to palliative care suggest.

“The community is made up of a lot of people willing to step into a leadership role to address issues in ways that may be different from the usual way,” Silvey said.