Keeping The Elderly Independent in San Francisco

John Mendelson, MD in consultation with members of SF Adult Day Health Network

Old Folks At Home

In cities like San Francisco, there are increasing numbers of frail elders. Despite their many chronic illnesses, these elders are living longer lives. Most of these people want to remain living in their own homes for as long as possible.

There is nothing new about this desire. What is new is the challenge it poses for the family, physician and the elders themselves. Living independently poses several challenges for even the most resourceful of frail elders. Often, there are no grown children nearby to take care of them. Living at home means living alone, or with a spouse who is also ill and exhausted by care giving responsibilities.

Two case stories illustrate some of the problems seen in this population. Mr. Andrews is 85 years old, blind, demented and crippled with arthritis. His wife at 83 is diabetic, obese and exhausted with caring for her husband but she is determined not to send him off to a nursing home. They live in a senior housing project on an SSI income ($740 per month) with MediCal benefits.

Mr. Bond is a 92-year-old home-bound man with Parkinson's Disease, dependent on a walker for safe ambulation. Mrs. Bond, her husband's primary care giver, died unexpectedly last week from a myocardial infarction. One week after the death of Mrs. Bond, her husband's physician gets a phone call from the daughter who lives in New York. She is concerned because there is no one to take care of her father, who is frail and stubborn. The family has money, but doesn't know where to get help. The daughter has promised never to suggest a nursing home for her father, but she cannot take him to her one-room apartment in Manhattan either.

These are tough challenges for everyone involved. Fortunately, others are responding to the challenge as well, As we all struggle to cope with too many patients and too little reimbursement, we can utilize community-based programs specializing in services that enable our chronically ill and aged patients to remain independent and living in their own homes. Core programs provide information and referral (I&R), case management, money management, in-home support services, adult day care and para-transit services.

Information and Referral

Helplink is the name of the I&R service run by United Way and is the simplest source of information for frail elders and their families. A single phone number, 415/773-0111, reaches trained staff with computerized information about available services, where they are located, who is eligible and how to reach them. Helplink covers services for all ages in San Francisco and is available 24 hours a day.

Specializing in information for elders are the ten neighborhood-based Senior Centrals. Here again, a single phone number, 415/626-1033, connects you to the Senior Information and Referral line, which will direct you to the Senior Central closest to the patient's home, where paid and volunteer staff are trained in local resources and how to access them. The Senior Centrals cover most of the languages and cultural variations found in San Franciscans. Both these I&R resources are free to all.

Both Mrs. Andrews, the wife in the South of Market, and Ms. Bond, the daughter in New York, can use these resources immediately.

Case Management

Case managers can be trained social workers, RNs or para-professionals. In all cases they know how to hook up disabled persons with appropriate community services. Some HMOs include case management services in the expectation that rational referrals may keep acute care costs down. Middle-income citizens can pay the Goldman Institute on Aging Eldercare program for case management (415/750-4141, ext. 312). This would be a good resource for Ms. Bond. A case manager will go to her father's home immediately, assess his situation and help him to enroll in useful services.

Several non-profit neighborhood agencies run case management programs, serving low income consumers. Helplink can identify the one in Mrs. Andrew's neighborhood. There also may be a resident services advisor in Mrs. Bond's senior housing complex who can help her make the first call.

In-Home Support Services (IHSS)

Day-to-day help with shopping, house cleaning, bathing, dressing, toileting and transferring requires a level of service quite different from the Medicare-funded home health programs, but equally important. Medicare only pays for professional care while the patient is recovering from an acute episode. In-home support services engage salt-of-the-earth women (and a smattering of men), some with home health aide training, to manage the daily care needs of chronically ill or disabled elders. Often provided by immigrants in this diverse city, IHSS is available in many languages.

Eldercare at the Goldman Institute on Aging can match up private-pay clients with home care workers. The IHSS Consortium trains and places such workers. Low-income citizens can receive IHSS help up to 283 hours per month, funded by MediCal and other state and county sources. The IHSS Public Authority at 415/243-4477 can put the consumer in touch with any of these resources.

Both Mrs. Andrew and Ms. Bond will be interested in the in-home support service. Mrs. Andrews is exhausted with the burden of caring for her husband. Getting help will prevent her collapse and his institutionalization. Mr. Bond has been dependent on his wife to shop and cook and clean. She also helped him to bathe and dress. Eldercare can provide these services for him now that she is gone.

Money Management

Money management is not something Mrs. Andrews and Ms. Bond are looking for because they can handle the household finances. But many times, a frail elder makes disturbing mistakes with household bills. A conservatorship is not necessary to get help in this area. In addition to lawyers and banks, other money managers are available to the middle-income and the poor. Helplink can assist patients in finding the appropriate service.

Adult Day Health Care

Adult day health care is the program specifically designed as an alternative to skilled nursing institutions for the management of chronic ailments and it is a major asset to physicians, as well as to patients and families.

As the name implies, at an adult day health care center, health care is provided to adults (18 and up) during the day. All of the professional services one receives at a skilled nursing facility are available here, too: skilled nursing, physical and occupational therapy, social work, recreation and speech therapy and personal care. Physicians approve the plan of care and work closely (by phone usually) with the day health nurses regarding changes. The client spends five or six hours a day and three to five days a week at the day health center, long enough to get all necessary professional services, a stimulating social experience, a hot lunch and a break for the care-giver at home.

There are nine adult day health centers in San Francisco, distributed throughout the city and responsive to the language and cultural needs of the different neighborhoods. (OnLok, a self-contained social HMO, also runs adult day health centers.) The centers are experienced in handling incontinence, dementias, mild mental health problems and developmental disabilities as well as all the common diagnoses of advancing age, including brain injuries and MS.

For the patient, day health enables him or her to continue living at home without being trapped there all day. For Mr. Bond, alone now that his wife died, day health will constitute the core of his life as well as his health care.

For the caregiver, day health provides a vital respite from the "36-hour day." While her husband is at day health, Mrs. Andrews will be able to shop, visit with her daughter, nap or,just be on her own. She can also get counseling, health education and peer support at the day health center. These aids will extend her ability to care for her husband at home.

For physicians caring for frail elders, the day health nurse and other professionals can become an important asset in care management, helping to prevent acute episodes and long hospitalizations. If the patient is a Medi-Medi (a beneficiary of both Medicare and MediCal) in a managed care program, the MediCal-funded day health program will reduce draws on the physician's managed care pool.

Paratransit Services

Getting to and from adult day health programs, as well as visiting doctors and other destinations is a major issue for frail and disabled persons. San Francisco has a well-developed paratransit program, funded substantially by the MUNI, which runs wheelchair accessible lift vans and other vehicles, including taxis, for the benefit of these consumers. Eligibility is determined by the paratransit broker at 415/227-4505.

Mr. Andrews will not use the paratransit service because he lives next door to an adult day health service and his wife can escort him there. Mr. Bond, however, will be met every morning at his apartment by a van which will carry him and six or seven other clients to his adult day health program and bring him back in the afternoon.

Physicians As Crucial Links

Case management will be indispensable to Mr. Bond and his faraway daughter. In-home support services will be vital to both families. Adult day health services will become the core of health care management and social life for both patients. Transportation will be crucial for Mr. Bond.

Knowing that these services exist and how to reach them is the first step and it has been documented that this first step is a major hurdle for elders in San Francisco. Physicians and their staffs are the crucial links here, the ones who can help patients and families with this first step in accessing community-based services to help them to continue to live at home.

Dr. Mendelson is a practicing internist and a researcher at UCSF. He is member of the board of directors of the North & South Market Adult Day Health.