October 30, 2003
Who Will Care for Our Aging Adults?
Life isn't so easy for Genia Cohen. The 68-year-old widow lives in a low-income apartment in Hollywood. She finds it difficult to get together with her sister, her only living relative in the area, who's also suffering from the aches and pains of age.
But Cohen is one of the lucky seniors, who benefits from a variety of public and private services: She visits the Freda Mohr Senior Service Center on Fairfax to exercise three times a week and lunch weekly, and receives assistance coordinating the bewildering array of available programs through her Russian-speaking case worker at the West Hollywood Senior Center.
Yet agencies like the ones that work with Cohen and other seniors have more clients than they can afford to serve. What will happen over the next 30 years, when -- thanks to higher life expectancies and millions of baby boomers advancing in age -- the population of adults over 65 doubles?
By the year 2030, 70 million adults, or 20 percent of the nation's population, will be over the age of 65. And when you consider that the number of seniors who are most frail and in need of services -- those over 85 -- is expected to climb from over 4 million today to 8.9 million in 2030, you have to wonder what our future will bring.
In the Jewish community, the trend is even worse: with a median age of 42, the Jewish population is seven years older than the general one according to the 2000 Jewish Population Study. Here in Los Angeles the number of area Jews over age 65 has almost doubled in the previous 20 years, a 1997 Jewish Federation survey found. By 2020, the report projected that those 65 and over would comprise 31% of our community.
Is the nation -- and our community -- prepared for the growing, changing needs of a rapidly aging population? What will those needs look like? And how will they be provided both logistically and financially?
In order to fulfill the needs of an aging population we first need to redefine the very concept of aging, says to Susie Forer-Dehrey, associate executive director of Jewish Family Service of Los Angeles (JFS).
"The way we look at older adults needs to change," she said. "The notion that someone goes off to a skilled nursing facility and their life is over is antiquated. These are people who have a lot to offer our community, our children and our society."
Forer-Dehrey points out that the majority of older adults do not live in institutional settings. In fact, 95 percent of older Americans live in their homes within the community, and most prefer it that way. Because of this, she said, "the way older adult services are set up now has to be rethought."
The future will see a host of "increasing needs likely to collide with shrinking public resources," according to a Los Angeles city task force looking at the delivery of services for seniors.
Sandra King, chair of the National Council on the Aging and former director of Los Angeles' JFS, who served on the task force, said, "Policymakers haven't given sufficient attention to this issue. The vast numbers of people who will need services, attention and planning have not been recognized."
One of the major issues raised by the city report was the "dire shortage" of housing that is affordable, connected with services and set up in a manner that supports the physical requirements of seniors. For example, frail elderly may encounter problems navigating in their own homes. Many of these barriers can be eliminated by making modifications, such as installing wheelchair ramps and walk-in showers. Yet when these modifications are not made, the difficulties may unnecessarily cause seniors to move to an institutional setting.
More complicated is the issue of housing availability and cost. "The average rent in Los Angeles is $1,000 for a one-bedroom apartment," said Steve Wagner, director of operations and property management for Menorah Housing Foundation. "If you live on a fixed income in an area of rising rents, there's going to be a problem."
Menorah Housing maintains 15 buildings throughout the city that provide one-bedroom apartments to low-income seniors, and are funded by the U.S. Department of Housing and Urban Development (HUD). Eligible residents pay 30 percent of their income for rent. Each building has an activities director and provides on-site classes, nutrition programs and other activities. The newest of Menorah's buildings, a 65-unit complex completed in Santa Monica two years ago, drew 3,500 applicants.
"HUD funds about five new buildings per year in all of Southern California," Menorah President and Executive Director Anne Friedrich said. "Obviously the supply doesn't meet the demand. There just isn't enough money available."
Friedrich's refrain seems to be expressed by almost everyone involved in the delivery of services to seniors.
Promptly at 9 a.m., 82-year-old Vicky Levy begins her exercise regimen on a treadmill, bicycle and step machine at the Eichenbaum Health Center, located at the Freda Mohr Center on Fairfax Avenue. Levy started visiting the JFS-run center after she was widowed four years ago. In addition to the exercise facilities, the center provides Levy with home-delivered meals and a network of friends.
"It's a pleasure and a blessing to have a place like this," Levy said of the center. "I can get out of the house and have something to do besides sit in front of the TV. People care about us here."
Levy is also a client of the Multipurpose Senior Services Program (MSSP), a program funded by Medi-Cal for low-income seniors who might otherwise be eligible for nursing home care. This program enables Levy to manage at home and stretch her limited Social Security check, the majority of which pays for rent. MSSP helps provide Levy with a package of services that includes taxi coupons to help her get to and from medical appointments, and twice-monthly house cleaning. Her case manager, a social worker at the Freda Mohr Center, helps Levy manage benefits and paperwork and assure that her needs are being met. A separate Medi-Cal-funded program, In-Home Supportive Services, provides Levy with a caretaker for about four hours per day who brings her home from her exercise session and assists her with shopping, cooking and bathing.
A nonsectarian agency, JFS is one provider of MSSP services in Los Angeles. Bernie Gruenbaum, director of MSSP Case Management for JFS, notes that this is a costly program, but one that is cost-effective for the state because it is much less expensive than nursing home care. This year, Medi-Cal reimbursement rates were cut 5 percent, so JFS and other MSSP providers are struggling to continue serving their existing clients. Yet many potential clients go unserved. According to the Medi-Cal Policy Institute, MSSP can only serve one in five people who might benefit from the program. And demand is assured to increase.
For those unable to live independently, the demand for assisted living and skilled nursing facilities will also rise dramatically. According to the City of Los Angeles report, five times the current number of seniors currently residing in nursing homes -- a number equivalent to the population of Glendale -- will require nursing home care in 2030. Yet, in a 1998 federal study, nearly one in three nursing homes nationally were found to have serious or potentially life-threatening care problems. California had twice as many reported deficiencies as the national average.
The Los Angeles Jewish Home for the Aging (JHA), which this year received a zero deficiency rating from the state's Department of Health Services (meaning that they had no deficiencies ) has a waiting list of about 350 for skilled nursing care, including its state-of-the-art Alzheimer's unit. JHA houses 800 residents with an average age of 90, and is currently constructing new facilities that include 249 beds. A Westside campus is under consideration.
How will these services -- both individually and communally -- be paid for? Only one-third of seniors can support the cost of care until the end of life. According to Businessweek, a 65-year-old who retires today and lives to 85 can expect to pay around $100,000 for health care, while those who retire a decade from now will pay at least twice that.
Meanwhile, employers are eliminating or scaling back health care coverage for retired workers. About half of U.S. seniors have any sort of job-based coverage, down from 50 percent nearly a decade ago. Even many of those seniors who accumulated what they felt would be adequate retirement savings have seen their nest eggs diminished by low interest rates and the stock market crash.
These factors will lead to more reliance on Medicare and other publicly funded services. At JHA, for instance, 80 percent of residents are on Medi-Cal, the state's Medicaid program that provides health care coverage for low-income people without health insurance. Spending for Medi-Cal, which is funded by the state's general fund and matching federal funds, has more than doubled in the past decade. For Medicare beneficiaries (those older than 65), long-term care is the single largest component of direct health-related out-of-pocket spending, followed by spending on prescription drugs.
Who will provide these services? The pool of professionals involved in care giving fields is shrinking. Nationally, there are shortages of licensed vocational nurses, registered nurses and certified nursing assistants, the people who provide the bulk of bedside care. These challenges will require innovative solutions. One such approach is a partnership between Jewish Vocational Services and the JHA to train low-income immigrants and refugees as certified nursing assistants. Another is a cooperative effort among JFS, four local colleges and several other agencies that serve seniors to address the shortage of geriatric social workers by steering social work students toward that field.
Is the Jewish community prepared for an aging population?
"We're having the discussions," said Miriam Prum Hess, vice president for planning and allocation for The Jewish Federation. "Our agencies are really rethinking senior services and the way that they're providing them. The whole issue of NORCs is a perfect example of trying to be proactive and test new models."
Prum Hess is referring to the Naturally Occurring Retirement Community, an innovative model for serving seniors that involves a geographic concentration of older adults who wish to "age in place" by remaining in their long-time homes as they grow older. A combined effort between the Jewish Federation, the Jewish Community Relations Committee and JFS has resulted in a half-million dollar allocation from the federal government for JFS to service a NORC in Los Angeles, the first such grant to be made in California. The NORC includes two areas: the city of West Hollywood and the Park LaBrea apartment complex.
"The idea is to provide services to seniors where they already are," says JFS' Forer-Dehrey. "We feel this is a model that we can take into the future."
An assessment is underway to determine what services seniors need, what's currently available and whether existing services are accessible. Based on the results, new services may be created such as recreational activities, counseling, transportation, preventive health care and in-home support services. JFS is applying for future grants in other parts of the Los Angeles area.
"We're moving in the right direction -- we need to get there faster," says Forer-Dehrey. "The problem is being paid attention to by those who work in aging, but the whole community needs to take this on as well."
As the community takes on this issue, it would behoove us to keep in mind the words of Molly Forrest, CEO of the Jewish Home for the Aging: "The choices we make today are the choices that we will live by tomorrow."