May 2016 INSTITUTE FOR URBAN HEALTH FELLOWS LIBRARY City Voices: New Yorkers on Health Aging: Health Challenges and the Role of Social Connections Lindsey Realmuto, MPH | Yan Li, PhD | Lindsay Goldman, LMSW Sharon A. Abbott, PhD | Dona Green, MBA, MA, MAgS | Linda Weiss, PhD CITY VOICES This data brief is part of a series—“City Voices: New Yorkers on Health”—developed to give a voice to the health needs of people in the city who are often unheard. “Aging: Health Challenges and the Role of Social Connections” does this by highlighting informative personal experiences of primarily low-income New Yorkers in the Bronx, Brooklyn, Manhattan and Queens. This collection of voices provides a direct glimpse inside the health issues and needs of New Yorkers to help inform the many decisions that are being made on a daily basis by community service and health care providers as well as policy makers. For more insights and perspectives directly from New Yorkers, visit NYAM.org to download the full “City Voices: New Yorkers on Health” series of reports. NYAM.org “I think that one of the things that we’ve identified for sure is that a lot of seniors are alone in the community. So what we see a lot of is social isolation. And we can demonstrate that that has an absolute effect on their physical wellbeing.” – OLDER ADULT SERVICE PROVIDER, QUEENS Aging: Health Challenges and the Role of Social Connections Table of Contents 1Abstract 2Overview 3Findings 12Conclusions 14Methodology 16References NYAM.org ABSTRACT This data brief is part of a series—“City Voices: New Yorkers on Health”— developed to give a voice to the health needs of people in the city who are often unheard. “Aging: Health Challenges and the Role of Social Connections” does this by highlighting informative personal experiences of primarily low-income, older adult New Yorkers in the Bronx, Brooklyn, Manhattan and Queens. More than 1 million New York City residents, or 12 percent of the total population, are age 65 or older, a number projected to increase by 41 percent over the next 20 years. In 2014, a mixed-method community needs assessment (CNA) was conducted including 2,875 surveys with primarily low-income New Yorkers in four boroughs, 81 focus groups, and 41 key informant interviews. Low-income older adults participating in the CNA were diverse with respect to age (the oldest participant being 102), race/ethnicity and neighborhood. We found that low-income older adults in New York are facing difficulties meeting basic needs, and are forced to make difficult choices, including the choice between buying food and medications. Older adults also reported relatively high prevalence of chronic disease and co-morbidities, which can be exacerbated by loneliness and social isolation; issues that were frequently reported by focus group participants and older adult service providers. Major challenges to accessing care included insufficient geriatric services, the growing complexity in the current health care system, and the lack of reliable, accessible transportation. Better coordination and integration of health and social services, as well as the expansion of health and wellness programs offered at senior centers, were recommended by key informants and focus group participants as potential ways to improve health outcomes and quality of life for older adults. Aging: Health Challenges and the Role of Social Connections 1 OVERVIEW More than 1 million New York City (NYC) residents, or 12 percent of the total population, are age 65 or older, a number projected to increase by 41 percent over the next 20 years.1 Nearly 97 percent of older New Yorkers reside in the community rather than in institutional settings.2 The growing older adult population in NYC suggests a need for changes to the social and built environment (e.g., housing, transportation access)—and an expansion in health and social services— so as to ensure an optimal quality of life, particularly for those older adults dealing with age-related conditions, such as impaired mobility, cognitive decline and/or multiple chronic conditions.3 This report is part of the “City Voices: New Yorkers on Health” series and based on findings from a comprehensive community needs assessment (CNA) conducted in four NYC boroughs. As a part of the CNA, six key informant interviews and eight focus groups were conducted that specifically focused on aging. This report examines issues of health, health care access and utilization, as well as factors contributing to suboptimal health, among low-income, older New Yorkers, including finances and housing. The goal is to inform policies, practices, and programs— across sectors—that may contribute to improving the health and well-being of this growing population. NYAM.org 2 FINDINGS Low-income older adults participating in the CNA were diverse with respect to age (the oldest participant being 102 years old), race, ethnicity and neighborhood. However, several consistent themes emerged across populations and are described in more detail below. These themes included: • Difficulties meeting basic needs on a fixed income, such as food and medications • Relatively high prevalence of chronic disease and co-morbidities • Social isolation and issues related to mental health • Health disparities across racial groups • Challenges to accessing care, including a lack of available geriatric services and accessible transportation Older Adults in Poverty Reflecting our focus on low-income populations, the older adults participating in the CNA reported a number of economic challenges including the high cost of medications, inadequate access to affordable food and housing, and the insufficiency of entitlement programs that could help them to make ends meet. More than half of the older adult survey respondents reported that they either “always” or “sometimes” worry they will not have enough money to pay for food or housing. This financial worry was echoed in the key informant interviews and focus groups. Some of them can’t even afford to buy food sufficient for the whole month because of the fact that the geriatric population cannot afford, on their Social Security checks sometimes and pensions, to get the proper foods ... so that is something that is very much prominent in our communities. (Focus group participant, Manhattan) Aging: Health Challenges and the Role of Social Connections 3 We also have identified that there’s food insecurity because of a lack of available funds to maybe buy the groceries that they need. So people are making those decisions every day about, ‘Well, what can I buy, what can I afford with my limited amount of income for this month?’ And oftentimes nutrition suffers in that mix, because they’ll get their medication instead of buying the food. And sometimes we found they won’t get their medication either. (Older adult service provider, Queens) And then, you know, affordable housing for seniors, subsidized housing. We have a waiting list, we have two buildings where we house seniors and we get applications and they’re on standby. There isn’t enough. (Older adult service provider, Bronx) For older adults with medical needs, living on a low income presented multiple challenges. As noted above, older adults may have to choose between purchasing food and purchasing medicine. Those ineligible for Medicaid may have other out-of- pocket costs associated with accessing care and maintaining their independence. I mean, one of the issues is ... the population that’s in the squeeze where they’ve got a little bit too much to qualify for Medicaid, but they really don’t have the resources to pay for things privately, comfortably. So anybody who needs something that’s beyond what the basic Medicare benefit covers, if they need some health care or some in-home assistance, that’s rough. Because there’s just not that much available, and so that also means that things like transportation to medical care would be an issue. Because, those are the things that are covered when you’re in Medicaid and not when you’re not, for the most part. (Older adult service provider, Manhattan) Health Concerns Forty-two percent of older adults completing the CNA survey reported being in fair or poor health. Among older adult survey participants, high blood pressure, high cholesterol, chronic pain, diabetes and osteoporosis were identified as the most prevalent individual health concerns. Survey participants were also asked to indicate the greatest health concerns in their community. The perspective of older adults was somewhat different from that of the broader survey population. For example, drug and alcohol abuse was one of the most important health concerns in the community NYAM.org 4 for all survey respondents, but it was not one of the primary concerns among older adults. In addition, older adults were more likely to report that conditions related to cardiovascular disease were a community concern compared to the broader survey population. Information about health concerns from key informants and focus group participants reinforced findings from the survey. Physical health concerns were described as having a bi-directional association with depression, cognitive decline, stress and social isolation. We have found that ... high blood pressure, arthritis and diabetes are the most significant health conditions, as is social isolation. And I really will emphasize that there’s been a lot of research lately on the implications of loneliness on physical health as well as mental health. (Older adult service provider, Manhattan) I think that one of the things that we’ve identified for sure is that a lot of seniors are alone in the community. So what we see a lot of is social isolation. And we can demonstrate that that has an absolute effect on their physical wellbeing. (Older adult service provider, Queens) [Speaking about a grandmother] I don’t think she is aware that she is falling into this depression, but I think her inability to get out into the community as much as she should be able to is affecting her and making her stay at home. (Focus group participant, Bronx) [Speaking of a friend] She locked herself in a house for months at a time. She didn’t realize she had depression until the landlord had to come and see the way she was living. Now she’s okay. But somebody had to tell her, like me, when I was under depression I wanted to stay in a room for two days. (Focus group participant, Queens) Aging: Health Challenges and the Role of Social Connections 5 Exacerbating depression and other mental health issues, is the risk of abuse. Several key informants noted that they have seen a growing need for elder abuse programs and support groups for those that have been victimized. People come to us in sometimes very dire situations of being physically abused, certainly emotionally abused. I would say that emotional abuse is the accompanier of any type of abuse because people feel vulnerable and at risk. The one major type of abuse is financial abuse. People, and that could be from strangers, as well as family members ... it is sometimes very clearly related to the changes that happen when you’re getting older, whether it’s your financial need or social isolation. (Older adult service provider, Manhattan) As noted previously, older adult survey participants reported chronic pain as one of their top health concerns. Focus group participants and key informants also discussed chronic pain and its implications for mobility and medication use. Older adults are by and large living with chronic illnesses and lots and lots of pain, and other burdensome symptoms like mobility problems. (Focus group participant, Manhattan) We’re also hearing about the increase of prescription abuse with the seniors, and, you know, people are living longer and, with that said, you have a lot of chronic diseases, not a lot of pain management. (Older adult service provider, Bronx) Health Disparities Although health issues were common across older participants in the CNA, disparities were evident. For example, service providers indicated that issues of social isolation and unequal access to health care may be particularly hard-felt among older adults who are lesbian, gay, bisexual or transgender (LGBT) due to NYAM.org 6 experiences of discrimination and lack of family support. Disparities according to race were also reported. Sixty-one percent of black/African American older adults surveyed reported high blood pressure compared to 49 percent of white older adults. Diabetes rates also differed: 32 percent of older blacks/African Americans reported having diabetes, compared to 28 percent of older white respondents. Key informants working with older adults noted similar disparities. Almost everything seems more prevalent in the African American community. Heart disease is more prevalent in the African American community. Diabetes is definitely more prevalent in the African American community. I find that they’re on more medications for things like high blood pressure ... and [are dealing with] cholesterol at a much younger age ... There’s a very big difference between African Americans that are of Caribbean descent versus African Americans who are third or fourth American generation and have moved up here from having family down south. They eat differently. ... I find that [with] southern African Americans, obesity is a tremendous issue versus Caribbean African Americans. (Older adult service provider, Queens) Access to Care Older adults reported significant barriers to accessing health care services, including co-pays, lack of insurance, the inability to get an appointment at the time needed, and an absence of particular services in certain communities. For instance, 37 percent of older adult survey respondents reported that primary care services are “not very available” or “not available at all” in their community, and 64 percent of respondents reported that mental health services are not available. In interviews and focus groups, the shortage of geriatricians and other aging specialists was repeatedly noted. Aging: Health Challenges and the Role of Social Connections 7 Can anybody else ... tell me what specified geriatric programs you have in your community? Because you have a pediatrician. You have childcare things ... but aren’t we the largest growing population, geriatrics? So, if we’re the largest growing population, how come we don’t see geriatric specialists and things to help us plan? (Focus group participant, Queens) So, the need for targeted geriatric specialists; if you look at the lists of doctors under geriatric care, they’re all over-subscribed. Most of them say we are not taking any new patients. In a city like this where there are lots of doctors, that’s really a problem. (Older adult service provider, Manhattan) Several other challenges with respect to health care services emerged from the focus groups and interviews. Participants felt that health insurance benefits and services provided to older adults have been decreasing over the years and that the complexity and inconsistencies in the current health care system are particularly problematic for older patients. I used to be on Medicaid and everything would go smoothly. Now that I’m over 65, or over 62, I have Medicare and Medicaid. I have MetroPlus and I have a nurse practitioner who may not be connected with my MetroPlus. My nurse practitioner refers [me] to a urologist and he takes all kinds of ultrasounds, and then I get another bill, but a notice from Medicare that they refused the ultrasound and the amount is $2,000. But they say to you that may not be billable. So it’s totally confusing. (Focus group participant, Manhattan) NYAM.org 8 They do change the doctors on you a lot. All the time. You have a doctor sometimes for a month or two months, until you go again. They change you to somebody else, and they’ll change you to a different plan, too. It’s confusing to some people, especially elderly people who don’t understand, who are used to having one doctor. Then when they come back, then they have somebody else telling them something else. (Focus group participant, Manhattan) The lack of reliable, accessible transportation to and from medical appointments was described in interviews and focus groups as problematic for older adults, despite the fact that survey responses by older adults indicate that public transit is considered available (75 percent of older adults reported that accessible transportation was “very available” or “available”). In particular, focus group participants talked about problems with Access-a-Ride, the city’s paratransit system, and the difficulties of utilizing the city’s subway system due to inadequate elevator service. Seniors are having problems with the access cars ... so they can go to the doctor’s appointment. Sometimes some seniors are waiting two and three hours for an access car, if they can even get the service. (Focus group participant, Manhattan) My aunt is 68 years old and she tried to [get] Access-A-Ride because she had a stroke, but you have to call at least two days in advance. ... Older people in the community need more help to get what they need. It’s real frustrating and real challenging. (Focus group participant, Brooklyn) For seniors, most of the trains that they have access to are all elevated train stations. ... It makes people more home-bound. We try to provide transportation services, but it’s not enough. (Older adult service provider, Brooklyn) Aging: Health Challenges and the Role of Social Connections 9 Improving health outcomes and health care access for older adults As noted previously, a large proportion of older adults have multiple chronic health conditions, as well as social and financial challenges. Therefore, better coordination and integration of health and social services, as well as the expansion of health and wellness programs offered at senior centers, were recommended by key informants and focus group participants as potential ways to improve health outcomes and health care access for older adults. This silo specialization in medicine is a problem for everybody, but it’s a particular problem for the geriatric population with 12 medications and four presenting conditions. And so anything that can happen to not just coordinate but actually integrate care across specialties ... you need the interaction of the medical institution to deal with a whole person as a whole person, not by its individually, coded and billed body parts. Anything that could happen along those lines would help everybody. (Older adult service provider, Manhattan) There are so many programs that make the depression disappear. I saw one old man, he has arthritis and he has depression and he was very depressed but when we were bowling he hit a strike and he was so happy. Since then, he joined bowling and went to social things and karaoke; then he feels more useful than before and it reduced all the problems. That’s why I say there are so many programs here that will cure your depression gradually. It is an amazing center and I’ve never seen one like our center. We have so many different programs. We have parties. You always enjoy it. Come to the outside world; go to the senior citizen center, participate in all kinds of activities that make people younger. (Focus group participant, Queens) 10 NYAM.org We have a health and wellness type of department for the seniors, but I really do think that it should go to every senior center, having someone from a health and wellness perspective. I think that you’re never too old to learn and educating the seniors is a tremendous part of them managing their health much better than they do because you, you’d be surprised that there’s so much that they don’t know. (Older adult service provider, Queens) Aging: Health Challenges and the Role of Social Connections 11 CONCLUSION In New York City, the number of older adults living in poverty is more than twice the national average, at 18 percent.4 Our findings suggest that low-income older adults have trouble meeting expenses related to daily needs such as food, housing and medication. Many older adults describe having multiple chronic conditions, which are oftentimes exacerbated by depression, cognitive decline and social isolation. Moreover, we found that health disparities were reported, with African American older adults considered particularly vulnerable. Access to care for older adults is also far from ideal. Several participants identified barriers including a shortage of geriatricians, inadequate insurance coverage and high co-pays, and a lack of accessible transportation to medical appointments. To address these issues and improve the quality of life for older adults in NYC, some participants highlighted the need for better care coordination across the care continuum. Key informants and focus group participants also called for an expansion of health and wellness programs in senior centers across the City. Although this report focuses on the health and health care needs of older New Yorkers, it is important to note that there are a number of initiatives under way that aim to better serve and benefit older adults. One such initiative, Age-friendly NYC, is a partnership between The New York Academy of Medicine, the City Council, and the Office of the Mayor, that works to maximize the social, physical and economic participation of older people to improve their health and overall wellbeing. Since 2007, Age-friendly NYC has made improvements to the built environment, such as new benches, bus shelters and pedestrian plazas, as well as implemented new programs, such as Senior Swim, to promote increased physical activity and reduce disability and dependence. Another important initiative has focused on the development of innovative senior centers, which are being piloted by the Department for the Aging. The innovative senior centers prioritize health and wellness programming and track outcomes associated with participation. These citywide efforts offer great promise with respect to improving the health of older adults through multi-sectoral collaboration. Despite the existing challenges, New York City is working to become a truly age- friendly city and an example for other cities around the globe. NYAM.org 12 This collection of voices provides a direct glimpse inside the health issues and needs of New Yorkers to help inform the many decisions that are being made on a daily basis by community service and health care providers as well as policy makers. For more insights and perspectives directly from New Yorkers, visit NYAM.org to download the full “City Voices: New Yorkers on Health” series of reports. Aging: Health Challenges and the Role of Social Connections 13 METHODOLOGY As described in greater detail elsewhere,5 The New York Academy of Medicine, in collaboration with NYC Health + Hospitals, led a four-borough community needs assessment (CNA) during the summer and autumn of 2014. The CNA included 2,875 surveys (translated into 10 languages) with primarily low-income residents, 41 key informant interviews and 81 focus groups. Participants were recruited using a purposeful sampling strategy, in collaboration with community-based organizations. There was intentional overrepresentation from those engaged with social services programs or with identified needs. The goal of the CNA was to better understand New Yorkers’ health issues, access to resources to promote health, use of medical and behavioral services, and their recommendations for improved service delivery. NYAM.org 14 Acknowledgements We are sincerely grateful to focus group participants for their time and for sharing their personal experiences. We would also like to thank the key informants, health care providers, and other partners who were involved in participant recruitment and provided insights on older adults. We would like to particularly express our gratitude to those organizations that provided venues for the focus groups. Authors Lindsey Realmuto, MPH Project Director, Center for Evaluation and Applied Research, The New York Academy of Medicine Yan Li, PhD Research Scientist, Center for Health Innovation, The New York Academy of Medicine Lindsay Goldman, LMSW Deputy Director, Healthy Aging, Center for Health Policy and Programs The New York Academy of Medicine Sharon A. Abbott, PhD Assistant Director of Strategic Program Development, Division of Corporate Planning Services NYC Health + Hospitals Dona Green, MBA, MA, MAgS Chief Operating Officer, Queens Hospital Center for the NYC Health + Hospitals Linda Weiss, PhD Director, Center for Evaluation and Applied Research, The New York Academy of Medicine The views presented in this publication are those of the authors and not necessarily those of The New York Academy of Medicine, or its Trustees, Officers or Staff. Aging: Health Challenges and the Role of Social Connections 15 References 1 New York City Department of City Planning. (2013). New York City Population Projections by Age/Sex & Borough 2010-2040. Retrieved from http://www.nyc.gov/html/dcp/pdf/census/ projections_report_2010_2040.pdf 2 U.S. Census Bureau. (2013a). 2013 American Community Survey 1-Year Estimates. Retrieved from http://factfinder2.census.gov/faces/tableservices/jsf/pages/productview. xhtml?pid=ACS_13_1YR_S0103&prodType=table 3 Wolff, J. L., Starfield, B., & Anderson, G. (2002). Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Archives of internal medicine, 162(20), 2269-2276. 4 U.S. Census Bureau. 2010-2014 American Community Survey 5-Year Estimates. Retrieved from http://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=CF 5 Weiss L, Griffin K, Chantarat T, Abbott SA, Green D, Shih A. Findings from a New York City community needs assessment: An overview. New York, NY: The New York Academy of Medicine; 2015. NYAM.org 16 About the Academy The New York Academy of Medicine advances solutions that promote the health and well-being of people in cities worldwide. Established in 1847, The New York Academy of Medicine continues to address the health challenges facing New York City and the world’s rapidly growing urban populations. We accomplish this through our Institute for Urban Health, home of interdisciplinary research, evaluation, policy and program initiatives; our world class historical medical library and its public programming in history, the humanities and the arts; and our Fellows program, a network of more than 2,000 experts elected by their peers from across the professions affecting health. Our current priorities are INSTITUTE FOR URBAN HEALTH healthy aging, disease prevention, and eliminating health disparities. FELLOWS LIBRARY NYAM.org The New York Academy of Medicine 1216 Fifth Avenue | New York, NY 10029 212.822.7200 © 2016 The New York Academy of Medicine. All rights reserved.