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A new vision of transportation

The 2019 ASA Awards p. 13 | Take a look at these winners!

p. 5 | A new column, Aging with Options, begins by exploring universal mobility.


Covering advances in research, practice and policy nationwide

MARCH–APRIL 2019 volume xl number 2

the bimonthly newspaper of the American Society on Aging

How are CBOs faring with healthcare contracts? New report reveals insights, data

In this issue

FORUM Seriously, again? The ongoing fight to save the ACA page 3 Care managers of the future: Georgia Southwestern State debuts a care management degree page 4

case studies in Aging Today that will help to prepare, educate and support community- based organizations and healthcare payers to provide quality care and services. To improve the health and well-being of individuals living in the community, healthcare providers and systems are in- creasingly developing partnerships with community-based organizations (CBO) to address the social and behavioral de- terminants of health. By paving the way for better integration of health, and so- cial and behavioral supports, these part- nerships improve the quality of life for older adults and people with disabilities. Business Institute Data Revealed New data from the Aging and Disability Business Institute, which is led by the National Association of Area Agencies on Aging (n4a) and Scripps Gerontology Center at Miami University, show that

By Beth Blair and Suzanne R. Kunkel E ditor’s note: The SCAN Foundation, The John A. Hartford Foundation, the Administration for Communi- ty Living, the Gary and Mary West Foun- dation, the Marin Community Foundation and the Colorado Health Foundation have united to fund a three-year grant to devel- op and establish the Aging and Disability Business Institute ( , housed within n4a. Under the grant, ASA and n4a are collaborating on a series of articles and

IN FOCUS Wellness as we age—a multi-pronged concept page 7 The 2019 Gloria Cavanaugh Award winner: a federal program prevents scams and fraud against elders page 14 What’s in a word? When that word is “retirement,” perhaps too much page 16

more and more CBOs recognize this trend and are readying themselves for partnerships with the healthcare sector. The results of a 2018 survey ( ybd34rbs ) show that the proportion of CBOs partnering with healthcare enti- ties has grown more than 3 percent over the past year, from 38 percent in 2017 to 41 percent in 2018. The survey responses provide insight into the needs of CBOs at a range of stages in the contracting pro- cess, while offering a glimpse of the chal-

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Beyond Zumba and karaoke: advance care planning comes to the senior center near you By Jacqueline M. McGinley and Deborah P. Waldrop T he Institute of Medicine identi- fies community-based organiza- tions, such as senior centers, as ideal settings to encourage older adults to do advance care planning by providing information that normalizes healthcare decision-making conversations ( tinyurl. com/h5frb48 ). Following the 2016 reau- thorization of the Older Americans Act, senior centers daily serve more than 1million older Americans in almost 11,000 locations. With services ranging from in- formation and referral to educational pro- gramming, these centers are increasingly being regarded as essential gateways for engaging older adult participants, who spend an average of 3.3 hours per visit to centers ( ). The traditional objective of advance care planning has been to have people make treatment decisions in advance so

Wellness and well-being— it’s all about connection

did not deter him from living. While do- ing his best to maintain his physical health, he also cultivated intellectual, so- cial, occupational, spiritual and emotion- al purpose—a life worth living. The Six Dimensions of Wellness The basis for such a life begins with focus- ing on the six dimensions of wellness, whichwere developed by past and present leaders of the NWI. These dimensions— physical, occupational, social, intellectual, Despite his physical limitations, Hawking had intellectual, social, occupational, spiritual and emotional purpose. spiritual and emotional—strongly influ- ence human well-being. Physical wellness is the dimension of- ten used to define wellness. Eating right and being active is the rallying cry. Young and old must get a yearly checkup by a primary care physician, a dentist and an optometrist. People with chronic condi- tions must manage them, and everyone

By Chuck Gillespie

W hen thinking about the terms wellness or well-being, mul- tiple definitions come to mind. Wellness, according to the National Wellness Institute (NWI), is an active process of becoming aware of and learn- ing to make choices that lead toward a longer and more successful existence—in other words, toward a life worth living. So, how to achieve wellness? Accord- ing to Gallup well-being research ( tinyurl. com/y8qpxjvk ), physical activity provides adults ages 65 and older with a 32 percent higher positive emotional outlook than for those who are not active. But to have a life worth living, it is critical to look be- yond physical wellness; Gallup research also identifies how there can be too much emphasis placed upon the physical di- mension of health and well-being. For example, Steven Hawking had been told in his 20s that he would never see age 30. In 2018, he died at age 76. In 2016, he noted that “however difficult life may seem, there is always something you can do and succeed at.” Hawking exem- plifies someone whose physical health

that healthcare providers can provide care that is consistent with their patients’ goals. The National Institute of Aging asserts that advance care planning involves Most survey participants cited “honest answers from doctors” as important in advance care planning. learning about possible healthcare deci- sions that may need to be made if an ill- ness progresses or a medical crisis occurs; considering these healthcare decisions in advance of a status change or emergency; and letting others know about these pref- erences through both conversations and documentation ( ).

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Aging Today March–April 2019




grant from The SCAN Foundation, The John A. Hartford Foundation, the Admin- istration for Community Living, the Gary and Mary West Foundation, the Marin Community Foundation and the Colorado Health Foundation, which united to de- velop and establish the Aging and Disabil- ity Business Institute, housed within n4a, as a resource for the field of aging. This 2019 supplement addresses chronic disease in an evolving health- care environment and the various ways community-based organizations increas- ingly are addressing social determinants of health, and preventing more expen- sive medical interventions. This guide in- cludes articles on Medicare Advantage, the CHRONICCare Act andmultiple pro- grams in the community that help older adults to better manage chronic diseases. Plan to attend the 2019 Managed Care Academy Summit on Thursday, April 18, at AiA, where the guide will be released and its content addressed in depth. After ASA is carrying on its advocacy work to foster policy change at the national level. the Summit, you’ll find the guide posted on the Business Institute’s page ( www. ) on ASA’s website. News on the Policy Front Continuing the advocacy agenda estab- lished by past ASA Board Chair Rob- ert Blancato, ASA carries on efforts by the ASA Public Policy Committee and its advocacy work group to foster policy change at the national level. This past summer, ASA engaged a small, woman- owned and woman-operated Washing- ton, D.C.–based firm, Chamber Hill Strat- egies, to advise us on advocacy and policy issues. An Advocacy Subcommittee (part of ASA’s Public Policy Committee) holds monthly calls with a Chamber Hill prin- cipal, and has now identified housing se- curity and elder justice as the two main advocacy pushes going forward. In December, the Policy Response Team (another Public Policy subcommit- tee) signed on to two Leadership Council of Aging Organization letters: one sup- ports extension of the Medicaid spousal impoverishment protections, which passed at the end of 2018; the other calls for the House’s new Democratic leader- ship to re-establish the House Select Committee on Aging (discontinued under the recent Republican majority). The Select Committee has not yet been rein- stated, but we will persist! As AiA 2019 draws near (April 15−18), I urge you all to finalize your travel plans—I hope to see as many of you as possible in New Orleans. If you see me in the throng, rushing from one session to another, please say hello! n Today articles and to guest commentar- ies, which present the opinions of their authors and not necessarily those of the American Society on Aging. Letters should be no more than 350 words long. We also welcome ideas for articles you would like to see in future issues of Aging Today .  mail Aging Today, “Letters” 575 Market St., Suite 2100 San Francisco, CA 94105-2869  fax (415) 974-0300  e-mail WRITE TO US We welcome your responses both to Aging

American Society on Aging Aging Today (issn 1067-8379) is published bimonthly by the American Society on Aging. Articles may be reproduced by those obtaining written permission. Postmaster: Send address changes to Aging Today, ASA, 575 Market Street, Suite 2100, San Fran- cisco, CA 94105-2869. Phones: editorial (415) 974-9619; advertising (415) 974-9600; or visit . For membership or other information about ASA, call (415) 974-9600, fax (415) 974-0300 or visit . Subscription Price: individual non- members: $74.00/year (included with annual membership); nonmember institu- tions/libraries: $110.00/year. Subscription Aging Today is indexed in the Cumula- tive Index to Nursing and Allied Health Literature and the Areco Quarterly Index to Periodical Literature on Aging. Printed in the U.S.A. © 2018 American Society on Aging. All rights reserved. The American Society on Aging (ASA) is the essential resource to cultivate leadership, advance knowledge and strengthen the skills of those who work with, and on behalf of, older adults. Chair: Robyn L. Golden, Director of Health and Aging, Rush University Medical Center, Chicago, Illinois Diane Brown, Executive Director, Medicare Strategy & Operations, Kaiser Permanente Northern California, Oakland, California Robert Espinoza, Vice President of Policy, PHI, Bronx, New York Paul Greenwood, Deputy District Attorney, Head of Elder Abuse Prosecution Unit, San Diego District Attorney’s Office, San Diego, California Carol Levine, Director, Families and Health Care Project, United Hospital Fund, New York, New York Anne Montgomery, Deputy Director, Center for Elder Care & Advanced Illness, Altarum, Washington, D.C. Kathy Sykes, Retired, Senior Advisor for Aging and Environmental Health, U.S. EPA, Washington, D.C. Laura Trejo, General Manager, Los Angeles Department of Aging, Los Angeles, California Peter Whitehouse, Professor of Neurology, Case Western Reserve University; and President, Intergenerational Schools International, Shaker Heights, Ohio agency rate (institutional rate only): $94.00/year. Publisher: Robert G. Stein, ASA President and CEO ASA Board Chair: Karyne Jones Editor: Alison Hood Senior Editor: Alison Biggar Design & Production: Michael Zipkin | Lucid Design EDITORIAL ADVISORY COMMITTEE

Of planning, policy … and persistence!

By Karyne Jones | ASA Board Chair

A s I complete my first year as ASA Board Chair, I’d like to update everyone on some current proj- ects, and reflect upon several of ASA’s accom- plishments over this past year.

succeed our successfully implemented Vision 2020 plan that launched in 2016— and to develop operations protocols (in conjunction with ASA staff) that will bring the strategic plan to fruition. The new plan has five pillars: leader- ship in the field of aging; membership; di- versity; equity and inclusion; and policy and advocacy. Family Really Matters I’d like to give a shout out to the Fall 2018 issue of Generations , “Family Matters: WhenOlderAdultsAreCaregivers,”which was one of my recent favorites. Thought- fully guest-edited by University of Iowa School of Social Work Professor Mercedes Bern-Klug, the issue focused on caregiv- ing—not for an older adult—but as an older adult. People not in this situation are rarely cognizant of the physical, emotional andfi- nancial tolls such caregiving can exact on older adults, in spite of the satisfaction and fulfillment this role can bring. Please give this issue a thorough read! Speaking of Generations , we have just finished producing the third Managed Care Field Guide Supplement to Genera- tions , to be released in April at the Aging in America Conference (AiA). The supple- ment is part of a generous three-year

Karyne Jones

I launched a Strategic Planning Com- mittee, composed of ASABoardmembers, which has been at work since Fall 2018 under the leadership of Cynthia Banks. Cynthia directed Los Angeles County Community and Senior Services since 2006, served as president of California’s Association of Area Agencies on Aging and has spent more than 30 years in man- agement and executive positions with LA County. She has done an exceptional job of leading the committee’s work, but stepped down January 30, on the occa- sion of her retirement. I’m pleased that Deborah Royster, CEO of Seabury Resources for Aging, will assume the duties of committee Chair. Deborah previously served as General Counsel to the District of Columbia Office on Aging. The ASA Board plans to focus its April board meeting on approving a new strategic plan for 2020 to 2024—to

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Aging Today March–April 2019



Let’s continue the fight against dismantling the ACA By Kevin Prindiville I n December 2018, a Federal District Court issued a decision in Texas v. the United States of America declaring the ( ). Older adults pur- chasing insurance through ACA market- places would face prohibitively high health insurance costs because insurers would not be limited in how much they could charge older adults based on age. In- surers would also be able to charge eight in ten adults, ages 55 to 64, more on the basis of having a pre-existing condition ( ). In total, 4.5 mil­ lion adults ages 55 to 64 would lose cover- age ( ). entire Affordable Care Act (ACA) uncon- stitutional ( ). While the decision has not taken effect and legal scholars say it won’t stand, if upheld it would dismantle the healthcare system upon which older adults rely and be even more devastating than Congress’ mostly failed attempts to repeal parts of the sweeping healthcare law. ‘Millions of adults ages 55 to 64 would lose access to affordable healthcare coverage.’

services, including annual wellness visits, nutritional counseling, vaccines and screenings for cervical and vaginal can- cer, colorectal cancer, HIV, depression, di- abetes and obesity. More than 40 million Medicare enrollees benefited from free preventive care in 2016 ( y78mynpb ). Because eliminating the ACA would mean elders and people with dis- abilities would have to pay out of pocket for these services, many who live on lim- ited, fixed incomes would be forced to make impossible decisions between going without basic and necessary care and put- ting food on the table. Further, the savings from the ACA that extended the life of the Medicare trust fund would be eliminated, placing Medicare at risk for dramatic cuts through the budget process, vouchers and privatization. Dual eligibles would be at greater risk. The ACAhelps older adults who are dually eligible for Medicare and Medicaid through initiatives aimed at better coordi- nating their care. Currently, 10 states are operating demonstration programs that coordinate Medicare and Medicaid bene- fits for 400,000 dual eligibles ( tinyurl. com/yc9wl7hv ). Duals also are benefitting from delivery system reforms through the Center for Medicare and Medicaid Inno- vation, and the December 2018 decision, if enacted, could eliminate this office and ‘Older adults would be at great risk for elder abuse.’ economic force and will continue to be so for years; why we should value the skills of older, experienced work- ers, who battle age dis- crimination; how older workers can be just as cre- ative as their younger peers, if not more so; why self-employment and en- trepreneurship lead the “work longer movement”; and how the growing trend among older adults to do good in their work options as they age, through positions at nonprofits. Some quick takeaways from the book: Americans are no longer retiring in the traditional sense, which remains a largely unappreciated fact. The labor-force par- a powerful

significantly slow this office’s efforts to co- ordinate care for those individuals dually eligible for Medicare and Medicaid. Finally, older adults would be at great risk for elder abuse. The ACA included the Elder Justice Act, which provides federal resources to help prevent, iden- tify and prosecute instances of elder abuse, including instances of abuse in nursing facilities. What Happens Next? Today, the ACA is the law and will remain so as theTexas casemakes itsway through the court system. Seventeen state Attor- neys General, who intervened in the case as defendants, appealed the decision in January to the Fifth Circuit Court of Ap- peals, which is widely expected to over- turn the lower court’s ruling ( y72med52 ). The U.S. House of Representa- tives also has sought to intervene in the case ( ). At a time when senior poverty is in- creasing, older Americans and people with chronic and serious health conditions sim- ply cannot afford to pay more or to forego care. By working together, we have suc- cessfully fought previous attempts to strike down the ACA. That fight continues. We will persist in order to ensure and im- prove Americans’ access to affordable and quality healthcare as they age. n Kevin Prindiville is executive director of Justice in Aging, a national organization with offices inWashington, D.C., Los Ange- les and Oakland. He is amember of the ASA Board of Directors and of the Generations Editorial Advisory Board.

Programs that help elders and people with disabilities to stay in their homes would lose funding. The ACA improves access to Medicaid at-home services through the Community First Choice Op- tions program ( ). This program allows states to fund personal at- tendant services for older adults and peo- ple with disabilities who need assistance with activities of daily living like bathing, dressing and preparing meals. The pro- gram serves as a key component of states’ efforts to help individuals stay out of insti- tutions and age in their communities. Without this funding, many states would be forced to discontinue these programs and more older adults and people with disabilities would be forced to seek care in nursing facilities rather than in their homes and communities. Older adults and people with dis- abilities would pay more in Medicare costs. One in four Medicare Part D en- rollees has high enough prescription drug spending to fall into the Medicare “donut hole,” in which they become re- sponsible for the full cost of their pre- scription drugs ( ). Eliminating the ACA’s provisions clos- ing the donut hole would cause 9 million older adults and people with disabilities to face higher drug costs at a time when they cannot afford to pay more ( tinyurl. com/ydatq4c3 ). Thanks to the ACA, Medicare enroll- ees have zero cost-sharing for preventive ‘Americans are no longer retiring in the traditional sense, which remains a largely unappreciated fact.’ ory and again proves there is substance to it. Farrell, who also serves as senior economics contributor to NPR’s “Mar- ketplace,” has been monitoring the aging population for years. He says adults old- er than age 50 are no burden—instead, they are saving the economy. “Purpose and a Paycheck” details why older adults in the United States are

Without the ACA, millions of older adults would become uninsured, fewer el- ders would be able to age at home and in their communities, Medicare costs would increase and its financingwould be threat- ened and successful efforts to improve care for individuals dually eligible for Medicare and Medicaid would be halted. As part of the 2017 tax reform legislation, Congress eliminated the tax penalty indi- viduals were assessed for not having health insurance. Texas and 19 other states filed a lawsuit arguing that the indi- vidual mandate could no longer be consid- ered a tax without the penalty, and that it and the entire ACA should therefore be deemed unconstitutional. The Texas fed- eral judge agreed. How will this affect older adults? Mil- lions of adults ages 55 to 64 would lose access to affordable healthcare coverage. Holding the entire ACA unconstitu- tional would roll back in 37 states the cov- erage made available to older adults ages 55 to 64 through Medicaid expansion What Are the Potential Impacts on Older Adults?

Finding purpose in meaningful work—and a paycheck A s AARP has been telling us for years, and backed by an Oxford Economics study from 2013

ticipation rate of men ages 60 and older has risen nearly a third to 35 percent (from 26 percent) in 2014. For women, that rate is 25 percent, up from 15 per- cent. Also, 25.5 percent of new business ventures in 2016 were launched by people ages 55 to 64, which is up from 14.8 percent. Farrell states that along with globalization, auto- mationandclimate change, our aging population and

( ), the older adults in the Baby Boom Generation are less of an economic drain on society than they are a booster. They are a “net positive con- tributor to economic growth and prosper- ity,” according to Jody Holtzman, senior managing partner, Longevity Venture Advisors, in Rochelle, N.Y. Journalist Chris Farrell’s new book, “Purpose and a Paycheck: Finding Meaning, Money, and Happiness in the Second Half of Life” (New York: Harper- Collins Leadership, 2019), tests this the-

workforce are among the most significant long-term forces shaping the U.S. econo- my and society. It is high time Jane and John Q. Public were made aware of this fact. Formore information about the book, go to . n

Aging Today March–April 2019


New—and needed— care manager education supports aging and disabled populations

healthcare worker—a care manager—who is trained to navigate our nation’s convo- luted healthcare system.

By Leisa R. Easom A merica needs a better prepared workforce to address a broader scope of needs and services for its aging and-or disabled populations. With- in the last decade, the population of peo- ple ages 65 and older has grown from 37.2 million in 2006 to 49.2 million in 2016 (a 33 percent increase) and is projected to al- most double to 98million by 2060 ( tinyurl. com/ya6lbmde ). This older adult cohort also must cope with multiple chronic illnesses, including cardiovascular disease, cancer and de- mentia ( ). Similarly, parents of children with disabilities face worries about healthcare management in the years ahead when they might not be present—or able—to advocate for and pro- tect their children. Families caring for older adults and children with disabilities need to knowwhat programs and services are available, how to connect with them and who can help manage their family members’ care over the long term. While each family is unique in how it deals with different stresses and issues, a trained care manager can advise families on available support programs and how to access these programs both in the commu- nity and nationally ( ). Traditional healthcare providers are not educated to address these needs. Thus, families need a new category of

Education Deficit Creates Service Gaps

Traditional healthcare providers are not educated to address all current needs. The healthcare workforce is critical to the healthcare system infrastructure, but in- sufficient or absent educational training for this workforce has created gaps in healthcare service. In traditional health- care training settings, physician and nurs- ing instruction is based on the medical model, which focuses on detecting and treating disease. There is little or no train- ing that focuses on caregivers, budgetary and management skills and “soft” skills, such as effective communication. What is missing are healthcare work- ers who can plan, organize, arrange staff- ing, direct people to community resources and assist with decision making—in other words, caremanagers. In past years, nurs- es or social workers have evolved into care managers as they completed additional training or benefited from experiential learning over years of employment. As noted by Zimmerman and Osborn- Harrison in “Person-Focused Healthcare

Management” (New York: Springer, 2016), the system for producing, delivering and paying for healthcare requires a new healthcare worker to oversee and guide families so that people being treated as pa- tients fare better than they do currently. Navigating this system is complicated at best and formal undergraduate educa- tion has not previously been available to prepare a healthcare worker to address the wide interdisciplinary area of patient needs and supports. Now, however, healthcare workforce training for long- term-care management is available in an academic interdisciplinary setting as an undergraduate degree. The Bachelor of Science in Long-Term Care Management originated in the Rosalynn Carter Institute for Caregiving at Georgia Southwestern State University in Americus, andwas created after holding focus groups and conversations with care- givers, and consulting with employers that offer long-term services and supports. Re- search also included in-person discussions with CEOs of a hospital and a long-term- care residential institution; and, to learn more about the most needed workforce skill sets, an electronic email survey was circulated to all known Georgia area agen- cies on aging, hospitals, home health agen- cies and nursing or assisted living facilities. Of the 116 surveys returned, 81 percent indicated a need for employees with long- term-care management education, and most reported that this type of degree would fit into current positions. The majority (65 percent) of those surveyed indicated an annual salary compensation of $45,000 to $50,000 for such an employ- ee in Georgia, but a review of care man- ager salaries nationwide revealed an annual salary range of $40,000 to $105,000 ( ). Employers noted that the needed healthcare workforce skill set should in- clude management and budgetary skills, cultural diversity knowledge, social skills, communication skills, awareness of care- giver and care receiver needs and an awareness of and ability to connect people to support programs in the community. Based upon employer feedback, only an interdisciplinary approach to training can prepare graduates of such a program to meet the wide range of needs experienced by individuals with chronic illness and-or disability who are living in the communi- ty or in residential institutions. In next steps, an interdisciplinary team was formed between Georgia Southwestern State University’s College of Nursing and Health Sciences, the School of Business Administration, the Department of Psychology and Sociology and the Rosalynn Carter Institute for Research and Teamwork Forge a NewDegree

A team spent two years planning content for the new Long-Term Care Management degree program. Acknowledging the need for flexibility in training, this Bachelor of Science degree is now offered online and-or in classroom settings. The training includes courses in business, psychology, sociology, nursing, caregiving and long-term-care manage- ment. Students also take a capstone intern- ship course, which ensures an opportunity to apply theory to practice. In the intern- ship portion of the program, students complete 150 hours of on-site training with an agency of direct service in long- termcare, such as an area agency on aging, an institutional residential setting, a hos- pital, a home health agency and others. Program graduates can join the na- tional organization, the Aging Life Care Association, which has established stan- dards of practice and a code of ethics for care managers. After two years of super- vised work in the field as a care manager, care managers are eligible for certifica- tion through a national exam for Certified Managers of Care (CMC). The test is ad- ministered by independent testing cen- ters, and candidates are tested on specific content domains unique to care manage- ment. To maintain certification, CMCs are required to participate in continuing education and professional development; certification is renewed every three years to ensure that care managers are practic- ing at the highest professional level ( ). ANew Path Forward Currently, the healthcare workforce can- not meet the needs of individuals and families attempting to navigate our na- tion’s complex healthcare system. Given the vast quantity of older adults in Ameri- ca with chronic illness, and large num- bers of individuals with disabilities, this degree offers a much needed and innova- tive educational pathway for people who want to support and work with these growing cohorts. n Leisa R. Easom, R.N., Ph.D., is associate dean and professor in the College of Nursing and Health Sciences at Georgia Southwest- ern State University in Americus, G.A. She can be contacted at Caregiving. This team met for two years to plan content for a four-year course of study that would develop the skill set needed by employers offering services to older adults, and that would offer long-term-care management training to program participants. An Accessible, Well-Rounded Curricula

Resources from the Aging and Disability Business Institute Hosted by n4a, the Aging and Disability Business Institute focuses on preparing, educating, and supporting CBOs and healthcare payers to collaborate and provide quality care and services. Visit ASA’s website to find information and resources produced by ASA that you can access at any time. · Web seminars available to you at no cost include complimen- tary CE credits · Articles from Aging Today & Generations · Blog posts on ASA’s website · Podcasts that you can download and listen to at your convenience · Two field guides, Generations supplements that you can view online and download. Access these resources at Planning to attend the 2019 Aging in America Conference in New Orleans? Make plans to attend the Managed Care Summit at the conference on Thursday, April 18. Visit for more information.

Aging Today March–April 2019



Universal mobility: a new vision for person-centered transportation

travel can request transportation from an origin to a destination at a specific time. Vehicles do not follow a fixed route and most passengers share rides to minimize costs. Many older adults are dependent upon this form of specialized transporta- tion because of frailty, disability or inade- quate public transportation service cover- age in their communities. Building “universal” into Mobility as a Service requires modernization of demand-responsive transportation, and one approach could be modeled after FlexDanmark ( ), a global model for coordinated, demand- responsive transportation. Twenty years ago, FlexDanmark, a na- tionwide software company owned by Denmark’s five regional public transpor- tation authorities, began to integrate and coordinate all of the country’s demand- responsive transportation. Initially, the task was to more efficiently provide medi- cal transportation. Prior to the establishment of Flex­ Danmark, transportation authorities car- ried out the federal mandate to provide medical transportation to qualifying citi- zens by arranging transportation for cli- ents via private taxis. While the cost of transportation was just a fraction of the total spending on healthcare and other services, on the aggregate, by itself the transportation subsidy still was huge, motivating regional transportation au- thorities to discover a more efficient means of delivering the service, thus pav- ing the way for FlexDanmark. Since its early days providing medical transportation, FlexDanmark has inte- grated additional services into its Flex- Trafik platform. FlexHandicap is a service for individuals with severe mobility im- pairment. Under federal law, Denmark’s regional transportation authorities must provide at reduced cost 104 one-way lei- sure trips per year to citizens with severe- ly reduced mobility because of disability or frailty, at an out-of-pocket cost no high- er than the cost of public transportation. Most municipalities invest in FlexTur , which allows any citizen to arrange de- mand-responsive transportation through FlexTrafik. FlexTur riders share the cost of transportation with their sponsoring municipality. Many older adults who do not qualify for FlexHandicap subsidies take advantage of FlexTur to get around their communities with ease. How FlexDanmarkWorks To best coordinate Denmark’s demand- responsive transportation services, Flex- Danmark’s regional call centers are in- tegrated through a central nationwide dispatch system. Its IT system automati- cally finds the lowest cost transporta- tion provider available to complete a given trip and then matches the customer with a given vehicle; trip requests can be assigned within seconds. More than 550 unique private transportation providers participate in this single system, which

MaaS aims to create transportation alternatives so appealing that car-dependent consumers will choose new ways to travel. Transportation is vital to help people with mobility limitations live as indepen- dently as possible in their communities. But access to transportation poses a major barrier for people who do not drive. In most American communities, there are inadequate transportation options and, where they do exist, service often is frag- mented and difficult for riders to identify. Despite decades-long federal and local ef- forts to coordinate specialized transpor- tation, progress has been slow. But the major disruptions currently occurring in the transportation sector al- low for hope that the aging services sector can harness emerging technology to mod- ernize transportation services and deliver higher quality service for older adults and people with disabilities. ANewVision: Mobility as a Service Enter the much talked about concept of Mobility as a Service (MaaS). Many play- ers in the transportation sector are work- ing toward MaaS, with the ultimate goal of providing a comprehensive package of transportation services to replace person- al vehicle ownership. The aim is to make transportation alternatives so appealing that even the most car-dependent would choose new ways to get around. These players are diverse—large transit authori- ties (LA Metro), ride-hailing companies (Lyft, Uber) and even car manufacturers (Ford). They intend to achieve MaaS by using applied technology to make trip planning, booking, payment and modes of transfer easy. Such a new world order could be life- altering for people who are unable to drive, but it will only happen if their needs are considered during planning phases. This requires that transportation actors think as much about specialized services as they do about modernizing regular public transportation, and to offer new on-demand services like Lyft, electric scooters and bikes. By Jana Lynott E ditor’s Note: ASA and Aging To- day are pleased to debut a new col- umn, “Aging with Options,” which is sponsored by the AARP Public Policy In- stitute. The column content will focus on in- novative solutions to change systems and empower individuals and their families to thrive at home and in community.

‘FlexDanmark has significantly lowered the cost of demand- responsive transportation.’ serves both urban and rural customers. And hospitals, medical offices and human service agencies can easily connect their clients using the FlexDanmark portal. Different categories of FlexDanmark customers are transported in the same ve- hicles (the service is open to all citizens) at the same time, thus the regional transpor- tation authorities can transport more pas- sengers in fewer vehicles, and offer them shared—and shorter—trips. Trips may be booked with lead times ranging from two weeks to two hours, and because each of the regional FlexDanmark operation cen- ters are part of the larger national system, geographic boundaries are not a barrier. What makes this coordination possible is that all players agree to exchange data about each trip in a common data format, automating the task of assigning a cus- tomer to a vehicle. The data standard has lowered barriers for private transporta- tion providers to enter the market, be- cause they no longer have to purchase a specific scheduling and dispatch soft- ware, but can choose one appropriately scaled for their business. Furthermore, FlexDanmark’s trans- portation authorities negotiate contracts with numerous providers on behalf of regional governments and each munic- ipality. As a result, FlexDanmark has significantly lowered the cost of demand- responsive transportation. Ninety-five percent of the 16,000 trips provided each day are on time, defined as a vehicle ar- riving no later than 15 minutes after its scheduled arrival time (and never earlier). This convenience and cost-savings benefit customers who pay out of pocket for the service, as well as the hospitals and mu- nicipalities that subsidize travel. FlexDanmark is fiscally driven by tech- nology that accurately distributes costs among payers. Passengers, hospitals and municipalities are billed according to clear cost-allocation formulas built into the IT platform, based on rider eligibility and subsidies provided by the public sector. Adapting the Model for America Though there are many differences be- tween Denmark and the United States (most obviously, geographic size and po- litical orientation toward social welfare), the FlexDanmark model is transferable. By applying it at the regional level, the United States could benefit from im-

proved market competition. This compe- tition, in turn, could lower the cost of pro- viding transportation service. In many respects, the pre-FlexDan- mark medical transportation system re- sembled that of today’s Medicaid Non- Emergency Medical Transportation (NEMT) in the United States. Only 0.40 percent of the federal Medicaid budget goes to transportation; however, that trans- lates into $1.5 billion in annual spending— the largest human services transportation outlay of any federal agency, surpassing that of the Department of Transportation. As a result, numerous states, which are responsible for sharing the cost of Medi­ caid NEMT, are exploring ways to lower transportation costs. Some have put in place transportation brokers that tapmul- tiple providers in the community. But none employs the underlying data specifi- cation that facilitates efficient, automated discovery of available vehicles, trip sched- uling and payment among numerous in- dependent transportation operators. In 2018, the National Academies of Sci- ence ( ) built a com- mon data specification modeled on that used by FlexDanmark and other Scandina- vian countries. Now, we need demand-re- sponsive transportation providers and their funding agencies to pilot the code and measure its benefits in terms of cost-sav- ings, service-quality improvements and improved beneficiary health. The technol- ogy would enable door-to-door transporta- tion providers such as senior shuttles, para- transit buses, taxicabs and ride-hailing platforms like Uber and Lyft to be linked. Implementing this specification would fos- ter coordination of transportation services. Current U.S. demand-responsive trans­ portation players have at best modest in- centive to revamp the system, given that human service agencies and the peo- ple they serve would be the big winners. Thus, the aging services sector must push the transportation sector to be better. It is the path forward to bringing the U.S. demand-responsive transportation sys- tem toward improved customer service. This is an essential step toward realizing Universal Mobility as a Service ( tinyurl. com/y7kbxsq5 ). Learn more about FlexDanmark’s coordinated transportation program at: lex danmark. n Jana Lynott is a senior strategic policy adviser with the AARP Public Policy Insti- tute. A land use and transportation plan- ner, she authored a series of publications about the Future of Transportation ( .

A Cost-Effective, More Human-Centered System

Demand-responsive transportation is a set of public and private services in which individual passengers, agencies or health- care providers that subsidize clients’

Aging Today March–April 2019


Aging Today March–April 2019


Live long and prosper: a look at aging and wellness The term wellness is much bandied about these days, and used in all sorts of contexts. But what does being well and cultivating wellness mean as we age? This In Focus on “Aging and Wellness” demonstrates that it’s more than a matter of physicality. There are six dimensions of wellness, according to Chuck Gillespie, interim director of the Nation- al Wellness Institute, and perhaps the most critical of these involves connecting to others and expanding one’s worldview. Paige Denison and Mark Stoutenberg stress the importance of exercise as medicine, Suzanne Haga explains how precision medicine may help us age more healthily (or not), Danielle Fixen outlines the do’s and don’ts around Yes, exercise is medicine— and part of integrated care planning

cannabis use for older adults and Jessica Wong takes on screen time and its mental health effects on elders. As always, ASA welcomes ideas and feedback on Aging Today content from its membership, and the field of aging at large. Email

Exercise professionals should be part of an interdisciplinary healthcare team. cal activity guidelines for older adults emphasize the importance of multi- component physical activity, which in- cludes balance training, along with aero- bic and muscle-strengthening activity ( ). To provide optimal care for older adults, exercise professionals whowork in the health and wellness arena—and the ing a narrowing of social networks. Fur- ther, social isolation is prevalent among individuals who are far from family and friends or who are not near a cultural center to which they feel connected. Not “fitting in” is an issue many people face. Civil rights legislation in the United States created legal precedent regarding discrimination (i.e., around race, religion, gender, disability, etc.) for protected class- es, but prior to 1990, people with disabili- tieswere not covered. Thanks to theAmer- ican’s with Disabilities Act, wheelchair users now have access to many venues to which they were previously shut off; this legislation opened up new avenues of so- cial, emotional and intellectual well-being. Other factors such as geography (where one lives), healthcare access and personal priorities also play a part in in- dividual well-being. For instance, work- place and community wellness initia- tives may promote the need to prioritize 60 minutes of exercise per day, but for people living in unsafe neighborhoods who are worried about putting dinner on the table, exercise moves down on the priority list. AMulticultural Perspective This type of situation is why the NWI developed the Multicultural Wellness Wheel. The wheel encourages individuals to look beyond their spheres of influence to understand how others might view life. How and where a person grew up, what they do for work, their family environ- ment and “life moments” all influence individual perspective. The Multicultural Wellness Wheel helps people to understand, without nega- tive judgments, the worldviews of cultur- ally different peoples, and to have respect and appreciation for human differences › continued on page 10

muscle-strengthening activities, and only about half meet recommended guidelines for aerobic physical activity alone. A lack of physical activity is linked to approximately $117 billion in annual U.S. healthcare costs and to approximately 10 percent of premature deaths. Promoting physical activity and reducing sedentary behavior in older adults are especially important, as physical activity levels tend to decrease with age. Current physi- Each dimension holds equal value in a life worth living. But the concepts for each dimension need to be understood in the right perspective. For example, as Hawk- ing overcame his physical obstacles, it is imperative for individuals to understand their own obstacles to overcome.

By Paige Denison and Mark Stoutenberg H alf of America’s older adults have one or more preventable chronic diseases; however, seven of the tenmost common chronic diseases in older adults can be ameliorated through engag- ing in regular physical activity. Yet nearly 80 percent of older adults do not meet key guidelines for performing aerobic and should avoid tobacco. But there is somuch more to wellness. Anyone who has experienced the stress of being in an unsatisfying job, or who has been employed by a company with a psychically poisonous work envi- ronment knows those situations consume significant amounts of energy; poor phys- ical working conditions also cause harm. Thus, occupational wellness is critical to well-being. For some, occupational well- ness involves whatever work makes them happy. For others, a paid job provides their desired financial and material life, but a working hobby such as gardening, wood-working or fixing cars also can pro- vide satisfaction and enrichment. The social dimension involves connec- tion to friends and family. Lack of a good social network, loneliness, feeling isolated and not fitting in at home, at work or in a community are major barriers to achiev- ing wellness. The intellectual wellness dimension means expanding knowledge and skills, while allowing time to discover the po- tential for sharing one’s gifts with others. Humans must be constant learners, not necessarily in the sense of “book smarts,” but in learning to find their own unique ways to learn and to teach. The spiritual and emotional dimen- sions both are critical to happiness and health. The spiritual dimension recogniz- es the human desire to search for meaning and purpose in life—exploring the ubiqui- tous question, “Why are we here?” The emotional dimension aligns with the other five dimensions by recognizing how each person must try to cultivate a positive outlook—to create enthusiasm about one’s self and one’s life. Wellness and well-being › continued from page 1

The Multicultural Wellness Wheel helps people to have respect and appreciation for human differences. that enable more positive and effective encounters. NWI Board President and CEO of Alturnative Linda Howard says, “One of the biggest issues we face across the globe is that we do not have a strong multicultural competency model from which to learn. Practitioners and organi- zations usemodels that are too focused on one particular issue like race or gender, and as such, fail to reach large segments of the population due to a lack of cultural competency. We see the opportunity to learn from each other through a wider lens that also incorporate such things like religion, disability, language, age, geogra- phy and other cultural factors that are a leading causes of social isolation.” If people can become aware of their beliefs and assumptions about human be- haviors, values, biases, stereotypes and personal limitations, they can open up and learn who different cohorts are as “cultur- al beings.” They can better see how cul- tural socialization shapes worldviews and enhances their ability to connect to and work with culturally diverse populations. Wellness is a simple, though multi- pronged, concept, which emphasizes a mission of connection. Now more than ever, it is critical to consider overall well- being from a more holistic perspective—in terms of our social connections, physical health, intellectual capacity, occupations and emotional and spiritual coping skills. n Chuck Gillespie is interim executive director of the National Wellness Institute in Stevens Point, Wis.

Social Determinants andWellness According to the recent survey by Waystar, “Consumer Perspectives on How Social Determinants Impact Clini- cal Experience” ( ), 68 percent of respondents had social risk- factor obstacles. Healthcare access, hous- ing insecurity, transportation access, food insecurity, safety and health literacy lead the list. The survey shows that much more thanmedical care affects health and wellness. “The most commonly reported social determinants of health issues are financial insecurity and social isolation,” the report’s authors write. Research by the National Institutes for Health ( ) shows that with aging, individuals often decline in physical and cognitive function, caus-

Aging Today March–April 2019


Taking playtime to the streets—an antidote to social isolation?

create a culture of healthy, socially connected behav- ior, interdependence, com- munity safety and playful- ness through increased community interaction. Themodel is an easy-to- replicate concept that pro- vides opportunities for neighbors to engage with one another where they live and empowers resi- dents to initiate and man- age these recurring events. Playing Out is an effective vehicle for promoting com-

less effective, as socially isolated commu- nities are less likely to engage in civic life. Historian Kenneth T. Jackson, quoted in “Bowling Alone,” noted: “… [O]ur lives are now centered inside the house, rather than on the neighborhood or the commu- nity. ... [T]he life of the sidewalk and the front yard has largely disappeared, and the social intercourse that used to be the main characteristic of urban life has van- ished” ( ). The decline of the public realm, according to Cortright, has helped to fuel growing distrust among Americans. “[P]eople exhibit less trust because they have fewer interactions; we have fewer in- teractions, so we have lower levels of trust and less willingness to invest in the public realm that supports it.” Playing Out—a Simple Solution The good news is that social isolation can be addressed. While it is a complicated and expensive problem, there is a simple Playing Out encourages neighbors to engage with one another where they live. and low-cost intervention worth explor- ing—Playing Out. Initiated in 2009 by two neighbors in Bristol, England, Playing Out empowers residents to organize and su- pervise periodic, temporary street clo- sures. Typically, these occur for a few hours after school, so that children can run, bike, jump rope and play in the public realm while neighbors of all ages get to know one another. The initiative encourages partici- pants—many of whom lack convenient ac- cess to parks and other safe outdoor activ- ity spaces—to be physically active, while providing an increasingly rare opportuni- ty for all neighborhood residents to forge vital social connections. Playing Out’s goals are to increase con- nections and improve relationships be- tween neighborhood residents of all gen- erations at a time when, according to Cortright, an alarming one-third of Americans say they have never interacted with their neighbors; to increase neigh- borhood collective efficacy, or the sense that residents have control over their en- vironments and collective futures; and to By Danielle Fixen I n the United States, 33 states and the District of Columbia have legalized marijuana in some form; however, under federal law, marijuana remains il- legal and is classified as a Schedule I con- trolled substance, along with heroin and lysergic acid diethylamide (LSD). The Drug Enforcement Administration states, “Schedule 1 drugs, substances or chemi- cals are defined as drugs with no current- ly acceptable medical use and a high po- tential for abuse.” Laws differ in states that have legal- ized marijuana; for example, in Colo-

By M. Katherine Kraft and Kathy Sykes A growing body of evidence sug- gests that in recent decades the amount of time spent interacting with others in the public realm has de- clined. “While we have more leisure time, we spend more of it alone or isolated by technologies as diverse as the private auto- mobile and personal headphones,” writes Joe Cortright, a contributor to City Obser- vatory, a website and think tank that ad- dresses cities’ issues and the policies that shape them ( ). Our car-centric landscapes and digital- ly focused lifestyles have not only expand- ed our waistlines, but also have helped to fuel social isolation. Just as creating safe places in which people can exercise and play in the public sphere can serve to coun- teract inactivity and its related ills, so can this effort be a valuable mechanism for improving community interactions and building social connections—for reviving what Cortright calls “the civic commons, the places we share with the rest of society ... where interaction underpins opportuni- ty and democracy.” Approximately one-third of Ameri- cans older than age 65, and half of those older than age 85 live alone. Many of them feel isolated, which worsens their health ( ). Social iso- lation and loneliness, which are major risk factors for physical and mental ill- ness, especially in older adults, have been identified as risk factors for “all-cause morbidity and mortality with outcomes comparable to smoking, obesity, and lack of exercise ...” ( ). The Price Tag of Social Isolation The costs of social isolation are both mon- etary and societal. According to a study by AARP and Stanford University, social iso- lation is estimated to increase Medicare costs each year by $6.78 billion ( tinyurl. com/y8o6rdjm ). Social isolation also can contribute to growing distrust among neighbors, and perpetuate unsafe conditions and the physical decline of public space. Societal- ly, it can make the process of democracy

spire similar efforts in Seattle (2014) and in Toronto, Canada (2016). A 2016 evaluation of Playing Out and similar street play events in England found compelling qualitative and quantitative ev- idence of success in building social cohe- sion and stoking physical activity ( tinyurl. com/yagb7l7p ). The street closures were found to increase intergenerational social interaction betweenneighbors, friends and families. The comments of one mother were typical; she and her 5-year-old son had lived on their street for years but bare- ly knewany of their neighbors before street play events began. Now they know a lot of people. “Before this, I hardly spoke to any- one,” she stated in the evaluation report. In some cases, researchers found street-play events generated invitations to different social gatherings and fur- thered interest in other community ini- tiatives that enabled residents to get in- volved in meaningful ways and to feel agency over the future of their neighbor- hood. They also found that the process of applying for street closures can help to build community connectedness. Finally, these events challenge existing social norms about the meaning of public rights and inspire communities to re- imagine how use of public space can sup- port vital and vibrant neighborhoods. America Walks, a national nonprofit net- work of walking advocates, is working with communities nationwide to lift up all of the ways that streets and the public space can provide effective and affordable approaches to address social isolation and create connected, safer, accessible, walk- able communities. n M. Katherine Kraft, Ph.D., is executive director of America Walks. Kathy Sykes, M.A., retired from the U.S. Environmental Protection Agency, is on the Board of Direc- tors of America Walks and on the Aging Today Editorial Advisory Committee. older ( The study found that 26 percent of patients using cannabis have a prescription or medical marijuana card. The remaining patients obtain their supply recreationally (49 per- cent), through a family member or care- giver (18 percent) or through other sourc- es (15 percent). The primary symptoms targeted for use of cannabis in this popu- lation were chronic pain (64 percent) and sleep (38 percent). Cannabinoids and Their Effects Cannabis plants are composed of more than 100 cannabinoids. Cannabinoid com­ position is the biggest difference between marijuana and hemp, both of which are species of cannabis. Hemp contains a very low concentration of tetrahydrocan-

munity engagement and mitigating social isolation, as it recognizes that our modern environments can fuel social isolation and thus leverages the scale of the neighbor- hood street to help mitigate this social ill. Playing Out events create people- centric spaces out of typical city streets, reviving, even if temporarily, their his- toric significance, while creating vital op- portunities for social interaction so people can again feel like valuedmembers of their communities. In sum, these events can help to expand social capital (defined by researcher Kevin Leyden as “social net- works and interactions that inspire trust and reciprocity among citizens”) by al- lowing neighbors a chance to become ac- quainted, to trust one another and to be more socially and even politically engaged ( ). Another of Playing Out’s strengths is its simplicity; because it relies upon one of a neighborhood’s most prolific and often underused public physical assets—its streets—and upon a captive audience of beneficiaries, its residents, the model ne- cessitates no permanent physical chang- es, nor does its success necessitate attract- ing people to distant venues. Playing Out is remarkably inclusionary, requires no specialized equipment or transportation and accommodates people of virtually all ages, levels of mobility and incomes. Also Playing Out events are recurring, rather than one-off, and their effects have prov- en to be catalytic. The Outcomes of Playtime At its heart, Playing Out represents a reca- libration of our long-standing attitudes to- ward the street, the public sphere and the meaning of neighborhood. Since its launch, the model has been employed to host events on more than 500 streets across the United Kingdom, in more than 60 local authorities, and has helped to in- rado, recreational and medicinal marijua- na are legal and there are 85,207 active patients in the Medical Marijuana Regis- try Program (for specifics on states’ laws, see ). Approximately 20 percent of patients on the Colorado registry are ages 61 years and older, and report using medical marijuana for severe pain ( ). Unfortu- nately, these numbers do not indicate the number of patients who use recreational marijuana for medical conditions. Reynolds and colleagues conducted a survey in a geriatric primary care clinic to determine characteristics and patterns of cannabis use in adults ages 65 years and

Some facts—and unanswered questions—about cannabis use in older adults

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