AgingToday_MayJune2020

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Leadership series kicks off p. 3 | Two leaders’ takes on pragmatism and inspiration

On baby boomer retirees p. 13 | Ken Dychtwald’s new book looks at life in the Third Age.

Aging

Covering advances in research, practice and policy nationwide www.asaging.org

MAY–JUNE 2020 volume xli number 3

the bimonthly newspaper of the American Society on Aging t i t l f t i i t i

In nursing homes, the “best care possible” is linked to the “best life possible”

In this issue

Medication adherence education does work page 4

AARP THOUGHT LEADERSHIP Improving the global health and wealth spans for an aging populace page 5 AGINGWHILE . . . Challenges—and opportunities—for women as they age page 6 IN FOCUS The nursing home reboot: it’s long overdue pages 7–11 New Learning Collaborative puts CBOs in the know about partnering page 15

What does it mean to live the best life possible? In this time where efficiency rules the day, some might believe that liv- ing a best life is too complex and therefore unattainable—especially for those living in long-term-care settings. But in reality, living one’s best life boils down to simple things that most of us who don’t live in these settings take for granted. The best life possible means recognizing that older adults are the experts on their own lives. In simplest terms, a best life possible means recognizing that adults living in nursing homes are the experts on their own lives. They have spent decades per- fecting every aspect of meeting their own needs; they know what works for them and what doesn’t, and they deserve to CMS annually updates the clinical quality measures approved for its pro- grams. Effective Jan. 1, 2020, CMS ap- proved including malnutrition clinical quality measures in two Qualified Clini- cal Data Registries, the Premier Clinician Performance Registry and the U.S. Wound Registry (see Table 1 on page 12). CMS’ value-based programs reward healthcare providers with incentive pay- ments for the quality of care they deliver to Medicare beneficiaries. These pro- grams are part of CMS’ larger quality strategy to reform how healthcare is de- livered and paid for in the United States. One example of a CMS value-based program is the Merit-based Incentive Payment System (MIPS), which is used by physicians and outpatient healthcare pro- viderswho do not report through a health- care system or a large group quality management program. Starting in 2020, outpatient providers reporting through MIPS can choose to report on the CMS- approved malnutrition clinical quality measures; a focus on malnutrition could help to improve patient quality of care be- cause, as documented in a recent U.S. Government Accountability Office report, “barriers to older adults’ meeting nutri- The CMS QualityManagement Program—andWhy It Matters

By Ann Wyatt and Tena Alonzo T hose of us who have worked in the field of aging have long been con- cerned with how to provide the best care possible for individuals who are frail, ill and in need of help. This concern remains, but our understanding of how to achieve such care continues to evolve, startingwith parsingwhat is meant by the “best care possible.” The most progressive among us came ear- liest to the notion that the best care pos- sible is inextricably linked to the best life possible, and that this standard is person- al, specific and differs for everyone: we cannot provide the best care for someone if we do not figure out all that we can about what constitutes a person’s best life, from their perspective. The Best Care Possible, the Best Life Possible CMS takes a significant step forward to help end elder malnutrition By Bob Blancato C urrently, up to one in two older adults is malnourished or at risk for malnutrition. Yet, malnutri- tion is not systematically screened for, as- sessed, diagnosed or treated in the U.S. healthcare system. As 2019 ended and the World Health Organization’s Decade of Healthy Aging began (learnmoreat tinyurl.com/wdat74f ), a significant achievement was reached that is worthy of recognition and atten- tion. For the first time, the Centers for Medicare & Medicaid Services (CMS) ap- proved multiple malnutrition-specific clinical quality measures for a CMS quali- ty management program. Clinical qualitymeasures are tools that help to measure and track the quality of healthcare services provided by health- care professionals and institutions. Evalu- ating and reporting quality measures help to ensure America’s healthcare system is delivering effective, safe, efficient, pa- tient-centered, equitable and timely care.

maintain a sense of their expertise no matter how frail or ill they may become. Nowhere is the link between quality of care and quality of life more apparent than in nursing homes, where people live for weeks, months and years with increas- ing frailty, and where choices about what matters most can easily be overwhelmed by organizational priorities. Changing the culture of long-term care to accommodate each person’s life exper- tise has been in process for years and is the basis of the person-centered movement. However, the challenge of fully embracing person-centered care lies in the struggle to change howorganizations get things done. To acknowledge and accommodate each

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The 2020 ASA Award winner: a staunch mentor, teacher and caregiver advocate T he 2020 ASA Award goes to Louis Colbert, who has spent four decades serving older adults in roles at area agencies on aging. The ASA Award is pre- sented to an individual who has made out- standing contributions to aging-related research, administration or advocacy. Louis Colbert is an extrovert with an infectious laugh, a matching sense of hu- mor and genuine warmth. But underlying that engaging exterior lies a serious well of concern for older adults and an immense desire to help not just elders, but also pro- fessionals in the field of aging. As a child, Colbert watched his parents care for his grandparents and older neighbors, and it wasn’t until he was midway through high school that he realized not everyone lived The caregiver support group ‘has been such a revelation and a joy.’

Louis Colbert

with a grandparent. “I have so many won- derful, positive memories, and it’s all con- nected tomy interest in this work,” he says. A Start in Senior Services Colbert held his first field placement in 1976 at an area agency on aging (AAA) in his hometown of Media, Penn., while earning his Masters in Social Work from Temple University. He says he was lucky to be mentored by his young bosses, and there he developed an abiding love for working directly with older adults. His first job out of graduate school was as a group services coordinator with the

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Aging Today May–June 2020

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Update

Aging

virtual sessions. This is a fluid process, but by press time in late April, multiple spon- sored conference summits and sessions are being conducted virtually, often as a set of webinars (throughout the spring, summer and fall), including the Managed Care Summit, the Diverse Elders Coalition session, and AARP Foundation’s session. The TownHall Meeting is likely to happen virtually, but on a date closer to the No- vember election. The National Forum on Access to Jus- tice has been pushed forward to AiA 2021, and we will offer added online content in advance of the Forum. Most constituent group meetings will go online as well, and some General Sessions will be available virtually, as will certain highlighted ses- sions. ASA staff polled workshop present- ers to determine their interest in holding virtual workshops, and answers have trended positive. Our friends at Creative Aging SF and Covia kindly offered to curate a creative aging series of sessions via Zoom, to en- able more AiA2020 online presenta- tions than our current capacity permits; we thank them for their generosity! Check www.asaging.org for announce- ments about online sessions. All virtual conference content will be archived and available for viewing. Moving Ahead, with a Positive Plan Similar to how some of our members lead by example (e.g., Seattle–King County area agencies on aging passing along criti- cal information from ground zero; San Francisco’s Community Living Campaign offering activities to prevent social isola- tion; Justice in Aging curating a list of fed- eral and state resources; tinyurl.com/ tq3s9p6 ), ASA staff and the membership at the large have shown a refreshing will- ingness to try new ways of disseminating the in-person education normally offered onsite at AiA. People in the community were also looking for ways to help. In March, ShireenMcSpadden, executive director of the City and County of San Francisco De- partment of Disability and Aging Servic- es, said that to prevent social isolation, “Neighbors need to reach out to neigh- bors. Leave a note. Knock on a door. Just stay 6 feet away, and ask if they need any- thing.” Or, she says, just call. While March was a rollercoaster ride, we are steadily moving toward spring and summer with a positive outlook for the future. And now we will get busy work- ing on our 2021 annual conference, to be held in San Diego next April! Again, our thanks to our members and the field for their patience and understanding, and we hope everyone takes advantage of our “virtual” conference offerings. n WRITE TO US We welcome your responses both to Aging 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 ahood@asaging.org

American Society on Aging www.asaging.org 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 www.asaging.org/publications . For membership or other information about ASA, call (415) 974-9600, fax (415) 974-0300 or visit www.asaging.org . Subscription Price: individual non- members: $74.00/year (included with annual membership); nonmember institu- tions/libraries: $110.00/year. Subscription

Stepping up in troubling times

Prior to serving at SoFIA, I was a se- nior executive in JPMorgan Chase’s Of- fice of Corporate Responsibility, where I managed a $20million philanthropic pro- gram that supported strategies to in- crease economic opportunity in cities worldwide. Having begunmy career as an attorney with the global firm of Weil, Got- shal, andManges, LLP, I also served as se- nior economic advisor in the Obama White House and worked in the Senate advising Sen. Debbie Stabenow (D-MI) on economic development policy. ASA Goes Virtual Little did I know that this past winter I’d be jumping into a new position during a global pandemic that has led ASA to shut- ter its 2020 Aging in America Conference (AiA), which prior to this year had run for 66 years straight. What I’ve learned since assuming my new role is that the ASA staff, its Board, members and partners are eager to forge opportunity out of this challenge we all face. I’d like to thank our members for their gracious acceptance of our decision to cancel this year’s conference. And I laud the ASA staff for working as diligently on the ramifications of this cancellation as they have done on the conference itself. Immediately after cancelling AiA, we began working on (with the organized, calming influence of InterimCEOCynthia Banks) which parts of AiA could work as

By Peter Kaldes | ASA President and CEO

H ello, ASA mem­ bers! OnMarch 10, I joinedASA

as President and CEO. March 9 was the day AiA2020 was cancelled due to COVID-19. You can say that I’ve had to hit the ground running! I trust all of you are well and you are get- ting used to the “new normal.” I am eager to learn all I can about our membership and your needs. By advancing ASA’smission, wewill expand and empow- er the field of aging. I hope also to become acquaintedwithmany of you personally, as I greatly admire the work of ASAmembers and want to assist in any way I can. A bit about my background: Most re- cently, I served as president and CEO of the South Florida Institute on Aging (SoFIA), where I successfully trans- formed the 55-year-old nonprofit with a new name, mission and innovative pro- gramming, bringing fresh energy, vitality and purpose to senior-facing services in South Florida. During my tenure, SoFIA developed a three-year strategic plan and launched many new initiatives to close the gap in socioeconomic well-being for older adults. Peter Kaldes

agency rate (institutional rate only): $94.00/year.

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.

ASA Board Chair: Michael Adams

ASA President and CEO: Peter Kaldes

Editor: Alison Hood

Senior Editor: Alison Biggar

Design & Production: Michael Zipkin | Lucid Design

EDITORIAL ADVISORY COMMITTEE

Chair, Robert Espinoza, Vice President of Policy, PHI, Bronx, New York Immediate Past Chair: Robyn L. Golden, Director of Health and Aging, Rush University Medical Center, Chicago, Illinois Donna Benton, Director, USC FCSC/ LACRCA, Los Angeles, California Diane Brown, Executive Director, Medicare Strategy & Operations, Kaiser Permanente Northern California, Oakland, California Paul Greenwood, Elder Abuse Expert Witness and Teacher/Consultant, San Diego, California Kristi Mellion, Director of Programs, Alzheimer’s Services of the Capital Area, Baton Rouge, Louisiana 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 Sandra von Doetinchem , Program Specialist, Outreach College Professional Programs, University of Hawaii at Manoa, Honolulu, Hawaii

Mark your calendar!

Present at AiA21! Submit a proposal to present at the conference in sunny San Diego! Call for proposals opens in June. www.asaging.org/aia

Aging Today is printed with soy-based ink on 100% recycled paper.

Union Bug

Aging Today May–June 2020

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Kathy Greenlee: care about and advocate for humans— but be finance-savvy E ditor’s Note: This past January, ASA surveyed its members about what it takes to be a leader in the field of ag-

AT : What do you think is themost critical skill to have as a leader? KG :To know that the greatest assets at your dis- posal are the people who work for you, and that your success depends upon them. AT: Can you speak to one leadership challenge encountered on the job and how you met it? KG : I was in a job once where I felt like I could do a better job at my super­ visor’s job than they were doing, but that person wasn’t going anywhere. So out of respect for that supervisor, I left. Sitting in that position is difficult and also isn’t respectful to the other person or to yourself. AT : What might you say to inspire younger potential leaders in the

Kathy Greenlee : The main differ- ence is the almost exclusive focus on hu- man services. It’s a very person-based type of work, an advocacy type of work— it’s not about widgets or numbers. Lead- ership in the field of aging means being involved in an area that is high-touch, human-centered and it shapes leaders who want a high-touch role. AT : How did you use networking to progress in the field of aging? KG : I come from a small state, and had been in state government for a long time, so it’s easier to navigate; I knew people

ing, what members would like to learn about how to develop leadership knowledge, skills and abilities, and who best personifies lead- ership. ASA members identified respected leaders in aging—many of whom are well known to the ASA community and to the field at large. The following Q&As with Kathy Greenlee and Sandy Markwood are the first two in a series of leadership profiles we will feature in Aging Today , and online at ASA’s AgeBlog , in the coming months. Kathy Greenlee is a consulting princi- pal in the Kansas City office of PYA, P.C., a healthcare consulting firm based in Knox- ville, Tenn. From 2009 to 2016, she served as Assistant Secretary for Aging at the U.S. Department of Health & Human Services, where she created the Administration for Community Living and was its first Ad- ministrator. Greenlee also has served as the Kansas Secretary for Aging, Chief of Staff and Chief of Operations for then-Gov. Kathleen Sebelius and as General Counsel for the Kansas Insurance Department. She is a member of the Board of Directors of the National Council on Aging. AT : How might you describe the ways leadership in the field of aging differ from leadership in other fields?

‘Leaders must understand money.’

from all branches of government. I have used two types of networking, one is pro- fessional, as a leader in aging in the state and a member of a national association. The other is political, where I was actively involved at the state and local level. I needed both networks. AT : What sort of education did you find most helpful? KG : Legal training [Greenlee has a Ju- ris Doctor degree] is a solid foundation for any type of involvement in government, in any branch. The most helpful things I

also have to have the ability to bring peo- ple together towork to achieve that vision. And though inspiration is critical, it’s not the only critical skill. AT: Can you speak to one leader- ship challenge encountered on the job and how you met it? SM : One of the major moments for me occurred after the passage of Medicare Part D in 2003, and its launch in 2006. The Administration, the Administration on Aging (AoA) and CMS saw a role for the aging network in the rollout of Part D. They asked for the aging network to orga- nize and increase awareness about Part D, and start the enrollment process. N4a was chosen to lead the coalition (with incred- ible partners) and come together as a net- work to achieve the goals AoA and CMS set for us. Not only did we achieve those goals, we exceeded them by 200 percent. To this day, I’m very proud of the collabo- ration we formed and the work done to achieve those goals. AT: What might you say to inspire younger potential leaders in the ag- ing sector? SM : When new staff are coming into our agency, even if they are a step away from direct service, we always provide themwith an opportunity to go to an area agency on aging and see the programs and see the people being served. That’s the most powerful way to be inspired, to put faces and stories to the people in- volved in programs. Once you see the people … you can’t help but be inspired, it ignites a passion in you to ensure that those who have lived a long time will be able to live out their years as well as pos- sible—to live in the ways they deserve to live, and to be supported. n aging sector? KG : People who are interested in ca- reers that can make a difference in peo- ple’s daily lives, working for the short- and long-term improvement of outcomes, should be attracted to this field, as that’s what it’s all about. What else should at- tract young people to the field is its com- plexity. I find it fascinating. The field of aging is so broad and complicated that people become multi-dimensional lead- ers. It’s very satisfying as a leader. n

learned about along the way are Medicaid and insurance. I was at the [Kansas] in- surance department for eight years and know the fundamentals of how insurance works. Because I knewMedicaid, I under- stood financing. When I talk to people en- tering any field, I talk about budgets. If you want to understand policy you must understand budgets. Leaders must under- stand money. Change comes from chang- ing how the money is spent, especially for long-term strategy. perspective, my goal is to elevate, amplify and ensure people understand the needs of older adults. AT: How did you use networking to progress in the field of aging? SM : When I worked at the National Association of Counties, I led the chil- dren’s coalition; the mantra was that it takes a village to raise a child, and the same applies here: it takes all aging orga- nizations coming together to be able to ensure that older adults get the services

choice in their homes and communities for as long as possible. “We focus on advo- cacy,” Markwood says, “[and] one of the primary goals of the organization is building the capacity of our membership base to be able to do the great work they do in the community. It’s a privilege to be able to support a network of ag- ing professionals on the ground, every day, serv- ing older adults and people with disabilities and their caregivers. “Every day it’s a differ- ent job as different issues arise, whether on Capitol Hill or at the state level or in an issue with the Elder- care Locator help line. I love my job.”

Once you see the people [being served] you can’t help but be inspired.

and supports they need and are valued to the degree they deserve. To succeed, it takes understanding what you bring to the table, and honoring and respecting what others bring, and recognizing that you’re stronger together. AT: What sort of education did you find most helpful? SM : I have a Master’s degree in urban environmental planning, but I have relied on the skills and mindset acquired through work in urban planning (I had a specialty in social planning) my entire ca- reer. How you look at and assess a com- munity, how you determine who the stakeholders are—you’re always looking at it from the lens of bringing people to- gether to solve problems, plus project management. AT: What do you think is the most critical skill to have as a leader? SM : You know the saying, “Manage things, lead people”? I think it’s inspira- tion. You have to have a vision, but you

Sandy Markwood: leadership = collaboration + inspiration S ince 2002, Sandy Markwood has served as CEO of the National Association of Area Agencies on Aging (n4a), in Washington, D.C., sup- porting n4a’s Board of Directors while leading the organization and staff to meet its mission to help older adults and people with disabilities to live with dignity and

AT: How might you describe the way leadership in the field of aging dif- fers from that in other fields? Sandy Markwood : Prior to coming to n4a, I worked for 25 years at local govern- ment associations—in aging, but also in healthcare and community development and transportation. I thought I had met the most committed people in the world, and I still have the highest respect for anyone working in local government. But I have never worked with people who have such passion and commitment for the work they do as I have in aging. It’s my job to honor and respect, but also to fun- nel that passion to others. The difference here is who we serve. From a leadership

Aging Today May–June 2020

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The Long-AwAiTed Book To heLp oLder AduLTs Thrive TodAy And Tomorrow

Educating elders about medication adherence can yield positive outcomes

Caregivers who assist with medication management can overlay their own set of non-adherence barriers, further compli- cating the situation. Edward: A Case Study Seventy-nine-year-old Edward has diabe- tes. He has been hospitalized several times due to severe dysglycemia. Not long ago, low blood sugar caused him to have a bad fall, and most recently he was on the verge of a diabetic coma from extremely high blood sugar levels. Both are especial- ly concerning because Edward lives alone. He is highly motivated to manage his dia- betes medications to avoid further com- plications—he has no cognitive issues, speaks English and has finished high school (demonstrating a basic level of health literacy), so he understands the im- portance of controlling his blood sugar. However, Edward is legally blind. Luckily for Edward, an observant case manager recognized his medication safe- ty issues and referred him to an in-home community medication safety program, called Community Medication Educa- tion, Data & Safety (C-MEDS) for assis- tance. C-MEDS is an in-home service established by Independence at Home, a community service of SCAN Health Plan (a nonprofit Medicare Advantage plan founded in 1977 with the goal of keeping older adults healthy and independent). The aim of C-MEDS is to identify and resolve medication-related problems and associated risks, in part by increasing self- efficacy in safe medication management and use. Available to those ages 55 and old- er and their caregivers, there are no in- come, insuranceordisabilityrequirements. Services are provided at no cost to the com- munity at large in Southern California. Home Visit Reveals Multiple Issues What did the medication team find when they visited Edward at home? His most recent hospital admission was related to extremely high blood sugar, but Edward believed he had been administering his insulin correctly. However, his insulin bottle had been empty for an unknown

An estimated 125,000 people die each year in the United States due to medication non-adherence. TheWorld Health Organization (WHO) reports that an estimated 125,000 persons with treatable conditions die each year in the United States as a result of medica- tion non-adherence. Additionally, the WHO estimates that 10 percent to 25 per- By Marsha Meyer M edicationmishaps are extreme- ly common in older adults. The Centers forDiseaseControl and Prevention (CDC) reports that adults older than age 65 are twice as likely to visit an emergency department for a medication- related problem than are younger people, with more than 177,000 visits reported per year. Also, older adults are seven times more likely to be hospitalized following an emergency department visit related to medications, primarily because of inade- quate monitoring of key medications. cent of hospital and nursing home admis- sions are the direct result of medication non-adherence. While non-adherence is a common problem, it also is a complicated one. Suc- cess in increasing adherence requires that all obstacles be identified and addressed. The WHO categorizes non-adherence barriers into the following buckets: • social and economic (e.g., language; health literacy); • health system (e.g., lack of continuity of care; poor provider−patient communica- tion/relationship;weak training andeduca- tion around the condition; and treatment); • condition-related (e.g., “silent ill- nesses” lacking overt symptoms, such as depression); • therapy-related (e.g., lack of immedi- ate benefit from the medication; high dose burden; treatment interfering with life- style); and • patient-related (e.g., physical factors like visual impairment; cognitive impair- ment; and fear of possible side effects).

special 40% discount for AsA members

9781119648086 • Hardcover • $28

In this entertaining and thought-provoking book, world-famous “Age Wave” expert Ken Dychtwald, PhD and author Robert Morison use 30 years of research to explain how individuals, businesses, non-profits and governments can gear up for a new era—where the demands of the “Third Age” will set the lifestyle, health, social, financial, marketplace and political priorities of generations to come. This exciting new stage of life, the “Third Age,” poses daunting questions among which are: What will “old” look like in the years ahead and with continued advances in longevity, will all of the traditional lifestage markers need to be adjusted? What ageist marketing practices are hurting people — and stymieing innovation? What incredible new technologies of medicine, life extension, and human enhancement await us in the near future? Will the majority of elder boomers outlive their pensions and retirement savings and how can this financial disaster be prevented? What is the potential for unleashing the growing ranks of retirees as a volunteer force for the greater good? What purposeful new roles can we create for elder boomers so that aging nations can capitalize on the upsides of aging? AsA memBers cAn sAve 40% by preordering the book now at: 800ceoread.com/WhatRetireesWant

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Aging Today May–June 2020

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Global aging: achieving readiness and competitiveness across the globe By Ben F. Belton E ditor’s Note: This column is spon- sored by the AARP Public Policy In- stitute. Thought Leadership drives AARP THOUGHT LEADERSHIP

How can we add well-being and value to those added years? form to highlight innovations from around the world that help people enjoy longer, healthier andmore financially secure lives. The ARC measures how select countries— large and small—are addressing the chal- lenges and opportunities of population aging. The 22 countries featured in the re- port were identified as regional leaders in aging policy innovation. Many of these countries’ most interest- ing programs were created around a set of common themes. The programs were person-oriented —developed by direct- ly engaging users. With national govern- ments providing strategic direction and funding, programs developed from the bottom up through NGOs and frontline stakeholders. Programs also were holistic and interdisciplinary , taking an integrative approach to developing solutions; and the interventions were evidence-based , with clear metrics for success and data collec- tion mechanisms. comes with worsening health, vulnerabil- ity to financial shocks and the risk of long- term economic instability. Older women are especially at risk, as they tend to have lower lifetime wages (resulting in less savings for retirement) and smaller pen- sions. They also are more likely to become impoverished. In developing countries where women tend to work in the infor- mal sector with little social protection, these challenges are further exacerbated. Thus, along with great opportunity, longevity brings great challenges. But so- lutions are available. Global Examples of Innovation In 2017, AARP commissioned the Aging Readiness and Competitiveness Initiative (ARC; arc.aarpinternational.org/) as a plat- via integrated health and social care and age-friendly environments; harnessing technology, science and medicine and as- sistive technologies to foster healthy ag- ing; and engaging civil liberty groups, communities and the private sector in policy and program design and delivery. It is aimed at changing how people think, feel and act toward age and aging; ensuring communities foster the abilities of older people; delivering person-centered integrated care and primary health servic- es that are responsive to older adults; and providing access to long-term care for old- er people who need it. Partnerships will be key to implement- ing such an ambitious plan, and the WHO will establish a platformuponwhich stake- holders will convene to promote action. The plan also mentions engaging elders in the process, and nurturing leadership. Progress on goals set will be measured and tracked in what the WHO calls a “whole-of-government,” “whole-of-soci- ety” response. The decade implementa- tionwill be led by each country, supported by the United Nations country teams. n

the creation of a marketplace for new ideas by advancing emerging issues, challenges the status quo and inspires new solutions that empower people around the world to make the most of a longer and healthier life. The United Nations estimates ( tinyurl. com/tdqczpj ) that by 2050 the world will be home to 1.5 billion people ages 65 and older. From Naples, Italy, to Naples, Flori- da, and from Athens, Greece, to Athens, Ohio, our global society is changing. Hu- man longevity is transforming markets and spurring innovation. Here in the United States, people ages 50 and older already contribute $8.3 tril- lion in economic activity, which will more than triple to $28.2 trillion by 2050, according to AARP’s recent report, “The Longevity Economy Outlook: How Peo- ple Ages 50 and Older Are Fueling Eco- nomic Growth, Stimulating Jobs, and Creating Opportunities for All” ( tinyurl. com/seq5uhm ). Greater longevity is one of the most significant achievements ofmodern times. However, this progress must not stop with simply extending years of life. The question becomes one of how we can add well-being and value to those years. Ulti- mately, every sector has a stake in ensur- ing aging populations can reach their full potential. To harness longevity’s transfor- mative power, investments in human cap- ital must not have an age limit. As part of achieving those outcomes, for people to age with dignity and inde- pendence, countries must improve the “health span” and “wealth span” of their populations. Too often and in too many parts of the world, a longer life span Decade of healthy aging T he World Health Organization (WHO) has named 2020–2030 the Decade of Healthy Ageing, which means that for 10 years there will be a con- certed effort to bring together governments, international agencies, professionals, aca- demia, the media and the private sector to collaborate on improving the lives of older adults, their families and communities. Theworldhostsmore than 1 billionpeo- ple older than age 60, most living in low- and middle-income countries, without access to basic resources. In a 24-page doc- ument ( tinyurl.com/ss4vg4v ), theWHOhas laid out specifics on this effort, the goal be- ing to add better years of life for all elders. Globally, older adults’ health has not im- proved over previous generations, nor is older age or good health distributed equal- ly between or within populations. Focused on the second half of life, the plan is based on a human rights approach, concentrating on fostering healthy aging

Ideas highlighted in the ARC can ben- efit countries around the world—and the United States can learn much from other regionally and economically diverse countries. Two areas in which many ARC countries, such as Germany, Singapore and the Netherlands, have made signifi- cant progress are healthcare and commu- nity social infrastructure. Community social infrastructure can be described as the social foundation that supports inde- pendence and aging in place. Progress in Healthcare : Many coun- tries’ health systems are working to ad- dress fragmentation, inefficiency, accessi- bility, affordability and health outcomes. As countries move to expand health cov- erage, the World Health Organization (WHO) calls for innovative age-friendly reforms such as “investments in integrat- ed health and social care for older people” ( tinyurl.com/v869gqu ). Greater Manchester, England, is an in- novator in this area. The Greater Man- chester Health and Social Care Partner- ship merged budgets for health and social care to “improve the health, wealth and wellbeing” of its 2.8 million residents. From the beginning, the Partnership made tackling dementia a priority, and supports care homes to improve residents’ quality of life. Meanwhile, as the ARC highlights, under Australia’s Health Care Home model, general practitioners (GP) coordinate care for patients with complex needs, facilitating access to personalized integrated care. For example, GPs work with patients to develop personal care plans incorporating medications and dai- ly strategies tomanage chronic conditions and to identify local care providers. In Africa, the small island nation of Mauritius has facilitated accessibility. The Ministry of Health designed a system of health facilities so that there is at least one such facility within 3 kilometers of all homes on the main island. Older residents on the main island are usually never more than 2 miles frommedical care. In Costa Rica, the delivery of primary care—especially to remote or poor popu- lations—is understood to be a key factor in reducing mortality rates in the country. A network of primary care clinics is the first level of care, which provides primary and preventive care for all residents in a community, including integrated care for older adults. Progress in Community Social In- frastructure : After healthcare, many ARC countries made the most progress in supporting independence and aging in place. Key elements of community social infrastructure are accessibility, social en-

Older residents on the main island of Mauritius are usually never more than 2 miles from medical care. In Norway, the Lindås municipality created the Interdepartmental Housing Team, in which a physical therapist, a construction expert and an economist work with older residents to develop per- sonal plans to help them age in place. Team members make a free home visit to perform needs assessments and then work with the resident to develop plans to gagement and the existence of community- based services and supports. Municipali- ties and sub-national levels of government have used WHO’s Age-Friendly Cities and Communities framework to foster holistic and age-friendly communities. improve accessibility and provide infor- mation on financial supports. In Turkey, Muratpaşa, a district in the city of Antalya, established social centers that are located in neighborhoods of dif- ferent income levels. These centers are where older people enjoy activities such as painting, dancing and reading. The mu- nicipality also runs a daycare center that provides social rehabilitation services for people with Alzheimer’s disease, as well as supports for their family caregivers. Finally, in Taiwan, Age-Friendly Com- munity Banks—first launched in Hsin- chu—typically have barrier-free facilities, areas where older customers can socialize and also have access to wheelchairs and magnifying glasses. This model has been so successful that it was replicated for the postal network. A Transformational Trend This massive global demographic shift requires a change in how we leverage the opportunities and address the reali- ties that accompany increases in longevi- ty. Outmoded ideas associating longevity with decline and non-contribution must give way to a new vision focused on op- portunity and possibility. AARP will continue to elevate aging in the pub- lic discourse, advance new research and engage global stakeholders to share promising innovations from around the world. As AARP founder Dr. Ethel Percy Andrus said, “It is vital that we pay at- tention to other important politi- cal systems—particularly those with a worldwide impact.” n Ben F. Belton is director, Global Partner Engagement, at AARP International, in Washington, D.C.

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serving 86 percent low-income job seek- ers, many of them women. Self-Employment Is an Option When women are consistently paid less, are forced out of the workforce early or become unable to get jobs after a certain age, it’s no surprise they might opt to work for themselves. Despite the lack of an employer-sponsored benefits safety net, more women are starting businesses than any other demographic group, and women-owned businesses now represent 42 percent of all U.S. businesses. The AARP Foundation helps women explore this option. People with an entre- preneurial bent can join the Foundation’s

penalty” for having children ( tinyurl.com/ qoyj2yl ). Mothers earn only 71 cents to ev- ery dollar paid to fathers. That penalty translates to a loss of $16,000 annually, which over a lifetime adds up to a consider- able amount, especially when considering the compound interest on greater wages, reduced Social Security and other benefits. Contrary to the assumption that more education might reduce the penalty, the earnings gap only grows as women obtain advanced degrees. Mothers with doctor- ates earn $25,000 less annually than do men with equal education. The mother- hood penalty persists across every age group, education level, occupation, race and ethnicity—and in every state.

AGING WHILE . . . Aging while … female: beyond the “business case,” what opportunities exist for women as they age? By Lisa Marsh Ryerson E ditor’s Note: This new Aging Today column, “Aging While…” is sponsored by AARP Founda- American women earning just 62 cents and Latina women bringing in only 54 cents to a man’s dollar. Women also earn lower wages because they are segregated into low-paying occupations ( tinyurl.com/yx6vcbr6 ). Male- dominated jobs, such as construction and

manufacturing, generally pay more than those jobs traditionally held by wom- en, such as teaching, nurs- ing and home healthcare. These jobs don’t pay less because they are low-skill jobs—they pay less because women do them. Gender-related age dis- crimination also plays a part. Although both men and women suffer from age discrimination in the workplace, it begins earli- er and is worse for women. Based on an examination of 40,000 job applications, a National Bureau of Eco- nomic Research study ( ti nyurl.com/w4uh6ar ) found “robust evidence of age discrimination in hiring against older women, es­ pecially those near retire- ment age” and much less discrimination against

tion. It will focus on creating and advanc- ing innovative solutions that help older Americans build economic opportunity and social connectedness. Many women ages 50 and older who earn low-to-moderate income still lack safe and affordable housing, food and job secu- rity, sufficient emergency and retirement savings and robust social connections. So- ciety has been slow to acknowledge these challenges that affect women’s financial security and well-being in later life. Society also has been slow to recog- nize the concrete financial value that women’s perspectives bring to the work- place. It wasn’t until 2016—232 years af- ter the first U.S. company was listed on the New York Stock Exchange ( tinyurl. com/wkpll43 )—that the Business Round- table (BRT), an association of American CEOs, endorsed the link between gender diversity on boards and long-term share- holder value. In so doing, the BRT made the first “business case” for gender diversity, which was subsequently confirmed by studies showing a strong connection be- tween women’s presence on boards and increased corporate profits. Another 232 years should not pass before the business sector recognizes the full value women bring to the workforce—and employs, pays and promotes them accordingly. WomenWork Hard, But Remain Poor Doreen, age 59 (a composite created from The Financial Health Network’s AARP Foundation–sponsored research; tinyurl. com/ts3ymya ), exemplifies challenges

male candidates. Evidence suggests that women may be denied training and promotion opportunities as early as age 40, while this starts at age 45 for men ( tinyurl.com/ t2ceu7w ). While a labor of love, female caregiving is strongly linked to a woman’s risk of aging into poverty ( tinyurl.com/wmc46xz ). Ac- cording to a 2019 AARP study ( tinyurl. com/sv6bjwn ), family caregivers who re- duce their hours, take more flexible or lower paying jobs or leave work can face short- and long-term financial difficulties. Time off from work for caregiving re- sults in an immediate loss of income, a re- duction in the caregiver’s ability to save for retirement and a possible reduction in eventual Social Security benefits. A care- giver who leaves work may find it difficult to regain a job that pays well—or any job. The same study found that 60 percent of caregivers are employed full or part time, a trend expected to grow in the fu- ture as more caregivers balance employ- ment and complex caregiving. AARP recommends that flexible workplace poli- cies, such as the ability to use sick days for caregiving, can help workers balance jobs with caregiving demands. Allowing care- givers the flexibility to work around care- giving responsibilities also could help. Apart from caregiving, National Wom- en’s Law Center research from 2018 con- firms what many women understand instinctively: women pay a “motherhood Penalties Paid for Caregiving andMotherhood

Women pay more than a third more per capita over their lifetime in healthcare costs than men. The AARP Foundation believes that one way to tackle the problem inherent in aging while female is with programs that spark economic opportunity for older, low-income adults—programs that will Women Pay Higher Healthcare Costs Healthcare costs also add to the expense of aging while female. Women pay more than one-third more per capita in health- care costs than men pay over their life- times, due to spending for pregnancy, post-partum care, family planning and longer life ( tinyurl.com/tqsunca ). Even a woman who is age 65 will spend about $47,000 more, just during retirement, for healthcare expenses than her male counterparts. help women create more opportunity and financial security across their lifetimes. One way is to help older adults get jobs. AARP Foundation’s Back to Work 50+ helps workers build the skills and confi- dence to compete in today’s job market. One successful program took place at Jefferson State Community College, in Birmingham, Ala. It offered job seekers strategy workshops, job search coaching and tuition assistance for job training,

Work for Yourself at 50+ program ( tinyurl. com/w4ase9t ) to investigate becoming entrepreneurs. With more than 40 part- ners across the country, the program gives older workers information on how to start and grow their businesses and ac- cess the capital needed to grow them. The many systemic problems women face and the economic toll these problems exact are not new, nor are their harmful effects on women’s economic welfare sur- prising. Rather, the United States must support policy solutions to eradicate dis- crimination, and design programs that create pathways of opportunity for wom- en throughout their lives. Paid family and medical leave, as well as affordable child- care, can help remedy the effects of the gender pay gap, the motherhood penalty and caregiving on women’s careers. Flexible workplace policies that let caregivers balance their responsibilities and use sick leave for care can be valuable options. Tax credits for caregiving are an- other possibility. Workforce development solutions that help employers continue to use older women’s talents, and that enable them to pay women fairly, would boost women’s earning power. We will continue to harness women’s collective power and voice and work with themand our allies to develop creative and bold solutions to aging while female. n Lisa Marsh Ryerson is president of the AARP Foundation, in Washington, D.C.

These jobs pay less because women do them.

women face. After a lifetime of working, illness forced Doreen to retire from her police officer job. While awaiting approv- al of disability benefits, she withdrew her nest egg of $15,000 from her 401(k). Until she can take Social Security at age 62, she scrapes by on less than $900 a month. Doreen’s lack of sufficient savings to cov- er her unexpected illness replaced her vision of a secure retirement with chron- ic financial anxiety. Doreen’s financial challenges are not uncommon. Nearly two-thirds of women ages 65 and older live in poverty. Older African American and Hispanic women are more than twice as likely to be poor as are older white women. One reason women age into pover- ty is because they consistently earn less than men. Women still earn about 81 cents for every dollar men earn ( tinyurl. com/t34weaq ), and women of color fare worse ( tinyurl.com/tbcp2hu ), with African

Aging Today May–June 2020

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Nursing homes: it’s past time for a reboot

This In Focus explores how nursing homes currently function and how they might be “rebooted.” In the Page 1 overview, Wyatt and Alonzo emphasize how elders are the experts in their own care— meaning they should always have a voice determining that care. Katz extends that concept to discuss improvements in care deliv- ery, regulation and care quality measurement. Montgomery expli- cates how culture-change training can prevent loneliness, bore- dom and helplessness among residents in care facilities. Edelman breaks down the need for better standards and enforcement around nursing home ownership, telling harrowing tales of bad actors. Greenwood updates us on the level of abuse in nursing homes, and what recourse families have. Baumann explains why comprehen- sive background checks would work to prevent abuse in nursing

homes. And Gauthreaux details how holding true to “authenticity” in senior living design can make these residential settings feel more like home. To send along your comments, ideas and feedback, email the Aging Today editor at ahood@asaging.org .

Ensuring the best care possible for future nursing home residents By Ruth Katz I t is time to bring nursing home quali- ty assurance in the United States into the 21st century. The last evidence-

although there was no comprehensive re- view of the evidence to ensure that they had produced the desired outcomes. Has this approach to quality worked? While overall nursing home quality has improved significantly, in a minority of places, unforgivable things still happen. Thirty-two years after OBRA 87, onMarch 6, 2019, the Senate Finance Committee held a hearing, “Not Forgotten: Protect- ing Americans from Abuse and Neglect.” As Harvard Professor of Health Care Poli- cy David Grabowski told the Committee at thathearing, “inspiteof [regulatory,financ- ing, ownership] changes…” many quality issues identified in 1974 persist today. But nursinghome qualityhas improved, and some harmful old practices have been eliminated. For instance, as late as 1996, 16 percent of facilities reported using phys- ical restraints on residents; in the third quarter of 2018, only .289 percent reported using physical restraints with long-stay residents. However, this is a very narrow standard by which to judge quality.

nursing homes in all parts of the country. But in many other government-certified nursing homes, individuals who are ad- mitted receive very inadequate—some- ‘Nursing home quality has improved, and some harmful old practices have been eliminated.’ times shockingly deficient—care that is likely to hasten the deterioration of their physical, mental and emotional health.” Soon after, Congress enacted the Nurs- ing Home Reform Act as part of Omnibus Budget Reconciliation Act of 1987 (OBRA 87), after which the Centers for Medicare & Medicaid Services (CMS) issued com- prehensive regulations and survey pro- cesses to “ensure that residents of nursing homes receive quality care that will result sons living with dementia also are experts on their own needs and they tell us all we need toknowthrough their actions. Armed with this knowledge, it is possible for everyone, regardless of circumstance, to live as fully as possible. For example, the United ChurchHomes of Ohio have deeply embedded these principals in all that they do ( tinyurl.com/yxyzrfjd ). Care Practice Progress Since OBRA The Omnibus Reconciliation Act of 1987 (OBRA ’87), also known as the nursing home reform law, provides an extraordi- nary vision and blueprint for providing high-quality care to people needing long- term-care services—a vision that has be- come only more relevant and more important than it was at inception. In the years since OBRA was intro- duced, there has been tremendous prog- ress on a number of fronts: care practice standards have greatly improved; the role of rehabilitation has been enhanced; there is increased focus on the essential role of cultural competence; there have been im- provements in equipment and environ- mental standards and design; the val- ue of palliative care is gaining attention; and discipline-specific professionaliza- tion has made great strides.

based, scientifically rigorous examination of nursing home quality, “Improving the Quality of Care in Nursing Homes,” was completed in 1986 by the Institute of Med- icine (IOM) ( tinyurl.com/so3qtoo ). The public policy context of that study, in part, was framed as follows: “… the implicit goal of the [nursing home] regulatory system is to ensure that any person requiring nursing home care be able to enter any certified nursing home and receive appropriate care, be treated with courtesy, and enjoy continued civil and legal rights. This happens in many

It is critical to remember that there is more variation within cultural groups than across cultural groups. Along with this progress, however, has come a tendency for increased compart- mentalization, as the focus is sometimes more on diseases, illnesses, disabilities and “behaviors,” than on the person. While cancer, heart disease, stroke and dementia are common late-life condi- tions, they do not affect any two people in in their highest practicable physical, men- tal, and social well-being.” Has Nursing Home Quality Improved? Over the 34 years since the IOM study, CMS created the five-star system, issued countless guidance documents, revised life safety and emergency prep rules, changed the survey process and wrote ad- ditional regulations nursing homes must comply with in order to participate in Medicare andMedicaid. The original 1988 Conditions of Participation were reissued in 2016 as Requirements of Participation, the same way. Care providers still strug- gle with how best to help people in their care to retain meaning and comfort in their daily lives. This is all the more true in a grow- ing multicultural world, wherein differ- ences (among staff as well as residents) in health status, race, national origin, religious affiliation, language, physical size, gender, sexual orientation, age, dis- ability (physical and mental), political orientation, socio-economic status, occu- pational status and geographical location all contribute to the challenge of differ- entiating between one person’s comfort and another’s.

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As Josepha Campinha-Bacote reminds us, “In obtaining cultural knowledge, it is critical to remember the concept of intra- cultural variation—there is more variation within cultural groups than across cultur- al groups. No individual is a stereotype of one’s culture of origin, but rather a unique blend of the diversity found within each culture, a unique accumulation of life ex- periences, and the process of acculturation to other cultures” ( tinyurl.com/sefvsll ). This idea, though challenging, gets right to the heart of why nursing homes exist in the first place. Aging, frailty and death are part of life, and as Dame Cecily Saunders, founder of the hospice move- ment, put it, “You matter because you are you and youmatter to the end of your life.” Those of us providing care in long- term-care settings face many obstacles. We don’t always succeed in supporting people, whatever their circumstances may be, to find meaningful lives, but we must never stop trying. As a 15th century folk saying advises, “Cure sometimes, treat often, comfort always.” n Ann Wyatt is consultant, Palliative and Residential Care, at CaringKind, in New York City. Tena Alonzo is director of Edu­ cation and Research at Beatitudes Campus, in Phoenix, Ariz.

person’s sense of expertise require not only a change in how things are done, but also a change in our beliefs. Long-term- care organizations with the greatest suc- cess in embracing residents’ individuality allow the following opportunities: • People can establish and maintain a daily routine that feels right for them, re- gardless of their circumstances. • People are afforded comprehensive pain management that focuses on physi- cal discomfort and, when needed, effec- tively addresses emotional distress. • People are assisted with activities of daily living—on their own terms. • People retain connections to those they care about and pursue life-long inter- ests that bring them joy. • People can live in environments that meet their needs, and which can be adapt- ed as their physical, cognitive andmedical needs change. Further challenges lie with caring for an ever-increasing number of people with dementia, who struggle to make basic needs known and require almost constant assistance. A tendency in the past has been for others to decide what is best for these adults. Professionals have learned that per-

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