Episode 62: Helping Our Patients Age in Place

Heather: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Heather Ward. My co-host Mike Clark is away this month.

Heather: In today's episode, we explore a topic that's been on my mind for a really long time. I'm a family physician and I practice in an aging county here in Maine. Part of my practice is really taking care of our older population. I see some of my older patients and their families just struggling with getting care and support that they need in order to age well and really safely at home. Families want help. I'd like to be able to give them help, but that can be really hard. Aging in place is a goal for most people, but the support to do so is pretty spotty and at best, inconsistent. Getting home health aides is sometimes impossible. Transportation can be tricky. Even like basic socialization can be hard. We are here today to talk about some of these challenges, but luckily there are glimmers of hope out there. And joining me today to discuss both the challenges and the hopes are Jess Maurer and Doctor Heidi Wierman. Jess is a longtime advocate for older Mainers and is the executive director of the Maine Council on Aging, and Heidi is a board-certified geriatrician and the division director of geriatrics at MaineHealth Maine Medical Center, Portland. Jess and Heidi, welcome.

Jess: So glad to be here.

Heidi: Thank you for having me.

Heather: Wonderful. So you both have dedicated your careers to improving the lives of older people. Naturally, your approaches and perspectives are very different. I would be really curious to hear from each of you your perspective on this work.

Jess: I think what I bring to this is a passion for social change in a way that is really defined my career generally. And so we look at challenges through the lens of aging and almost always are implementing solutions that work for everyone. And that really does work for us. And it actually creates a much broader conversation and many more opportunities to advance some of the solutions.

Heather: Fantastic. And Heidi, how about yourself?

Heidi: I bring the, I think, the clinical focus in focusing on older adults and aging with the working in healthcare. But I think my journey began actually growing up in that I grew up in a family that talked a lot about quality of life and what was important and what our wishes were. And so, I think that flavor has brought me into this role and as a piece that I would emphasize is that we shouldn't wait till we're an older person to be having these conversations, but really incorporating it into what we do. My clinical role is working almost exclusively with people with cognitive impairment and dementia. And so that's certainly a situation where, you know, things are going to get worse. So the map for planning is a little different than if you just look at everyone who's 70 and it's incredibly variable. And so I think, you know, that's kind of I think the frame or the perspective that I kind of bring to things. But I think so much around being healthy is not about the health care, but about how we interact with our environments. And I think that we've all become more aware of that. And so, I think none of us can exactly stay in one lane. We have to kind of all work together. So, I'm just excited to be here with Jess, because I think we have different perspectives and bring some different expertise.

Heather: That's fantastic. You can see how both perspectives and forms of expertise could be brought together to make some powerful change. Really exciting to have this conversation. I think one of the challenges that seems to me is that, you know, the basic thing we see is that mostly people are living longer, and it's sort of seems like society forgot about any possible consequence that might come of that, which might be the need for care for older populations longer.  I'm wondering if both of you could address that. And maybe we'll start with Jess again.

Jess: Sure. Absolutely. And and I love I'm just going to riff off of Heidi's, uh, response to the last question because of course, aging is something that starts when we're born, and it and it ends when we die. And so, everything we're doing all day, every day is aging. We are, in fact, living longer than ever before, which is really terrific. Not everybody, not all populations, but even globally, we're all living longer than ever before. And so, that's a good thing. I don't see that as a bad thing. And Maine has a really healthy older population that the challenge is that we've outlived the useful life of the normal things we've always relied on, that have always worked for us. That's what I say, right? Two story houses with a bathroom on the second floor. It's great until you can't go upstairs anymore. Single passenger vehicles and living really rurally outside of any public transit is great until you can't drive anymore, right? And, we can't have this conversation about longevity without having the conversation about the fact that, again, worldwide, we are seeing unprecedented and unchanging reductions in birth rates.

Jess: And so, we have fewer people coming behind us. There is a confluence of challenges that says we have fewer workers. I mean, I'm literally at a conference talking about this issue right now. And Maine's, you know, available workforce are mostly all working. And we still have really big gaps in care for populations, older people, people with intellectual disabilities, and people who are trying to, you know, get behavioral health, mental health counseling. We're just in a tight spot where we haven't, in fact, prepared. We haven't built what we're going to need when we're living to our 80s, 90s and hundreds. But that also comes with great opportunity, I guess I just want to say that sort of the opportunity of our new age is to create what's next for a generation or two to come. And so there's real excitement in that possibility while we're, you know, also handling a few challenges. So I'll leave that there.

Heather: Heidi, what do you think?

Heidi: Yeah. I think I forgot what the question was to begin with, but I know it's about living longer. And we are. And it is such a success. I just look at all the successes we have in the consequences that we do live longer and so we should be celebrating that. But I don't think our societies have been set up to do that. And so we do focus on the negative. And I do think it's also really important to remember that most of us are not going to need really intensive health care for a long time, but we may need it periodically. But we are going to want to live in our communities continuously. And so I think that's where the, you know, where in health care we focus on some things, but our communities needs to look kind of at the overall needs. And I think that's where, you know, all the tensions come from really, is that we have developed communities that don't center around having all your needs within walking, bus and, you know, biking range, like having three different ways to be able to get every place. We just haven't built our societies in that way. Our families, I mean, my families live lives on the West Coast, so our family units are a little bit different. And so, what worked historically won't necessarily work going forward. And I think I've been thinking a lot about this with some conferences and hearing Jess talk and just thinking about what it means to age in place. And for some people, it truly is staying in their home where they raise their family and that sort of thing. But that's not for everybody. For some people, aging in place might really just be about staying in the same community. And so do we have housing to support someone who wants to live in their community, but maybe not in their four bed house, which could then be housing for someone else. But we need to create those opportunities. And then I think it would allow us all to be less panicked about aging, I guess, and what we're going to, you know, what we're going to do. And we can't expect that everyone is going to be able to save enough money to do whatever they need to do. And so, we need the infrastructure to help support those changes.

Heather: Yeah. And from my perspective as a family physician, like one of the biggest issues that I can't solve or point a patient like in the right direction is honestly just help with socialization and reducing isolation. You both mentioned, like your patients growing older in homes that they've been in their whole lives that are pretty isolated. And then all of the sudden that really becomes not helpful for them to be there because they have nobody to talk to, nobody's like just passing their house casually, and they have very little social interaction. And then how can we help support that in our communities? Whether it's helping patients to get more centrally located or maybe bringing socialization to them? I don't know I don't know what the answer is, but it's definitely one of the problems. Maybe we could focus a little bit on some of the resources that are out there. I know, like some of the problem is like some towns have fantastic resources, or at least it seems like they have some pretty good resources available, and then other places have very little resources available. Maybe we could talk about what are some resources that are out there for patients. And also, what we envision needing to happen to help the patients that don't have resources. I don't know, Jess, do you want to start?

Jess: Sure, absolutely. And you're. I mean, you're right on. I could just take this conversation in so many different ways. But I'll start with, some things that have happened in Maine, and we are on the leading edge of aging in America, but other countries have gone before us. And so we really do have the opportunity to show other states how it's done and what's possible. And we've done a great job of that. We have about, well, 480 communities in Maine, and about 100 of them have some sort of initiative that is very focused on making sure that people can remain in their community. And I think you hit the nail exactly on the head, Heather. It's way better for people to remain in their community. And so, for instance, the way we have created affordable housing, congregate housing, even just congregate housing, for older people is always in population centers. And so therein lies a problem, right? Somebody has to leave their community. And it's actually it's worse for them to leave their faith community and their friend community and their social community and move to Auburn. I'm not picking on Auburn, by the way, but where they have no connection. And so, you know, then they're just going to sit in an apartment with no connection. And so, we really have to build what's next. Right? We have to build a different, you know, sort of models of housing at a very local rural level. And there are some really good strategies for doing that.

Heather: Fantastic. Heidi, I'm super curious to hear from your medical perspective what resources are out there and really like what you see as needs and what is available for our patients.

Heidi: It's a patchwork of resources. And much like the age friendly communities, it varies by community. It's hard to keep up on that. As a consultant in Portland, I see patients from all over the state and, you know, our social workers trying to keep up what's in any given community is really challenged. I think the resource that we tend to refer to are the local Area Agency on Aging, because the whole state is covered with that footprint. They do a better job keeping up on those local resources. But I think that's hard because there are always people having passion and focusing on an area, but then having challenges with continuing it. Like you can't have things rely on a single individual, it needs to, you know, have a system in place to support it. And for folks with cognitive impairment, the Alzheimer's Association has some programs to work with people, often remotely, but often with helping them kind of navigate what's in their community for support for the individual with cognitive impairment, but also for the people around them and the supports that they need. There is a fair bit you can do anticipatory wise to try and prevent the behaviors and things developing. And so, you know, a lot of that work on the front end can help people be able to remain at home as well. So those are kind of the two big ones. And then, you know, if people have money, there are tons of agencies out there that can provide various levels of support.

Heidi: That being said, staffing, staffing, staffing, like even if you've got the money, you may not be able to find the human beings to do all the work that you need to do. So it is often tapping into the formal hired, but also the informal, you know, in my own neighborhood, what do I do for the people in my neighborhood? And it varies over the years because people's needs kind of change. But it's very informal. And so I think we have opportunities to take these informal desires and make it easier for people to make the connections. And so that's something that I hope we kind of continue to drive. And what, Jess's community has been able to do what and how to make that translatable? So, everyone doesn't have to reinvent it? But some of those building blocks kind of can get there. And then connecting with the resources we have within health care. I mean, we have a whole lend-a-hand team now that that is mostly around social determinants and helping people make connections. And so, within MaineHealth, at least we have that resource and utilizing those folks. But it's some duplicating and overlapping, and it still feels like there's you're never going to have one person who knows everything that's kind of going on.

Heather: You know, most of the people listening to this podcast are physicians and people in healthcare. And I'm wondering if both of you might have a little bit of advice regarding how we can all help. Maybe, Heidi, would you mind starting with that one?

Heidi: Yeah, I think, as far as in health care, taking the time to listen to older adults and what's concerning to them, but also understanding what's most important to them so that we can make sure we're directing our care to the things that that matter to them, rather than doing things that don't matter. And it's always a balance because, you know, no one's ever going to say, my blood pressure is my peak priority because you can't feel it and that sort of thing. But there is some importance to that. But I think we can frame things around what's, you know, what's important to people. And then as care teams, I think we could do better about figuring out how to document these conversations so we can build on those conversations rather than having the same conversation over and over. And it would really help our patients feel like we were really working with them and for them. So it does get back to trying to be anticipatory and as we see our patients in their office and look at them and trying to help them anticipate what is going to get them into trouble or what their needs might be.

Heidi: If you take folks 65 and older, one of the biggest things that's going to happen most frequently, but also really contribute very negatively to their quality of life is falling. If we can prevent falls, which, I mean, there are so many reasons why people fall. But, you know, Maine has a high alcohol use rate, so, you know, not overindulging. It's okay to have some alcohol. I'm not saying it's abstinence for everybody but being very thoughtful about that and addressing and giving specific recommendations to older adults so that they can be healthy, being physically active. And you know, we've got these supports. But boy, if we can get ahead of frailty and physical decline by helping people stay physically active in their community, I think that's in health care we have a big role to really emphasize that we're very disease focused, but this preventative focus that we do so well in kids, we need to continue as we age. I don't know if I answered your question very well, but I think there's so much we can't do. But we have to think about the things that we can do and use that time we have with people. Well, and don't get me wrong, managing their hypertension is very important. But like if they fall and break their hip and get delirious, that blood pressure management isn't going to actually mean that much in the long run for their quality of life. So we do need to focus on some of those things.

Heather: Yeah. No, absolutely. I'm right there with you on that. And I think for me, like one of the big things that I've been focusing on in our conversations is strength and mobility. And so many times, like I'm sitting at a desk, I'm sitting at a desk right now talking to you guys. And so many times we've spent so much of our lives sitting and working that then as we get older, we just lose ability. If we haven't had a concerted focus on maintaining strength, maintaining exercise tolerance and maintaining mobility. Yeah, I see that as a big thing that all care providers can emphasize and focus.

Heidi: That's really across the lifespan, right?

Heather: Yeah.

Heidi: I'm a middle-aged person now, you know, for whatever that span, however you want to define that and my ability to maintain my strength has totally tanked in the last ten years, like, you really have to work at it. And so, it's just that's kind of normal, like that's going to happen. And so, we really have to focus on that. When we talk about, you know, having places for people to live in their community. I am definitely not talking about setting up senior, just senior housing, because I think we lose some synergies when we segment the population. And so if you can imagine, probably an apartment or condo setting in a rural community that had families and older adults, working people, you know, all of that. Imagine the older adult needs some help with getting there, maybe getting groceries occasionally or getting, you know, physically getting things out to the garbage or whatever. And then someone else has two working parents, and it would be great if their kids had someone to check in to when they got off the bus. And so you've got synergies there where we're supporting each other. And as much as we can have communities that can do all of that, it's not just I'm an older person and I'm sucking resources, but I'm still a valuable member in the community.

Heidi: And so we, you know, if we bring people together and not segment, but really bring together, we can, you know, create that more organically in our communities. But then I think we have to be thoughtful about that because like tends to join like so if you have a setting where there are a lot of older people, more older people move in. But how do we allow access for a diverse population in age, not just in gender and ethnicity? And then, you know, on the individual level, just thinking about your own responsibility and your own communities and how you may be able to help make those connections, whether you know it's through your local church, just your neighborhood, and how you interact with people, and just thinking about the ways that you can support some of those community connections, formally and informally. Learn what's in your own community and how you may be able to interact and support then your patients who live in that community. And if we do that as care teams, we're going to have a lot of knowledge that we can share with our patients.

Heather: That's fantastic. I always remind my care teams that our patients are our family and our neighbors. And that's real when we go out into the real world as well. Jess, what advice do you have for us?

Jess: I think there's real opportunity for practices at the local level and MaineHealth at the statewide level toto think about how to become more involved in building a robust network. And then finally, right at the individual practitioner level, thinking about how do you get involved in age friendly communities or lifelong community initiatives, like Heidi said, being a better neighbor and helping to build that that informal care network in our towns.

Heather: That's fantastic. Thank you both. I think I'm leaving this conversation with a lot of steps forward from really asking and clearly documenting what matters most to our patients, to being a more active neighbor. Well, I think those are all really fantastic points for us to walk away from this conversation with and hopefully start some of these conversations. And maybe if we are in the position that we can help donating to the our local area agencies on aging, then we could potentially contribute in that way. So, so many fantastic positive things to leave this conversation with. I really appreciate having you both here. It's been wonderful to talk to you and thank you so much for giving me this time.

Jess: Really appreciate being asked.

Heidi: Yeah, thank you for the time.

Heather: Thanks for listening to BACON this month. You can find all our episodes on our podcast app and at our web page, MaineHealthACO.org/BACON.

Heather: And if you have questions, comments or suggestions, we would love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org.

Heather: Bacon is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.