“One City, One Strategy” – San Francisco Tackles Aging Together

Alicia Neumann

A California journalist with a medical death sentence – terminal cancer — recently heralded new improvements in immunotherapy for keeping her alive beyond the one-year life span her doctors had given her. Medical advances, it appears, are often the fastest in cases of acute care.

Yet medical solutions often pale mightily when faced with prevention and long-term care — especially when treating older adults.

As adults age and become frail, they often face a maelstrom of confusing agencies and health providers in a Sisyphean effort to stay healthy. Endless doctors appointments. Limited access to long-term care. Overworked family caregivers. Problematic transitions from hospital to home, or from rehab to assisted living. Expensive housing, food and utilities. Add to that the wildly difficult issues like dementia patients with psychiatric disorders and the problems seem insurmountable.

It’s a fragmented system of care that’s painfully documented in the excellent 2015 state Senate report A Shattered System: Reforming Long-Term Care in California.

Entering this storm is the Optimize Aging Collaborative at UC San Francisco, which last summer received a three-year $2.5 million federal grant to help fill these service gaps in San Francisco — a city with an economy rivaling that of Thailand yet diversity making coordinated care far more unwieldy.

Its catchphrase: “One City, One Strategy.”

The funds are critical as California faces a dwindling emphasis on geriatric workforce training just as its senior population begins to skyrocket – in 2030 nearly one in five Californians will be over 65.

“There’s lots of people doing lots of great stuff around aging in San Francisco, and the idea was ‘How do we bring everything together?’” asks Louise Walter, who heads the division of geriatrics at UCSF. “That’s the vision of this collaborative. That we have a better integrated approach to aging.”

The task is as sexy as adding mortar to a brick building. Yet in aging services, there may be nothing more important.

Carrie Wong, who heads long-term care operations for the Department of Aging and Adult Services, or DAAS – UCSF’s chief partner in the collaborative – echoes the sentiments of those working with older adults in the city.

“We’re clunky,” she says. “We work in silos.”

Even DAAS and its sister organization the Department of Public Health have a failure to communicate: “We don’t have ways to share data easily,” admits Wong.

These shortcomings cause several system failures, she adds, many of them exacerbated when health insurance is lost or patients are moved.

“That’s one of the biggest systems gaps I see,” says Wong. “Things get dropped at each of those marker points.”

The Optimize Aging Collaborative focuses on San Francisco Health Network, the city’s health safety net,  along with UCSF’s division of general internal medicine and the San Francisco Veteran’s Affairs Medical Center. Besides DAAS, another key collaborator is the Alzheimer’s Association of Northern California and Northern Nevada.A dozen other advisor organizations, including the LGBTQ advocacy organization Openhouse, Little Bothers — Friends of the Elderly, and other city agencies have joined.

UCSF program director Alicia Neumann, who heads the collaborative, says it’s focused on five key areas: 1) recognizing and treating Alzheimer’s disease and other forms of dementia; 2) helping older adult live independently; 3) safety concerns, including fall prevention and elder abuse; 4) empowering elders with improved decision-making and goal-setting; and 5) mental health for both older adults and caregivers.

“Our process has been to work closely with our community partners to first develop these five topics,” says Neumann.Wong says UCSF is uniquely positioned to lead the effort.

‘They have the clinics and intersect with the social services components, and they do research,” says Wong, citing a medical model increasingly focused on psycho-social solutions – psychiatric causes and social services support.

“We’re never going to have enough specialty trained geriatricians and nurses,” says Dr. Anna Chodos, co-principal investigator and assistant professor in geriatrics at UCSF. “The approach we’re taking is to enhance everyone’s competencies.”

Besides improved education — for everyone from clinicians to social workers, aging services staff and home caregivers — Chodos says the keystones to training are adding “teamlets” to clinical work to ensure wraparound care; “troubleshooting” flowcharts that allow clinicians to follow clear paths to treatment for elder patients; and a safety net geriatric consulting clinic that is expanding from just half-a-day a month to a full day – yet still remains woefully short of geriatricians skilled in older adult care.

Wong cites in particular a critical problem among older adults: the intersection of dementia and mental illness — most acutely depression, but also schizophrenia and anxiety. With the help of UCSF and the Alzheimer’s Association, in December DAAS’ Adult Protective Services staff will be trained in dementia awareness, followed by In-Home Supportive Services staff next July.

Steeped in the 1960’s counterculture, San Francisco has always prized itself on caring for the needy hidden in the shadows of epic structures like Coit Tower and the Transamerica Pyramid. Its renovated Laguna Honda Hospital and Rehabilitation Center is the city’s sparkling “hospital-based nursing facility” for its underserved population. The Community Living Fund is a collaboration between the city and the excellent Institute on Aging to keep the elderly and disabled living independently.

In recent years, San Francisco has heightened its commitment to aging, producing the report Foresight 2020: San Francisco’s Strategy for Excellence in Dementia Care which spawned a handful of pilot programs.

Prompting great excitement in the aging world, in January geriatric specialist Dr. Susan Ehrlich was named head of the city’s safety net hospital (formerly San Francisco General Hospital and now the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center). Ehrlich was previously CEO of San Mateo Medical Center, home to the highly-regarded Ron Robinson Senior Care Center.

Besides quarterly meetings, the Optimize Aging Collaborative last month trained about 75 clinicians on recognizing and treating dementia, and previously co-sponsored a panel event on end-of-life discussion called “Talk to Me: Conversations That Matter.”

With so many resources and such passionate people in aging services, why hasn’t anything like the Optimize Aging Collaborative already been created?

“The real answer is ‘I don’t know,’” admits Chodos. “There are just not enough people working in the aging circle.”

Meanwhile, the Optimize Aging Collaborative itself has faced its own rocky start.

Its initial project leader left suddenly last fall on medical leave. Neumann had to hit the ground running and is still finding her way through the morass of people and agencies involved. There is no website. And team members talk largely about previous efforts instead of a clearly defined direction for the new collaborative – admittedly still a work in progress. Finally, some participants hadn’t even heard the name Optimize Aging Collaborative — only of the grant given to UCSF.

Still, the passion for improvement and desire for change is abundant: “To make aging a better experience in San Francisco for our older adults,” summarizes Chodos.

As UCSF continues to seek more funds to continue its efforts, will the collaborative extend beyond the three-year period?

“That is absolutely our hope,” says Neumann. “Part of our grant is to create a sustainable collaborative.”

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