Issue 6: The New Maturity
As we know, conversations about health care resonate with nurses. In every conversation, at least two elements are present―personal reaction and professional response.
Ageism, when it serves as a subtle form discrimination, qualifies as a matter to be examined for both personal reaction and professional response. For example, is it possible, because of age, that quality, type and choices of care for older adults are inevitably limited?
As technology evolves, we evaluate and update (or not) our own personal philosophies on quality of life and the interventions we would want for ourselves. Do we undertake the same sort of review for the older adults in our care? Perhaps ageism is more a subtle, private bias operating in our day-to-day practice and if so, it’s something to be on the alert for. Does ageism challenge those private biases, or does it underscore them?
What do you think? Let’s start a conversation.
As discussed in Issue 4 of N21, New Conversations about End-of-Life Care, life’s endings are something of an American cultural sticking point for individual patients and for a medical establishment trained to cure illnesses, and if not to cure, to extend life by any means. The option of discussing the quality of the life being extended is frequently not part of the dialogue.
Ageism continues the discourse. What are the approaches or philosophies we cultivate as we ourselves age? Are we guided by our perspective, allowing it to inform choices for accepting or rejecting an array of potential interventions? If our older patients have requests, do we honor them as we’d want our own preferences to be honored? Are we as enlightened about ageism as we can or should be?
A quick Google search on the topic of nursing and ageism reveals studies that measure provider bias against older adults going back decades. It is worth noting that until six years ago certification guidelines for the subspecialty of Gerontological nursing did not exist. In fact, it was just six years ago that The American Association of Colleges of Nursing and the Hartford Institute for Geriatric Nursing first issued recommended baccalaureate competencies for the care of older adults. Six years. Older adults have been around much longer than that.
This is a sobering reality set against two sets of statistics:
1 – In 2002, an article in Health Affairs sounded the early alarm, noting the United States’ health care workforce was not properly prepared for the country’s rapidly aging population. Only three of the nation’s 145 medical schools had geriatrics departments, and fewer than 10% required a geriatrics course. Less than 1 percent (21,500) of the nation’s 2.2 million practicing RNs were certified in geriatrics. (Kovner, Mezey & Harrington, 2002)
2 – According to the Administration on Aging (AOA) and the Centers for Disease Control and Prevention (CDC), 1 in 5 U.S. residents will be 65 and older by 2030, some 70 million people, or 20 percent of the population. By 2030 all members of the baby boomer generation will have moved into the ranks of the older population. Which means we are either among those thinking about the time when we will become an older adult or we are among those whose parents are older adults.
Recently, I discovered and want to share two provocative, radically different examples of people asserting responsibility for their aging. One, an interview with Dr. Ezekiel Emanuel, a bioethicist and lightning rod public persona who served as a White House advisor during the shaping of the Affordable Care Act. Here, he makes a compelling argument for why he wants to opt out of health care at age 75.
The other, a brief inspirational video of an 86-year-old woman who performs publicly as a dancer and gymnast.
While not technically representing societal norms, each of these videos got me thinking about how consumer/ patient beliefs about aging dovetail with our evolving health care system. We have known the wave was coming for over a decade, but is our delivery system current enough and flexible enough to accommodate a spectrum of choices and needs?
John Nesselroade, Ph.D., psychologist and statistician at University of Virginia, and outstanding researcher in the field of Gerontology asks the following:
“Are we facing an increased number of very sick old people or is the new elder population healthier and more robust? Is what matters not how many diseases one has but how problems affect one’s ability to function and what we can solve to improve effective living?”
Certainly, topics of ageism and the new maturity seem to raise more questions than they can answer. I would say that as a society, we want to manage our aging process. But are we set up to do it? Certainly, no one wants to be forced into irrelevance, to be warehoused in hospitals or institutions.
The authors in this issue of N21 offer us professional guidance and a look into some on these pressing matters.
Tara Cortes Executive Director of the Hartford Institute for Geriatric Nursing and Professor at NYU College of Nursing discusses the ins and outs of a clinical community partnership for caring for older adults. Dr. Cortes calls for the primary care setting to be the hub for management of chronic illness to prevent avoidable function loss and coordinate care as people who are aging move in and out of different health care settings and as their health care needs change.
Cathy Levine a participant in the Community Catalyst program and very recently retired as director of a ground-breaking demonstration project in Ohio addresses integrated financing of care for the dually eligible. She reports from her sphere of expertise and experience detailing the possibilities for new approaches to financing care for dually eligible Medicaid and Medicare beneficiaries and also cues us in on why good plans sometimes don’t succeed.
Elaine Tagliareni Chief Program Officer at the NLN describes efforts to improve the quality and content of education on the care of Gerontological patients. The program Elaine leads called ACE.S provides resources and teaching tools to nursing faculty to help prepare nursing practitioners for the care of patients who are newer as well as the older members of the elder adult demographic. Her paper reminds us of the complexities of acute and chronic care and urges consideration of the concept called individualized aging.
And, with a note of realism, a wonderfully personal view of life as an older adult entitled “Old Lady Who?’ submitted by Sandra Dollinger a writer, artist, and college instructor. Just the right touch to keep it all in perspective.
So with this issue, we begin a conversation about the new maturity as defined by newly minted older adults in contrast to society’s entrenched views on ageism. Perhaps we continue this conversation about how, as caregivers, professionals, academics and policy makers we contribute to developing strategies to provide the basis for successful aging in fact and policy in America.
What say all of you, dear readers?
Dr. Maureen BoshierFACHE, RN, is a senior healthcare executive currently on the faculty at Old Dominion University and Eastern Virginia Medical School in Norfolk Virginia.
Selected References and Resources
Kovner, C.T, Mezey, M., Harrington, C, Health Affairs (2002) Who cares for older adults? Workforce implications of an aging society, 21 (5). Retrieved from http://content.healthaffairs.org/content/21/5/78.full?related-urls=yes&legid=healthaff;21/5/7
Caring for our Older Population:
Online Journal of Issues of Nursing
Nurses’ Attitude Toward Older Patients in Acute Care in Israel
Attitudes in Swedish nursing students http://www.sciencedirect.com/science/article/pii/S026069170090546X
Perpetuation of ageist attitudes among present and future health care personnel (2008)
American Nurses Credentialing Center’s (ANCC) Gerontological Nurse Certification Examination http://www.hartfordign.org/education/gero_certification_review_course
National Gerontological Nursing Association (NGNA) http://www.ngna.org/
Community care options:
Village to Village Network, a program designed to permit one to stay in one’s own home, has become a national phenomenon with 190 such sites across the country and 185 more villages in development. www.vtvnetwork.org
Village to Village network, a community model to keep people in their neighborhoods and in their homes
Until the Affordable Care Act (ACA), the American paradigm of healthcare focused on treating disease not preventing it. As a result, people diagnosed with chronic illnesses will eventually require care management in order to maintain highest quality of life. A healthcare delivery system transformation that values 1) population health, 2) payment based on better outcomes, and 3) cost reduction achieved by keeping people healthy and out of acute and long term care institutions, is critical.
Since 1996, the Hartford Institute for Geriatric Nursing (the Hartford Institute) at New York University College of Nursing has been focused on 1) improving the health of older adults, 2) helping healthcare professionals to provide age sensitive, evidence based care to achieve better health outcomes in older adults, and 3) assisting older adults in maintaining optimum cognitive and physical function.
Because of its long history, the Hartford Institute has become the global “go to” place for information on educating the geriatric workforce, implementing innovative models of care for older adults, and advocating for older adults around health and social issues. Over the past 20 years the Institute has developed a robust e-learning system that houses more than 600 resources, including the renowned Try This Series, which has more than 40 assessment tools to be used in caring for older adults. Each issue is clear and concise with accessible content in two pages that can easily be administered in 20 minutes or less.
One of the first models to come out of the Institute was the NICHE program (Nurses Improving Care for Healthsystem Elders), which was begun as an initiative to educate hospital nurses about the unique care of older adults and has become a model of best practice for over 680 NICHE-designated hospitals committed to the value of age sensitive healthcare.
With an eye on the changing landscape of healthcare, largely driven by the Affordable Care Act, and the high cost of caring for an increasing number of people with chronic disease, the Institute has spent the last few years educating the community-based workforce and developing ways to increase access to care for frail older adults living in the community with multiple chronic diseases.
This article provides an overview of some of the barriers to healthy aging and describes some of the initiatives of the Hartford Institute to address those barriers through inter-professional and community education, community engagement, and the development of partnership models between community-based organizations and clinical healthcare systems.
Landscape and Barriers to Healthy Aging
As people age they are prone to developing chronic diseases that decrease the quality of life and increase the use of expensive health care services. More than two-thirds of Medicare beneficiaries have two or more chronic conditions and 14% have 6 or more (Centers for Medicaid and Medicare Services, 2012). Furthermore, older adults at a lower socioeconomic level, such as those dually eligible for Medicaid and Medicare services, account for a higher proportion of adults living with 4 or more chronic conditions. Multiple chronic conditions increase the cost of care, and statistics show that people with 4 or more chronic conditions account for 74% of Medicare spending.
Currently, Americans can expect to live 78 years, but only 69 of these years will be spent in good health (Adams, Barnes & Vickerie, 2008). Managing the primary care of older adults who are often frail with multiple chronic diseases is difficult. The uniqueness of an older person’s needs is often not recognized and adequate coordination of care across a team, which should include patients, families and caregivers, is absent. Quality coordinated care for this diverse population is dependent on:
- a healthcare workforce prepared to address the challenging healthcare needs presented by this population;
- a delivery model that values collaboration among professionals, patients and their family members and caregivers;
- coordination and cooperation in designing the plan of care, and;
- strong partnerships with non-traditional providers in the community.
At present, the traditional American healthcare system does not offer appropriate care to diverse and complex populations of older adults. There is a tendency to rely on costly emergency services as a default, and acute care treatment is often futile.
Things to Consider: Workforce
By some estimates, 2020 will see a shortage of as many as 45,000 primary care physicians. The number of medical students entering careers in primary care in general internal medicine and family medicine are declining. Recent workforce projections estimate that 150,000 physicians will be needed in the next 10-15 years to provide primary care access to all U.S. citizens. (Association of American Medical Colleges, 2008) Meeting this workforce projection will be particularly difficult since only 2% of new physicians chose primary care for their career path in 2008. (Hauer, K. et al, 2008)
Of particular concern, as spelled out in the 2008 Institute of Medicine (IOM) Report (Institute of Medicine, 2008), is the fact that our current health care system is ill-equipped to deal with this pending confluence of demographics, health status, long-term needs and the unique challenges of caring for the aging population.
Clearly, with 10,000 people turning 65 every day, and the number of people 65 and older expected to double from 35,000 to 70,000, the number of older adults will far exceed the number of primary care providers, especially those equipped to meet their unique needs. It is projected that by 2030, 20% of the population will be 65 years or older and 76% of older adults will have at least one chronic illness. (Administration on Aging, 2010)
Geriatricians can address the health care concerns of older adults, but there simply are not enough physicians prepared as geriatricians to meet the need. Most internists and family medicine practitioners have little or no preparation in geriatrics. There are less than 7,000 physicians nationally certified to treat and manage the multiple and chronic medical conditions of older adults. This number actually represents a 22% decrease in the number of geriatricians practicing over a seven-year period. It is estimated that 37,000 geriatricians are needed. (Maiden, F., Horowitz, B., & Howe, J.L., 2010)
A prepared healthcare workforce that understands and can address the intricacy of caring for this varied, older population and its challenging needs is a necessity and a goal. Ideally, this workforce will include professionals as well as non-traditional members, such as community workers, capable of working together to deliver age sensitive, person-centered care and create healthy communities. So, how to get there?
Education and Community Engagement
While it is necessary to build the physician workforce in primary care practices, it should be noted that advance practice nurses, or Nurse Practitioners (NPs) are a vital source of primary care for older adults. Several studies have demonstrated that NPs:
- provide high quality and cost effective care,
- produce outcomes comparable to physicians, and
- provide care that covers 80-90 percent of the services physicians provide (Mezey, et al., 2005)(Lenz, E., 2004)
In 2010 President Obama addressed the House of Delegates at the American Nurses Association to announce a number of investments to expand the primary care workforce. The President’s address included the concept of increasing funding for nurse/NP-run clinics“ that work well for nurses and doctors to improve the quality of care for patients” (White House, 2010). Nurses have been providing care to vulnerable and medically underserved populations through Nurse Managed Health Clinics since the 1960s. Many of these sites are Federally Qualified Health Centers (FQHCs), which have traditionally served families with children and are now experiencing aging of their patient population. These patients are staying with their practitioners even though they now have Medicare, which enables financial access to other care sites.
Of the approximately 255,000 certified advanced practice nurses in the country, only about 5,000 are certified as geriatric nurse practitioners (GNPs). Approximately 27,000 are certified as adult nurse practitioners (ANPs) and about 52,000 are certified as family nurse practitioners (FNPs). With HRSA funding, the Hartford Institute has developed 11 online modules to help non-geriatric prepared primary care providers to deliver age-sensitive care. Over 1000 providers across the nation have used these modules and more than 85% report they have significantly changed their practice as a result of this education.
Less than 1% of registered nurses (RNs) in the country are certified in geriatric nursing and pre-licensure nursing education programs vary in the amount of geriatric content included in the curriculum. This is also true of programs preparing social workers, physical therapists, occupational therapists, nutritionists, dentists or pharmacists. Nurses and social workers are most often the care managers who assist patients, families and caregivers between doctor visits. Training all members of the healthcare team to understand an inter-professional care model focused on managing chronic illness and keeping older adults at their highest level of wellness would help meet the anticipated need for elder care. The Hartford Institute has many resources including interactive modules and videos to educate nurses and other health professionals.
Communities can be a vital source of information that is culturally and linguistically relevant. The Hartford Institute is training a volunteer health corps in a New York City community which is ranked last in the NYS County Health Rankings, 2014. Recruiting from senior centers, houses of worship and community networks, the group is being educated through the Hartford Institute on maintaining best function in older adults, and managing the three most common chronic diseases in the community- asthma, diabetes and heart failure. This group will do individual teaching upon referral, as well as planned sessions in community centers and other gatherings, and places of worship. Furthermore, the Institute is training home health aides to work with people with dementia and depression.
Community Engagement, Going Deeper
Of course the engagement of the community is a necessary element in the transformation of healthcare paradigms. However, community engagement requires careful planning for successful implementation. In addition to education, communities must feel they have a stake in their own healthcare. One way of doing this is to start with small community sections in those regions that have the greatest risk, often those areas with the lowest socio-economic determinants. Focus groups of community members can help define what is important to improving health and quality of life in the community. Partnerships can be established between community based agencies and clinical healthcare entities. An example of this can be seen in a case study of a project implemented several years ago in a large urban area.
The emergency room in a local medical center was in the throes of high volume patient flow in the middle of the flu season. This community had a large number of older residents with asthma. Acute exacerbations of this disease were compounding the overuse of emergency services. In an effort to reduce the use of emergency services it was decided to try a program that would engage the community in addressing the issues surrounding this illness. Focus groups were held with providers, patients, and with volunteer and employed caregivers to establish what was most important for helping control their own well-being as related to their asthma. Through this work it was determined that the most important factors in self-management were the proper use of inhalers and recognition of “triggers.” Faith-based organizations and the local state representative’s office recruited “volunteers” to participate in educating the community on living well with asthma. By including the community, teaching became a culturally sensitive peer-to-peer activity. Use of emergency services in the nearby hospital was reduced by 35%. (Cortes, 2004)
The ACA and the triple aim have stimulated the growth of similar models. There are not enough clinicians available to educate and reinforce positive behavior in patients. Primary care providers need to use team members functioning within their scope of practice as educators to establish community partnerships and further the implementation of the plan of care established by the patient and the provider.
Better outcomes do not come solely from individual providers spending time with a few patients, but from collaborative care models that transform healthcare into a team approach that encompasses patients, families and all available resources in the community. Care coordination from the clinician’s office through a community-based care manager or, as appropriate, with the patient/family as the lead in managing self-care, can reduce the burden of care on clinicians and empower communities to be educated, responsible and accountable members of the primary care team.
An example of this model is illustrated through a funding initiative the Hartford Institute received through HRSA to implement the Geriatric Workforce Enhancement Program. The Institute built the model for this program using the National Prevention Strategy, which urges enhancement of the traditional health workforce by training non-traditional care givers and including community resources and patients themselves as part of the healthcare team. This strategy requires the community and, in particular, families and caretakers be educated about the nuances of aging. Such engagement can encourage supportive/friendly community participation and integration of healthy aging into our culture. The program involves five Patient Centered Medical Homes and a home care agency (which are part of a large health care system) and a large social service agency in an underserved community. The intent is to extend primary care from inside the clinician’s practice to a continuum of care across community resources.
By training the professionals, paraprofessionals, community-based professionals, and a volunteer community health corps, the program aims to encourage involvement of the community in promoting healthy aging into the culture and furthering the goals of the person centered care plan developed in the clinician’s office. This program is rolling out over the next two years. Resources for inter-professional education, lay person education, and care coordination models from clinical sites through the community resources will be available on the Hartford Institute websites.
Through innovative models that prepare professionals and non-traditional healthcare workers, we can develop age-friendly communities, engage communities to be accountable for health, provide age sensitive care to our expanding older population, and achieve better quality of life and health outcomes for millions of older people.
About the Contributor
Tara A. Cortes, PhD, RN, FAAN is the Executive Director of the Hartford Institute for Geriatric Nursing and a Clinical Professor in the NYU College of Nursing. Dr. Cortes’s career has spanned nursing education and nursing and hospital administration. She was a Health and Aging Policy Fellow from 2013-2015 and continues to serve as a Senior Advisor to the Medicare Medicaid Coordination Office at CMS.
Selected References and Resources
Adams PF, Barnes PM, Vickerie JL. (2008). Summary health statistics for the U.S. population: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(238). Retrieved from www.cdc.gov/nchs/data/series/sr_10/sr10_238.pdf
Administration on Aging: www.agingstats.gov/Main_Site/Data/2010_Documents/Population.aspx (Online accessed March 18, 2012)
Association of American Medical Colleges (2008). The Complexities of Physician Supply and Demand: Projections Through 2025. http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf.2008
Centers for Medicare and Medicaid Services. (2012). Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD.
Cortes, T. A. et al. (2004). Using focus groups to identify asthma care and educational issues for elderly urban dwelling minority individuals. Applied Nursing Research, 17:3, 207-212.
Hauer, K. et al. (2008). Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine. Journal of the American Medical Association, 300(10): 1154-1164
Institute of Medicine. (2008). Retooling for an Aging America, Rebuilding the Healthcare Workforce. Washington, DC: National Academy Press.
Lenz, E. et al. (2004). Primary care outcomes in patients treated by nurse practitioners or physicians: Two-year follow-up. Medical Care research and review, 61(3):332-351.
Maiden, F., Horowitz, B. & Howe, J. L. (2010). Workforce training and education gaps in gerontology and geriatrics: What we found in New York State. Gerontology and Geriatrics Education, 31(4), 328-348.
Mezey, M. et al. (2005). Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. Journal of the American Geriatrics Society, 53(10):1790-1797.
U.S. Census Bureau, P.23-212. (2014). 65+ in the United States: 2010, U.S. Government Printing Office, Washington, DC.
People who are enrolled in both Medicaid and Medicare (more than 10 million in the United States) have long been the subject of efforts to improve care and lower costs by offering team-based care coordination. These so-called “dual eligible” individuals are among the sickest, poorest, and most expensive to treat in our health care system. Because coordination is lacking between Medicare and Medicaid, navigating the two programs can be confusing and difficult for beneficiaries, their families, and providers. Coordinating services for beneficiaries holds the potential to enhance quality of life and lower health care costs.
The Affordable Care Act, enacted in March 2010, provides the opportunity for states to integrate both financing and delivery system management for dually eligible enrollees. The federal Medicare-Medicaid Coordination Office was created to coordinate these are three-year demonstrations, with the opportunity to extend to five years, and Ohio was the third state (after Massachusetts and Washington) to receive approval and begin implementation. Although Ohio’s demonstration―dubbed “MyCare Ohio”―is relatively new, important lessons can improve future efforts in integrated care across the nation. Among the critical lessons learned are the importance of developing a care coordination model for complex patients provided by an interdisciplinary team of providers trained in geriatric and disability-competent care, and the need to build in structured consumer engagement at all levels.
The Promise and Risks of Integrated Financing
Medicare and Medicaid are two separate programs, each covering certain benefits for people who are dually eligible. Roughly speaking, Medicare covers medical care and Medicaid covers long-term services and supports (LTSS), including most nursing home and home care. Older adults with multiple chronic conditions, and individuals with disabilities, need a continuum of medical and non-medical services to optimize their health and quality of life. But neither program has structured mechanisms or financial incentives to provide services that would reduce costs to the other program. Integrating financing and delivery system management between these two programs creates the opportunity to provide comprehensive, person-centered care that is designed to optimize quality of life for enrollees and avoid preventable and costly institutionalized care. For example, the Center for Medicare and Medicaid Services (CMS) estimates that 45% of hospitalizations of dual eligible patients from either Medicare skilled nursing facilities or Medicaid nursing facilities in 2005 could have been avoided. (“Care for the Dual Eligibles,” Health Affairs Health Policy Brief, supra.) http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=70)
According to Ohio’s Memorandum of Understanding:
“[The] financing approach will minimize cost-shifting, align incentives between Medicare and Medicaid, and support the best possible health and functional outcomes for Enrollees.”
With the promise of improvements come considerable risks for beneficiaries. The move to managed care threatens disruption of vital services and existing provider-patient relationships, as well as loss of benefits and compromises to access and quality. In 2013 Community Catalyst, a national consumer advocacy organization with extensive experience in development of new care models for vulnerable populations created a publication, A Seat at the Table, to examine these concerns.
Building the Consumer Voice in Integrated Care
To protect the interests of enrollees, CMS consulted with national consumer advocates and has required consumer engagement in the demonstrations. In addition, Community Catalyst received funding to create a national project. Consumer advocacy organizations in five states with integrated care demonstrations, including Ohio, receive funding, technical support and involvement for the project coordinated by Community Catalyst. This video explains how Voices for Better Health with Community Catalyst works.
During the planning stages for MyCare Ohio, UHCAN Ohio (Universal Health Care Action Network) organized a coalition of advocacy organizations called Ohio Consumer Voice for Integrated Care (OCVIC) to strengthen the voices of enrollees in MyCare Ohio and advocate for policies that protect consumer interests. OCVIC members include independent living centers, the Ohio Association of Area Agencies on Aging and local AAAs, legal services programs, and other advocates for older adults and people with disabilities. OCVIC’s Statement of Principles contain the elements the coalition believes is necessary to achieve the promises of MyCare Ohio for better care and quality of life.
Since its formation, OCVIC has provided regular input to CMS, Ohio Department of Medicaid, and the MyCare Ohio managed care plans. OCVIC has also built a robust network of MyCare enrollees who serve on the plans mandated Consumer Advisory Councils (CAC) and participate in OCVIC’s regional enrollee networks. OCVIC’s membership base comprises more than 3,000 MyCare enrollees and provides vital input on the enrollee experience.
Overview of MyCare Ohio
Like most demonstrations for the dually eligible, Ohio chose to use a capitated financing arrangement, contracting with five managed care plans. Dually eligible older adults and people with disabilities [Certain populations are excluded, including persons under 18, persons with intellectual or other developmental disabilities served through waivers, people with a delayed spend down, those enrolled in PACE, and those enrolled in Independence at Home in seven regions (29 of Ohio’s 88 counties) are required to enroll in a MyCare Ohio plan for their Medicaid services, but can opt out of having their MyCare plan coordinate their Medicare benefits and use either fee for service or a Medicare Advantage plan. By contrast, the OneCare demonstration in Massachusetts allows enrollees to opt out entirely. In each region, beneficiaries can choose between two managed care plans (three in the most populated region, which includes Cleveland). Plans are responsible to assign a care manager to each beneficiary.
Effective care coordination involves a well-coordinated team of providers with different roles and skill sets. MyCare Ohio promised a “single point of contact,” a trans-disciplinary care team” and “person-centered care” for each beneficiary. Yet, effective care coordination, the central promise of MyCare Ohio, remains the biggest challenge after the first year of the demonstration.
Mandatory enrollment in MyCare Ohio for Medicaid services began in spring of 2014, with enrollees having until December 31, 2014 to decide how to receive their Medicare services. In May through July 2014, over 90,000 dually eligible Ohioans either chose a MyCare plan or were auto-enrolled, with the right to change plans monthly.
As of November 2015, MyCare Ohio had 92,343 enrollees, two-thirds of whom were enrolled in the Medicare portion. One unique feature of Ohio’s demonstration is that initial enrollment included concurrent implementation of mandatory Medicaid managed care for the dually eligible. It is worth noting that none of the five participating plans had prior experience in providing Home and Community Based Services.
Rocky Start to MyCare Ohio
As documented by Kaiser Family Foundation, which produced several issue briefs on dual eligible demonstrations, beneficiaries experienced many problems during the start-up of MyCare Ohio. Since Medicaid pays for most long term care services and supports (LTSS), disruptions in LTSS services began almost immediately after enrollment in the new plans. The most widely publicized problem was that people providing personal care services stopped receiving payment when MyCare Ohio began, because the managed care plans lacked appropriate claims processing systems for home care providers. In some instances, people with disabilities who rely on their personal assistant for help getting out of bed, bathing, dressing and toileting, lost long-time providers during this crisis. Another lingering issue was the state’s inability to provide accurate lists of enrollment changes in a timely basis, leaving managed care plans and their contracted providers unable to verify enrollment for those who switched plans. This led to lapses in services for enrollees and the inability of providers to identify the financially responsible plan. Delays in authorization of critical durable medical equipment and supplies left threatened the safety of an untold number of enrollees.
Other commonly reported problems included unreliable transportation services, with people either missing medical appointments or getting stranded at them; long delays in provider payments jeopardizing access to services; and delayed enrollee assessments. By contrast, passive enrollment into the Medicare portion of MyCare Ohio in January 2015 resulted in relatively few reported problems for beneficiaries.
Documenting and Addressing Beneficiary Problems: As reported by the Kaiser Family Foundation, many beneficiaries did not know how to find help when they encountered problems. As required by the Memorandum of Understanding, Ohio established an ombudsman program
specifically for MyCare Ohio, but many beneficiaries were unaware of the ombudsman services, especially during the early months. At the beginning of the demonstration, the ombudsman had no funds available to do outreach to enrollees. Even before the demonstration began, OCVIC’s manager and organizations conducted outreach to dually eligible Ohioans to explain MyCare Ohio. The manager went to public housing developments, housing communities, nursing facilities, and other settings with significant numbers of dually eligible residents, explaining MyCare and answering questions. He asked for volunteers interested in serving on the plans’ consumer advisory committees and offered his contact number for assistance. In the first six months, the manager and other OCVIC leaders were inundated with calls from enrollees needing assistance, leading OCVIC to collaborate with the ombudsman program on a referral system and directly with the plans – and occasionally regulators - on systems issues.
Building OCVIC’s Consumer Voice
In the first year, OCVIC gradually built up a database of over 3,000 enrollees, set up monthly enrollee calls in each of the seven regions, and recruited enrollee co-chairs for each regional group. Feedback from the monthly calls is reported to OCVIC’s leadership team of advocacy leaders and enrollee co-chairs to assist in developing OCVIC’s advocacy strategies. Several OCVIC enrollees have testified before the Ohio legislature and administrators on issues related to MyCare Ohio.
The managed care plans received OCVIC’s assistance in recruiting enrollees to their Consumer Advisory Committees (CAC), which is required by their memorandum of understanding (MOU). Participant recruitment follows a strict method of soliciting applications from potentially interested enrollees and selecting based on an agreed set of criteria. OCVIC then invited Community Catalyst to pilot, with one plan’s CAC, a day-long training session for CAC members developed specifically for the integrated care demonstrations. OCVIC’s recruitment methods and the CAC training were both based on Community Catalyst’s Consumer Engagement Toolkit. Based on positive feedback from enrollees and the participating plan, most MyCare plans have indicated interest in contracting with OCVIC to train their CAC members. When properly trained and operated, a CAC provides plans with timely feedback on enrollee experiences and input into design and policy issues from the enrollee perspective that they would otherwise not have. The CAC also has a direct communication channel with the plan’s governance. The CAC is, thus, an important form of structural consumer engagement.
Perhaps the most striking form of enrollee engagement came as a result of OCVIC’s unsuccessful effort to have the Ohio legislature fund and authorize an early independent evaluation of MyCare Ohio enrollee experiences. Data on reported problems from the ombudsman and OCVIC are inadequate, because they contain only the issues of those enrollees who sought help from the ombudsman. Ohio lacks a system for monitoring consumer experience, unlike Massachusetts, which has an “Early Indicators Project,” and no evaluation will be released on MyCare Ohio until 2017.
Having failed in its effort during the state budget process, OCVIC instead conducted its own survey of enrollees, using its database and service coordinators in residential housing who recruited participants. OCVIC received more than 400 responses, some with detailed comments, and compiled a report for Ohio Department of Medicaid (ODM). Although the survey was not conducted scientifically, both ODM and the plans recognized that the results indicated areas for improvement, especially in care coordination.
Weaknesses in Care Coordination
Many of the problems encountered by beneficiaries in the first 18 months of the demonstration could have been addressed more quickly, had an effective care coordination model been functioning in each plan.
An August 2015 Issue Brief from Kaiser Family Foundation provides insights into early beneficiary experiences in integrated care demonstrations in Ohio, Virginia, and in Massachusetts. One significant finding was that initial implementation of better-coordinated care was slow. As illustration, the brief describes the challenges encountered by a MyCare Ohio beneficiary named John, a 41-year-old man who became quadriplegic in a diving accident when he was 19. His independent providers did not know how to bill the plan, so John, a college graduate, created a template for his 5 providers to file claims. But, getting a replacement battery for his ceiling lift was a greater challenge, Whereas before MyCare, John could get a new battery authorized immediately, his MyCare plan’s process delayed battery replacement for several weeks, putting the health and safety of John and his caregivers at risk.
Echoing the Kaiser findings, the OCVIC survey results reflect weaknesses in the plans’ care coordination model:
1. 71% of respondents believe they have a care manager (CM); however, 50% report that they have not been able to reach their CM when needed; 29% report that they do not have a CM.
2. 45% reported never having had an assessment.
3. 61% stated they were not included in their care planning process.
4. 63% reported that their care plans did not include services, supplies, and equipment the member needed.
5. 67% stated that their care team did not include their providers, friends, or family.
MyCare Ohio promised a “single point of contact,” who was supposed to be the enrollee’s care manager, but the findings indicate a different experience for many. Also, the failure to include the enrollee, chosen family members, and providers in the “trans-disciplinary care team” described in the MOU not only falls short of contractual expectations, but also reflects a failure, during the initial stages, to achieve the central promise of MyCare Ohio – better care coordination across settings. ODM and the plans have agreed to work with OCVIC on developing a more effective care coordination model for MyCare Ohio.
Collaboration with Geriatric Providers: A vital arrow in OCVIC’s quiver is its network of Geriatric Provider Advocates (GPA’s), made possible by a grant from the John A. Hartford Foundation to Community Catalyst. OCVIC leaders have recruited several geriatric experts currently serving MyCare Ohio patients to build provider participation in MyCare Ohio, both to ensure that patients needing geriatric-competent care receive it and more generally, to strengthen the care coordination model overall. These geriatric providers understand the fundamental elements of effective care coordination, including practical ways the plans can help providers coordinate care and ensure their patients’ safety and well-being. Thus, they are able to partner with enrollees and advocates in proposing and seeking improvements in program design.
OCVIC’s survey confirmed what OCVIC already knew: While many LTSS (Long Term Services and Supports) providers had been recruited to participate in MyCare Ohio, no plan had a robust outreach strategy for engaging medical providers, who play a central role in managing the health of enrollees with complex medical conditions. The plans have acknowledged that their current care team includes only employees of the plan – no providers or enrollees. Furthermore, although the plans have portals by which providers can see their patients’ care plans and records, many providers are unaware of the portals and know little or nothing about MyCare Ohio, even though their patients are enrolled. As a result, providers are not taking advantage of the opportunity to find assistance, through MyCare Ohio, in addressing their patients’ medical and LTSS needs across settings.
In the eighteen months since Ohio first enrolled dually eligible individuals in MyCare Ohio managed care plans, the demonstration has, thus far, fallen far short of its promise to improve care coordination across settings, leading to better quality of life for enrollees and reduced spending on avoidable institutional care. However, transformation in care delivery to a team-based model to achieve care coordination across all settings is difficult because it entails organizational culture change in interactions among different professionals. Patient-centered care seriously requires collaborative decision making and a community-based approach
Yet, with four years remaining on the demonstration and increased engagement of enrollees, advocates, and provider experts, the opportunity created by the capitated financial alignment demonstration to build a new model of care coordination for individuals with complex medical and non-medical needs remains a viable opportunity to improve the health and well-being of dually eligible individuals.
For more information on Ohio Consumer Voice for Integrated Care, contact John Arnold, OCVIC Director, UHCAN Ohio, firstname.lastname@example.org.
About the Contributor
Cathy Levine, JD, recently retired as Executive Director of UHCAN Ohio, a nonprofit consumer health advocacy organization working to achieve quality, affordable health care for all Ohioans. UHCAN Ohio organized the Ohio Voice for Integrated Care, to build the consumer voice in “MyCare Ohio,” Ohio’s demonstration to integrate care for Medicare/Medicaid beneficiaries. Cathy enjoyed twenty years at UHCAN Ohio, including 14 as Executive Director, in which she led several coalitions promoting the interests of vulnerable consumers in diverse aspects of health care reform.
In the past several years, significant efforts have been made to improve the quality of gerontological nursing content in nursing education programs (American Association of Colleges of Nursing [AACN], 2010; National League for Nursing [NLN], 2011). The John A. Hartford Foundation (JAHF) has been a generous supporter of efforts aimed at improving gerontological nursing education and research, and several of its funded initiatives (Building Academic Geriatric Nursing Capacity Program — now called the National Hartford Centers of Gerontological Nursing Excellence — and New York University’s Hartford Institute for Geriatric Nursing) have led to significant increases in faculty with expertise in gerontological nursing and programs of research aimed at improving the care of older adults (Franklin et al., 2011).
In 2007, the NLN, in collaboration with the Community College of Philadelphia and funded by the Independence Foundation, the JAHF, Laerdal Medical, and, since 2012, the Hearst Foundations, began developing the Advancing Care Excellence for Seniors (ACE.S) project and the ACE.S framework to improve the care of older adults (Tagliareni, Cline, Mengel, McLaughlin, & King, 2012). ACE.S is the first national effort to prepare students in all pre-licensure nursing programs to deliver high quality care to older adults in a variety of settings by providing new educational opportunities, teaching tools, and other resources to help pre-licensure nursing faculty offer geriatric content to their students.
ACE.S was developed based on the premise that graduates of nursing programs must be competent in caring for older adults of various ethnic and racial backgrounds and their families across multiple health settings (Institute of Medicine [IOM], 2011). A key component of ACE.S is that nursing students identify how older adults and their families interact with multiple health professionals along a continuum of care and how they make decisions about care before, during, and after life transitions. Coordinating care during significant life transitions is fundamental to ensuring competent, individualized, and humanistic care for older adults and their caregivers. Pre-licensure nursing education is assures that nurses understand and embrace these concepts. An NLN vision statement, Caring for Older Adults (2011), describes the NLN’s vision for transforming nursing education to enhance the knowledge, skills, and attitudes of graduate nurses caring for older adults.
Recognizing that adding new content to an already full and intense pre-licensure nursing curriculum is challenging, ACE.S was designed to work without adding additional content. Instead, ACE.S provides flexible, classroom-ready teaching tools, strategies, and opportunities for interactive learning. In addition to the classroom, there is a skills laboratory, a simulation lab, and direct patient care experiences in a variety of environments such as hospitals, rehabilitation centers, long-term care facilities, and community settings. These teaching tools include unfolding cases, simulations and teaching strategies that are free and available on the NLN website.
The ACE.S Program
For faculty, the framework can be used as a guide to plan and organize intentional student learning activities that build on elemental components of the framework: essential knowledge domains, and essential nursing actions. Incumbent in the framework is student acquisition of knowledge, skills, and attitudes related to quality care of older adults. NLN created a video overview of the ACE.S program.
ACE.S Essential Knowledge Domains
The three essential knowledge domains are:
- individualized aging,
- complexity of care, and
- vulnerability during life transitions.
Throughout the ACE.S project faculty often asked how they would know if their program incorporated essential gerontological content. The knowledge domains were developed with the intent to assist faculty to focus on the most essential elements of knowledge acquisition; an NLN video describes the knowledge domains.
Aging is a process unique to each individual that occurs over time and is continually influenced by personal experiences and biological aging processes (Cline, 2014). The heterogeneity of older adults, influenced by their past experiences and biological aging processes, contributes to variability in health outcomes. This fact is important for students to fully understand; often textbooks use the term “normal aging” which signifies to students that age-related changes are patterned, inevitable and most commonly lead to sequential decline. The concept of individualized aging creates a different perspective. It requires health care professionals to address the unique heterogeneous needs and preferences of older adult patients and refrain from applying clinical practice guidelines or protocols routinely, without accounting for difference and variability. For example two common diseases that are prevalent in the older adult population, diabetes and chronic renal disease, have well-established protocols, but those protocols may not be appropriate for every older adult (Cline, 2014).
An important consideration of individualized aging is that it differs from the concept of patient-centered care. Patient-centered care focuses on ensuring that the health care system and providers focus on the needs of the patient and their family or caregivers and that providers not force care on patients, but rather collaborate with them on making care decisions based on the patients’ personal beliefs, preferences, and desires. Individualized aging defines the process of aging from an individual perspective, but does not define how the health care system or providers should interact and collaborate with patients (Cline, 2014). When providing quality care to older adults, the range of possibilities is as diverse as the older-adult population itself.
The term individualized aging holds the promise of seeing each older adult as unique and requires nurses, and all care providers, to conduct a thorough and comprehensive assessment of each older adult for whom they provide care. This assessment allows the nurse to better understand how the older adult has internalized the lived experience of aging: What personal meaning does aging have for them? What physiological changes have resulted from the aging process? What is the impact of those changes on activities of daily living (ADLs) and quality of life? How does the patient define quality of life from a unique perspective? Conducting a comprehensive assessment, including both physical and functional assessment of each older adult can have important clinical outcomes.
Complexity of Care
Complexity of care considers both the acute and the chronic needs of older adults. This interplay of factors often leads to polypharmacy, the use of four or more medications. In addition, advanced technologies may not be the choice of older adults, and can lead to further geriatric syndromes. Complexity of care directly affects older adults by having positive or negative impacts on their quality of life and the quality of the care they receive (Cline, 2015.) It is critically important for nurse educators to understand that simply telling students that care of older adults is complex does little to help them understand the concept. Using the ACE.S framework as a guide, nurse educators are able to assist students to understand the implications of complexity and the ways in which complexity can improve as well as diminish an older adult’s life. Most importantly, nursing students need to recognize that complexity itself is neither bad nor good; rather, what is important is to manage complexity (Cline, 2015). It is not always possible to decrease the complexity; rather the focus needs to be on acknowledging the interplay of chronic conditions and acute exacerbations in the context of significantly improving the quality of life and care for older adults.
A major component of the ACE.S project is disseminating the NLN’s belief that older adults represent a nurse’s most complex clients. The NLN recognizes that this has not always been evident in how faculty teach care of older adults in both the classroom and clinical settings. So often students ascribe older adult care as “simple” since clinical experiences in nursing homes are often in the fundamentals course and the focus is on basic skill performance.
Additionally, later experiences in critical care environments are often not intentionally focused on the complex needs of older adults, using the ACE.S framework. Didactic and clinical experiences are needed to teach students to recognize, respect, and respond to the management of multiple, co-existing acute and chronic conditions. For example, the immediate and long-term life goals and physiological and mental health of older adults may converge in complex and unexpected ways as a result of changes in environments, levels of independence, and functional abilities. The ACE.S program calls on nurse educators to facilitate learning environments for students to care for older adults and their caregivers in a ways that recognize the complexity of care inherent in the aging process.
Vulnerability During Life Transitions
Vulnerability during transitions for older adults is defined as the inadequate continuity of care, and poor communication and coordination among health care providers, patients and their families (Cline, 2016). Consequences of vulnerable transitions, include readmissions to previous or new care settings, caregiver stress and the potential for poor health outcomes, and are important components of this essential knowledge domain. The fragmented U.S. health care system also influences vulnerability (Cline, 2016).
Coordinating care and advocating for the older adult during significant life transitions are fundamental to the ACE.S approach to delivery of competent, individualized, humanistic care for the older adult, the family, and caregivers. In fact, ACE.S asks faculty and students to reframe their thinking about patient discharge, recognizing that older adults are never fully released or discharged from the health care delivery system. Their continuity of care requires that their providers begin to understand the experiences older adults face when transitioning from one setting to the next and when experiencing changes in function or role. Using ACE.S as a framework suggests that health care providers no longer use the term discharge planning and consider transition planning as a more active and realistic alternative. In clinical teaching settings, for example, where older adults are discharged to home, nursing students would ensure that patients have a clear understanding of their medications and follow-up appointments with their primary care providers, and that their caregivers have adequate support and guidance.
Integral to ensuring quality care is the nurses’ understanding that older adults are vulnerable during all transitions, whether from acute-care or rehabilitation settings, to community and long-term care, or from complete independence with ADLs to dependence on others. Coordinating care during transitions involves analyzing risks and benefits of care decisions in light of the older adult’s needs, resources and treatment plans. Evidence from the Transitional Care Model, developed by a multidisciplinary team at the University of Pennsylvania, has demonstrated the important role nurses have in mitigating vulnerabilities and improving outcomes for vulnerable older adults transitioning from acute care services to home (Naylor et al., 2012). Nursing programs that integrate the ACE.S Essential Knowledge Domains into their curricula will provide students with crucial knowledge related to quality care of older adults.
ACE.S Essential Nursing Actions
The essential nursing actions allow nursing students and practicing nurses to translate their knowledge of individualized aging, complexity of care, and vulnerabilities during life transitions, into actions that promote high quality care for older adults. Furthermore, use of these essential actions in clinical experiences, skills lab/simulation, and lecture develops knowledge, skills, and abilities related to the care of older adults while promoting positive perceptions of aging.
The nursing actions build upon existing Hartford Foundation-funded resources (i.e. Consult Geri-RN).
Key components are:
1) assessment of the older adult’s functional status; strengths, resources, needs, and cultural traditions; and the wishes and expectations of the older adult and caregiver;
2) management of multiple complex co-morbidities;
3) use of evolving evidence based geriatric knowledge, technology, and best practices to encourage a spirit of inquiry and provide competent care for the older adult; and
4) coordinating care during significant life transitions, while weighing risks and benefits and accounting for the older adult’s wishes, expectations and strengths.
An NLN video facilitates use of the essential nursing actions by faculty.
ACE.S Teaching Resources
There are two important resources available through ACE.S that can be used by faculty in teaching the ACE.S framework: The NLN ACE.S unfolding cases, and its series of teaching strategies. The unfolding cases evolve over time in a manner that is unpredictable to the learner. The traditional case study tells the student what they are looking for, such as introducing a patient as an 82 year old diabetic to a student who is being asked to address diabetes. In contrast, the ACE.S unfolding case studies, challenge students to identify the health issues affecting the patient featured in each case.
Four unfolding case study simulation scenarios using the “gero” lens and three Alzheimer’s disease-centered unfolding cases are available on the NLN website. Cases are written to be modified to address the needs of diverse curricula, different teaching methods, and individual style.
Each case includes the following:
- A first-person monologue that introduces the individual or couple and the complex problems to be addressed.
- Simulation scenarios with links to appropriate evidence-based assessment tools, including those from the How to Try This® Series
- A final assignment that asks students to finish the story.
- An instructor toolkit with suggestions on how to use the various components of the unfolding cases and incorporate them into the curriculum.
The teaching strategies are a series of teaching/learning activities that have been used by educators to engage students in learning about complex care issues facing older adults. In 2015 ACE.S expanded to develop ACE.SXPRESS starter kits on the topics of care-giving, mental health and the three essential knowledge domains that include selected unfolding cases and teaching strategies around a core topic. These starter kits have been downloaded by extensively by faculty who desire to focus learning experiences on critical content areas essential the care of older adults, and the caregiver in a community-driven health care system. Additional resources also include archived webinars which are available on the NLN ACE.SXPRESS website.
The NLN ACE.S initiative is a targeted effort to enhance the geriatric expertise of nursing faculty by providing ACE.S resources and encouraging faculty use in classroom, lab and clinical nursing education. The ultimate goal of ACE.S is to enhance student learning experiences and prepare nursing graduates to address the complex healthcare needs of the aging population.
Dr. Beverly Malone, NLN CEO, created a video directed toward students
to embolden them to consider a career with older adults, and change the trajectory of senior caregiving in the current health care system. The video has been used by faculty in both introductory nursing courses and specialized geriatric seminars.
As the nursing profession embarks on the challenge of incorporating care of older adults as core nursing knowledge throughout the curriculum, the NLN ACE.S project and the teaching resources embedded within it provide a useful and practical guide to facilitate this process.
About the Contributor
Elaine Tagliareni is the Chief Program Officer at the National League for Nursing. For more than 25 years, Dr. Tagliareni was a professor of nursing and the Independence Foundation Chair in Community Health Nursing Education at Community College of Philadelphia, and is a past-president of the NLN (2007-2009). As Independence Foundation chair, Dr. Tagliareni served as president of the National Nursing Centers Consortium (NNCC) to advance state and federal health policy to include nurse-managed health centers as essential safety net providers for vulnerable populations.
As a child, one of my most special memories was sitting around the record player with my father and my brother and having Dad play all the 78s on a Sunday afternoon, followed by the 45 RPMs.
The record collection ranged from cowboy songs, to Polkas, to Perry Como, with everything between: Hank Williams Jr., Irish music, Sophie Tucker, Kate Smith, and a host of others. We would sing along with the records, Dad leading us in his best off-key Bing Crosby. Gene Autry was invariably our favorite. Why? Not only because he had a horse named Champion, but because he yodeled. Yodeler from Tulsa, his albums read. “Old Lady Who!” we’d sing out“Old Lady Who!” We also liked the word Lady, it was the name of our pet dog. After the record session with Dad was over, we’d call out Old Lady Who and our little runt would come galumphing out. We’d saddle her up for her Sunday afternoon walk to the field across from Mr. Hayes’ grocery store on the corner of Bissell Avenue and East Ferry Street.
Yodel lay he ooh! He yodeled and we yodeled our version right along with him.
That the expression “Old Lady” would ever come to mean anything other than a child’s yodel or a call for a beloved dog never occurred to me. It would be years before I was to realize that there was a new connotation to this phrase. A stigma even. To understand the whys of this growing phenomenon, let’s backtrack a little. It seems that a male can be called Sir from the day he is born into this world until the day he takes his leave of it. It’s different for a female, however. A woman starts out with Miss, quickly becomes Ma’am and then enters the realm of Sweetie, a euphemism for Old Lady or just plain Old.
But I am getting ahead of myself here.
An early encounter with this terminology occurred some year’s back when I was cat-sitting for a friend in Rensselaer. A snowstorm had whipped up outside and I found a shovel in the garage and went out to keep up with the snow that was piling high in the driveway. Now and then I’d stop to take a hit of my asthma inhaler. A guy in a service truck pulled up to the man next door, also shoveling away, and said in his loudest stage whisper: “Do you think the Old Lady needs a hand?” What the young man didn’t count on was the fact that though I may wear glasses, I have hearing like a dog. So I called out in response: “This Old Lady does her own shoveling.” His head spun around, and then he called over to me that he’d be glad to give me a hand. I said if he wanted to earn $20.00 that would be fine, but he quickly said “On the house” and we had a deal.Truth be told, I was glad for his help. He just needed to ask in a slightly different way.
Sadly, this little encounter signaled to me that there was a new creature out there to deal with, a new Grendel, if you will. Old Lady Who no longer emanated from a child’s misinterpretation of the sound of yodeling. Ultimately the expression, once fun, dwindled down to the word Old, which Society has been cleverly advertising since 1938, when the phrase Senior Citizen was introduced into the pedestrian vocabulary. People began ooh-ing and aah-ing about all sorts of discounts, though no one was quite sure at what age one graduated from Junior Citizen to Senior Citizen. Were individuals Seniors at 70, 67, 65, 55, or perhaps younger? In other words, when and where does Old begin?
This past spring, a friend I was vacationing with suddenly began making noises which I can only describe as sounds from a barnyard or a bedroom. Stunned, I asked if something was wrong or if she needed help, but she replied she was simply making “Old Lady noises.”
“Why are those called ‘Old Lady’ noises?” I wanted to know.
“Well, they’re the noises I heard Old Ladies make when I was a child,” she replied. Quite honestly, neither my grandmothers nor any of my great aunts or neighbors ever made comparable sounds. My friend and I, though roughly the same age, were not “aging” on the same page.
In the spring, I flew off to Warszawa, Poland, where I had a gig at a private university teaching Speech and Theatre classes to English and Business majors. As I have friends and relatives in Warszawa, my evenings and weekends were spent visiting. First of all, Polish friends and family all wonder why I am not a Pensioner. At my age, in Poland, I am entitled to free rides on any public transportation. So why work? Aren’t all Americans rich?
On my last Saturday in Warszawa, my friend Mariola invited me to have dinner with her mother and her son, Wojtek, at their flat. After dinner, Wojtek wanted to take a walk with his grandmother. Mariola argued that it was all right for his Babcia to cook dinner, but after that, Babcia must sit.
“Because Babcia is Old Lady!”
There it was again. That dirty word. Later, Wojtek, Mariola, and I took a tram to Francziuska Street and sauntered for miles through a park. Wojtek told me he was impressed with me that I was such a rigorous walker. Why? I put plenty of miles on my legs each day, and I am talking genuine walking, not footing it on a treadmill.
It seems these little anecdotes beg that question of when and where does Old start? Oddly enough the word itself is part of the youngest birthday.
“How old is she?” someone will ask of a newborn. “One day old? One month old? One year old?”
It is a natural process to be growing Old. It is part of aging, which is a healthy thing. No one can stay a baby forever. Human beings are meant to grow into a more mature physical and spiritual self as they intermingle with the world outside. A world which offers relationships, a world which awakens “Passion.”
It is this very word passion which provokes the sounding of alarms. For what the maturing human may desire and what
society desires for that human, may conflict. American Society seems to operate on its need for us to stay young forever, intellectual children, needing for us to always to be needing new things. Society may even trick us into a perpetual state of coping in order to achieve these ends. We run with the herd, we buy what the herd buys, we think like the herd.
At what age, then, in this system of “Forever Young,” does Old Lady begin? Sometime into my early 30s, I met a man who told me he could get me some film work, but warned me not to tell anyone my age. I was 34.
When I was 39, I landed a job in publicity at Viking Penguin in NYC. The following July they were throwing a birthday party for me: “How old?” inquired Marcia.
“Forty years old!” I beamed.
Marcia almost fell through the floor. Not long after, I found myself in the unemployment line.
Almost a decade later, I moved to upstate New York and was applying for work as an adjunct professor at a local college.
“Be sure not to tell anyone you are 47 years old,” advised a technician from Human Resources.
It seems the “Forever Young” demand that society places on women is quite powerful.It can distract people from pursuing their own passion because we must buy the right clothes, wear the right makeup, have the right cosmetic surgeries to appease and participate. And for what? To be dropped like the proverbial hot potato the minute a liver spot occurs or a breast begins to sag? It’s a race we will never win.
Unpursued passion results in numbness. Too much following and a deadened state of coping ensues. It takes great courage to allow for passion to rise from the smoldering embers of deadened states. We are here, though, those of us willing to hold a torch up high and beckon the dazed herd back to life.
My meta-physician recently mentioned to me that his young daughter, Mia, sees a woman Doctor who is 94 years old. Mia’s pediatrician has always loved her profession. It is her passion and she has no plans of abandoning those who need her care, no matter what number is assigned to her years.
It is a struggle at times not to follow the herd, but I, deemed an Old Lady since age 34, have chosen role models as Mia’s Doctor to keep me on a path of my own making. I choose not to buy the largest television set to babysit me or the most comfortable La-Z-Boy to hypnotize me into a permanent state of dullness, without whatever prescription drugs they’re trying to convince us we need. I choose not to investigate every Mature Adult Living Center in preparation for Assisted Living and Nursing Home facilities. I choose to mingle with ALL of society. I choose to be led by my passion.
Earlier in the year I heard that there were auditions for a play named “Angel Street.” It is a play that has always fascinated me, especially the character of the maid Elizabeth, who is described as a woman 50 years of age and ample. A number of generations ago, I saw fifty. But it did not stop me from auditioning. And I did! I even auditioned wearing glasses, and, lo and behold, I was cast. If I hadn’t showed up, I never would have had the joy of playing Elizabeth.
When I write my own plays, I like to write parts for varying ages, particularly female characters over 50. Some people have asked me if I wasn’t afraid of older actresses forgetting their lines. I have twenty-something year olds in my acting class who have a great deal of difficulty learning lines. Does that mean parts shouldn’t be written for twenty-year olds?
Who I am is an artist, a teacher, a playwright, and actress. Like my mother before me, I also make art visually. I serve as a mentor for all of the above. One of my former students calls me to keep in touch. “See ya soon, Babe!” she always says before hanging up.
A friend in her early eighties teaches an art class through a University in St. Petersburg. There she met a man eleven years her junior and they began to see each other. She told me she never thought she’d fall in love again after her third husband died. “Now Steve wants to move in” she exclaimed, “but my canvases come first.” Old Lady Who?
Every now and then someone will ask when I plan to retire. They ask it in a whisper, and I whisper back, “No Old Lady for me.”
About the Contributor
Sandra Dollinger is a playwright, actress, and artist. She is also an instructor at The College of St. Rose in Albany, New York.
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Published by Hudson Whitman/ Excelsior College Press, Nursing in the 21st Century (N21) aims to be THE place for nurses to question, discuss, define, and creatively resolve challenges facing their profession.
Transforming the nation’s current health care model into one that works for both care providers and care recipients is a tall order. N21 was created to stimulate conversation around that transformation.
More than another passive, one-way conversation, N21 represents a culture of change. It is a call to think, to engage, to solve, and to take on an opportunity to bridge thoughts and ideas into reality. It is also a call to accomplish change collaboratively, across the range of the professional spectrum.
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PhD, RN, FAAN, Professor and Senior Faculty Associate, Hartford Institute for Geriatric Nursing both at the College of
Nursing, New York University. She is a Nurse Attending at New York University Langone Medical Center. Her work focuses on the organization and delivery of nursing care.
PhD, RN, NE-BC, FAAN, Professor, College of Nursing and College of Public Health, University of Iowa, is a nationally recognized nursing administration expert, researcher, academic, speaker, and consultant. She specializes in leadership and nursing care management, emphasizing case and population health management.
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