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This chapter covers the troubling demographic trends spurring on ACCESS Health International’s work in elder care research. The demographic shift toward older populations is attributed here to overall increased life span, lower mortality rates, declining immigration numbers, and lower fertility rates, as illustrated in the accompanying tables and figures. Though is primarily aimed at the United States, the chapter takes care to note that these demographic patterns are nearly universal across the globe. The authors also comment on the shrinking potential support ratio for this growing number of aging people, which brings readers to the crux of : the need for comprehensive, preventative, wider ranging elder care.

This chapter presents the state of the current elder care crisis in the United States. According to their analysis and that of their interviewees, less than optimal spending and health outcomes, a geriatric workforce shortage, and the prevalence of chronic disease all contribute to the desperation of a worsening situation. In contrast to that desperation, the authors note that the increased life expectancy in the United States and elsewhere is in fact a triumph of medicine. The chapter nonetheless makes clear that increased length of life cannot be conflated with its quality. The authors describe as “a book of solutions” and begin to describe the way those solutions will be unfurled through the course of the coming chapters.

The primary concern of this chapter is the long-term financing of improved elder care. By beginning their detailed discussions with this point, the authors anticipate a primary scruple of those who would resist elder care reform. The chapter begins with a discussion of elder care demand and its anticipated increase over the coming decades. With growing need come growing barriers to action; the chapter covers such barriers as public knowledge (or the lack thereof), cost, reimbursement policy, and long-term care insurance. This chapter also includes the first interview subject of , Claude Thau of Thau Incorporated, a company that provides consulting services to insurers, employers, regulators, and businesses who assist the long-term care insurance industry.

This chapter introduces the concept of person-centered long-term care, a cornerstone of the recommendations offered in . Through a summarized interview with Christopher Perna formerly of the Eden Alternative, the authors discuss the process of culture change, beginning with the hierarchy but requiring a complete buy in from an entire organization. Rebecca Priest of St. John’s Home describes the importance of empowering a care team and keeping the staff satisfied with company culture in every respect, from uniforms to the freedom to interact with the residents. The accompanying analysis of person-directed care makes the case that keeping the person and family at the center of decision making and organizational structure creates a positive daily routine and leads to better health outcomes.

This chapter makes the case for home-based palliative care and aging in place and community as alternatives to assisted living and hospitalized end-of-life care. The physical, psychological, and financial costs of protracted end-of-life care are discussed in the context of interviews with Dr. Diane E. Meier of the Center to Advance Palliative Care, Dr. Kristofer Smith of Northwell Health Solutions, and Dr. Allan Teel of Full Circle America. Along with these wider concerns, the authors discuss prioritizing patient engagement in prioritizing their care while living with chronic illness through the end of their lives. The chapter also considers the challenges to palliative care and the barriers to its adoption and implementation.

This chapter begins with the shocking projection that the United States will need 14,900 to 52,000 more primary care physicians by 2025. Foreseeing this development, the chapter advocates fully integrating those primary care practices with elder, dementia, and end-of-life care, citing (among other things) the frequent comorbidities among older patients that make them prime beneficiaries of integrated primary care. The authors analyze the additional benefits of coordinated care, from efficiency to decreased staff burnout and better outcomes. Interviews with Dr. Erik Langhoff of the James Peters of the VA Medical Center and Drs. Erin Giovannetti and Michael Barr of the National Committee for Quality Assurance confirm these findings and offer unique perspectives into the importance of coordinated primary care.

This chapter considers the problem of emergency department care as a fallback for the elderly. The chapter focuses on alternatives to emergency department services and includes interview material from Mark Prather and Kevin Riddleberger of DispatchHealth, who discuss the importance providing home and work-based acute-level care. Dr. Kristofer Smith of Northwell Health Solutions and Dr. Bruce Leff of Hospital at Home offer their own best practices and recommendations for avoiding hospitalization by providing home-based palliative and hospital care. Regarding cases in which a visit to the emergency department is necessary or unavoidable, the authors discuss post-emergency care and the transition back to life at home.

This chapter offers detailed recommendations for supporting those living with dementia and their caregivers. The authors discuss the many specific challenges of dementia care and the extra support required for those providing that care. Interviews with Dr. Mary S. Mittelman of NYU Caregiver Intervention, Jed A. Levine and Elizabeth Bravo Santiago of CaringKind, Karen Love, Jackie Pinkowitz, Lon Pinkowitz, and Brian Leblanc of the Dementia Action Alliance, and Dr. Davina Porock cover a wide range of best practices for both dementia care and caregiver support. Among the topics covered here are the importance of supporting the family caregiver, wandering, stigma, financial and legal planning, and the prevalence of underserved dementia sufferers among minorities in the US.

The authors and interviewees delineate best practices for integrating health and social care that improves quality of life and health outcomes for older adults through prevention, engagement, and social connections. The summarized interviews with June Simmons of the Partners in Care Foundation and Sarah Szanton of CAPABLE detail interventions that address the social determinants of health including the condition, accessibility, and safety of the home, community connection and inclusion, and access to healthcare, transportation, and food. The chapter discusses the benefits of staying at home and the means of avoiding the hospital (and ultimately the nursing home). At the core of the chapter is the independence and self-management of older adults, which the authors acknowledge as both a challenge and a solution.

This chapter approaches the subject of social inclusion as a healthcare priority and key component of optimal aging for the older adults. Summarized interviews with an expansive group of experts provide examples of best practice in creating environments that enable social inclusion, including intergenerational connections, for people of all ages and abilities. They also impress upon the reader the importance of involving older adults in all aspects of creating such environments. Interviewees include: Rebecca Priest, Administrator of Skilled Nursing at St. John’s Care Home; Tena Alonzo, Karen Mitchell, and Ivan Hilton of Beatitudes Campus; Anne Doyle of Lasell Village; Mia Oberlink of the AdvantAge Initiative; Ruth Finkelstein of Age Smart Employer and Exceeding Expectations Initiatives; Lindsay Goldman of Age-Friendly NYC, Paul Tang of linkAges; and Emi Kiyota of Ibasho.