Congressional Briefing on Aging in America

Please note: This is an unedited transcript. Note: This is an unedited transcript.

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SARAH DASH:  Good afternoon, everybody.  Go ahead and get us started.  Hi, I’m Sarah Dash; I am President and CEO of the Alliance for Health Policy, and we are delighted to have everybody here today.


For those of you who are not familiar with the Alliance, we are a non-partisan organization that is dedicated to advancing knowledge and understanding of health policy issues.  We serve the public servants, and the healthcare leaders who really hold the future of healthcare in their hands, and I want to acknowledge public service today. We are happy to have today with us Assistant Secretary of Aging, Lance Robertson, who is — it’s very exciting to have a public servant here.  And I just want to acknowledge, of course, our country lost a very important public servant in President George HW Bush.  So I just want to acknowledge that today, and if we could just have a brief moment of silence.  Thank you.


So we are here today to talk about aging in America.  This is the third and final installment in our signature series on opportunities for progress, and it is the final public event of the year for the Alliance. So we created this series to really highlight progress on persistent health policy issues and examine progress — ideas for progress for moving forward.  Earlier this year, we examined health care costs, and you can find everything archived on our website.


I want to add that we’re going to talk about services that are likely to help people from needing expensive healthcare services, and as we talk about costs, you know, this conversation on aging really follows along with that.  So we’re going to do things a little bit differently today, for those of you who have been to some of our briefings.  We are pleased, as I said, to have Assistant Secretary for Aging, Lance Robertson, who is going to share some of his perspectives on aging in America.  Then we will follow that with an expert panel of age friendly innovators who will spend the remainder of their time discussing their successes and challenges working in this space.


I want to thank first some of our sponsors who have supported this series and we would not be here today without them.  Health is Primary and Pharma.  Our champion sponsor is Aetna, Anthem, Ascension, Blue Cross/Blue Shield Association, Cambia Health Foundation, GlaxoSmithKline and InnovAge, and our signature sponsor for aging, the Catholic Health Association of the United States.  So we have a few of our sponsors here to make some brief opening remarks to highlight this issue.  I’m going to introduce them all right now, they will come up here and speak, and then we will turn to our program.


So first we will hear from Dr. Chamain Labird [?], who is Vice President of Medicare Clinical Operations at Anthem. Next, we’ll hear from Fran Sossaman, Executive Vice President, and President of Government Services at Aetna, who will say a few words.  And finally, we’re happy that we will hear from Ann Sebold who is campaign director for Health is Primary.  So with that, let me know turn the podium over to Dr. Labird, thank you.


SPEAKER:   Good afternoon, thank you, Sarah. So first and foremost, as a physician, it behooves me to remind everyone with the holiday season coming up, with family gatherings, make sure you gather family history and document that, as well as make sure you see your primary care doctor, and get those screenings done. As a physician, I feel with a captive audience, I must do that.


So I represent Anthem, and from a clinical standpoint, Anthem serves 1.8 million Medicare members.  We comprise Medicare Advantage, Part D, Medigap, and a group retiree.  And today, you’re going to hear from a panel that will attest to the importance of really addressing the needs of the whole person and not just the medical portion of the member, or the patient. And I think it’s really important today to take note of that, and be able to bring this back to wherever you are in your day-to-day work life, and family life, to be able to understand that the whole person is really important. And Anthem actually does this in a few ways. We have a couple of innovative products as well as programs that we’re doing, and I just want to highlight a few of  them today. We do have a new product offering as of 2019 that looks at helping our members get transportation to where they need to go, or have access to meals. And that’s thanks to CMS’s ability for a Medicare Advantage Program to do that, and we have that in select areas. We also have — CareMore is a subsidiary of Anthem, and what CareMore has done with the togetherness program, is we’ve taken some of our employees and linked them with our members who may be — seniors who may be isolated and lonely. And we found that by engaging our employees — we have about 800 CareMore members, or seniors, who get phone calls from our employees. And in looking at the some of the stories, what you’ll hear is that sometimes this is the only phone call that they get all day. And the member, our patients, are so engaged, that they — we found that they are more active, and so 53% of them are going to exercise classes. We’ve noticed a decrease in ER usage. And so by not going to the ER and having someone to talk to, or help to manage what they need, is really making a significant difference as well as decreasing inpatient admissions, which can be sometimes significant. Additionally, we have case managers who are nurses and social workers, who actually work with care coordination. And clearly, by connecting our members and our seniors with those services that they need, let’s say on discharge, they maybe need to get a wheelchair, or they need to make sure that their primary care appointments are set. Those are key things that we find that have been helpful.


And finally, we also have a Silver Sneakers program which works with health clubs, and that helps to engage our members and get them active. Where we find that, you know, as we age, and as time passes, our bones and joints just don’t work as well. And by being more active, it actually decreases fractures, falls, all that is really important in keeping our members healthy and safe.


Lastly, Anthem clearly can do more, and we are striving to do more in 2019 and going forward. But hopefully with having the insights of the panel today, I will be able to bring that back to anthem, and you all will be able to take those insights as well back to respective areas, and be able to influence change for our seniors.


Lastly, I really want us to consider how the social and physical environments affect how our healthcare is delivered. By influencing policy, we’re able to make a difference, and I think it’s very, very important to remember that the social determinants of health really are important in making sure that the entire — the whole person, remains health and stays healthy. Thank you.




SPEAKER:   Clock’s running. Good afternoon. I’m Fran Sossaman [?] from Aetna, and it’s a pleasure to be here. I want to thank Sarah and thank the Alliance for organizing this series on aging in America.


It’s been an extraordinary series to surface the challenges, which may be for some are the obvious, but for others, it’s been enlightening. And it’s very timely, because the reality is that every day, 11,000 Americans are aging into Medicare eligibility, and that continues out for the next three decades. So America is getting older, and we can’t stop that. That is something that we are facing in terms of what’s happened with the acceleration of the Baby Boomers aging into Medicare eligibility. So it’s beyond the statistic. The reality is that not only are we aging into Medicare eligibility faster, unfortunately those who are aging in, are coming in with more chronic conditions. So the challenges that we face are even greater. So more co-morbidities, more chronic illness, and as a country, you know that means we have even more costly events that we have to deal with when the Medicare trust fund may not be sufficient longer term.


So what are we doing about it? Well, Medicare Advantage has been a good alternative to original Medicare, to drive better outcomes at lower cost. But that still has to evolve. So at Aetna, we have been, and will continue to focus on the challenges holistically. We have been approaching this from an integrated perspective in terms of the physical, behavioral, social, and pharmacological components of healthcare. And the social determinants have become even more of a focal point, because we realize that it’s the basics of life that oftentimes lead to the medical challenges that present in the ER. And whether it’s a Medicare patient or a Medicaid eligible patient, and we have to solve those. So we have to tackle this at each end of the spectrum, each end of the continuum.


And Aetna’s world has changed recently. As of last week, we are now owned by CVS Health. And that presents an incredible opportunity to accelerate transformation. CVS Health has nearly 10,000 retail locations across the United States, within three miles of 85% of the U.S. population. Getting us closer to consumers. The reality is, with the growing of the Medicare eligible population, we are not going to have the infrastructure as a nation to deal with the population growth of Medicare eligible not having enough beds in the right locations. So more care is going to be delivered in the home. So this is important to us, to allow us to have greater access to our members, to patients in the home. And that’s not a bad thing, that’s actually a good thing, because most people would rather be in their homes; certainly would rather be in their homes, than in the nursing home. So we are approaching this in a multidimensional fashion — telemedicine, working with home and community based providers, telemonitoring. Every available technology, every available community resource and asset, is how we’re approaching this. There is no simple solutions, no one size fits all. And we are approaching this in a manner that reflects the diversity of our American society, meaning a multicultural competency.


So the challenge is daunting, we are up for it, and I think we can tackle this. So thank you for this opportunity. Thanks, Sarah.




SPEAKER:  Hi, I’m Ann Sebold, and I’m a co-director of the Health is Primary campaign, which is a campaign run by American Academy of Family Physicians, and seven other family medicine organizations. Basically to promote the value of primary care within the context of healthcare. We have been a sponsor of the Alliance series for two years, because we believe primary care needs to be a part of every conversation about healthcare. Because the foundation of primary care, we know for a fact, having a strong foundation of primary care delivers better outcomes, better patient satisfaction, at lower cost. And this especially true and important for the aging population. Our campaign has been about the good news of healthcare, and we have spent the last four years telling the stories of primary care and innovation and transformation that are happening at the practice level, and at the state level, where investment in primary care is happening. And you’re going to hear one of our best case studies today from Dr. Tom Cornwell. But our goal really is that in policy moving forward, that these case studies and sort of microcosms, have the opportunity to be taken to scale, to serve the aging population, and frankly all of population. Thank you.




SARAH DASH:  Thank you all. It is now my pleasure to introduce to you the United States Assistant Secretary for Aging, and the Administrator of the Administration for Community Living, Lance Robertson.




You have his full bio in your packet, but I will say that Assistant Secretary Robertson hails from the great state of Oklahoma, where he served for ten years as Director of Aging Services within the state’s Department of Human Services. Prior to that, he spent 12 years at Oklahoma State University where he co-founded the Gerontology Institute, and served as executive director of the nation’s largest regional gerontology association, Mr. Assistant Secretary, thank you so much for joining us today.




LANCE ROBERTSON:  All right, hello everyone. Do you not realize it’s Friday afternoon? You are on cruise control to the weekend. It’s an honor to be here. Thank you, Sarah, so much, and I’m delighted to be here to kind of honor and help kick off this Aging in America briefing. I think the timing, of course, of today’s briefing is well placed, given the upcoming reauthorization of the Older American’s Act.  Since 1965, the bipartisan legislation certain has placed and helped provide critical services that have better enabled millions of older Americans to live independently, and with dignity in their homes and communities. Never before has this law been so relevant, and so timely. As has already been referenced, some of the data I think we all know across the United States, 10,000 people turn 65 each day. And by the year 2030, we are talking about basically 20% of the population being 65 and older.


So it’s my distinct privilege as the Assistant Secretary for Aging, to head the Administration for Community Living, which is the federal agency tasked with implementing the Older Americans Act, as well as several other very critical pieces of legislation and programs.


You’ve got an impressive cadre of speakers that are going to no doubt reaffirm that we all have an imperative to respond to the rising aging demographics with smart, cost effective, and person centered strategies. I know we all look forward to hearing from this panel of innovators on what they are doing as we usher in this new era of age friendly communities. I’ve had a chance to look at their power points, and it’s going to be a wonderful conversation.


To set the stage for their remarks, I am pleased to share with you just a slice of what we’re doing at the Administration for Community Living. Through partnerships across the federal government, and with state and local leaders, to promote the following simple, but profound goals:  First, that all people, regardless of age or disability, should have the right to live independently and participate fully in their communities. Secondly, that every person should have the right to make choices, and to control the decisions in and about their lives. And finally, that this right to self-determination includes decisions about where to work, where to live, and other daily choices that most of us simply take for granted. So by funding services and supports provided by networks of community based organizations and with the investments in research and innovation, ACL helps make this principal a reality for millions of Americans. We are proud pioneers in transforming communities to become age friendly, and doing so long before the term was really ever coined. And we do this by advocating across the federal government for older adults, people with disabilities, their families and caregivers; by investing and training in education, from workforce training to helping families learn to support a loved one with a lifelong disability, and also training to help the aging and disability networks improve their abilities to partner. And finally by funding research and innovation, that includes everything from new business models to improving the long-term sustainability of community programs, to high tech research and development of assistive technology tools.


I would like to emphasize the value of each of these goals that I just referenced, through the different pillars that I created when I was going through Senate confirmation last fall, and something we continue to champion at ACL. So our five pillars:  Connecting people to resources, protecting rights and preventing abuse, supporting families and caregivers, strengthening the networks, and expanding employment opportunities.  The majority of the work that we do at ACL is administering programs that provide services and supports in the community.  They are provided primarily by a network of community-based organizations, and that also includes universities, faith-based organizations, and various other non-profits. Collectively, we refer to them as the Aging and Disability Networks. The Aging and Disability Services Networks, honestly, is like the glue. It holds together all of the pieces of the community, and really helps provide what that individual needs to remain functional. It is the nation’s home and community-based long term services and supports, infrastructure, and system, and enables people to reside in their homes and in their communities. Our programs meet the goals established by Congress, providing assistance to help people maintain their health, independence, dignity, and to avoid institutionalization. They are effective in targeting the poor, the near-poor, and those who are frail, and certainly those who are at risk of institutionalization.


That last point:  The effective prevention role that our programs play through the provision of critical services and supports, to often vulnerable adults, is pivotal to one of Secretary Azar’s top priorities. As the Secretary of Health and Human Services, he’s identified as one of his four key priorities — transforming healthcare to a value-based system, which has again, direct applicability to today’s conversation. By that, he means creating a healthcare system that pays providers for outcomes rather than simply procedures. The value-based transformation has multiple components. One key element of quality assessment for post-acute care facilities, is cutting down of course, on re-admissions.  And as Secretary Azar also has said, “A system that pays for value, will aim to move patients into the lowest cost, and most appropriate setting.” That means avoiding hospitalization, avoids nursing home admissions, shortening durations of stay, and preventing re-admissions where possible. Considering the depth and breadth of services and supports that ACL provides millions of Americans through programs that target the social determinants of health, Secretary Azar has pointed out when he has spoken to healthcare organizations recently, that we need to do a better job of engaging and involving aging disability networks if we are going to achieve the goal of that value-based healthcare system. So I’m pleased to be working closely with the secretary and his team to realize that goal. As the secretary recently remarked, and I quote, “Social determinants of health is an abstract term, but for millions of Americans, it is a very tangible, frightening challenge. How can someone manage, as an example, their diabetes if they are not sure how they are going to pay for their meals?” So thanks in large part to the Older Americans Act, ACL administers programs that strive to alleviate those types of worries. For example our nutrition programs support 5,000 community based organizations serving more than 900,000 meals a day all across the country, through both congregate meal settings and home delivered meals, Older Americans Act nutrition programs provide of course more than just food. They also address other health disparities. The program’s goals of course include decreasing hunger, decreasing food insecurity, decreasing isolation, and to offer other health promotion activities. And this is done every day across 20,000 different meal sites in every corner of our great country.


Increasingly, the issue of social isolation among older adults has been gaining traction in the field of public health. As one of the earliest programs authorized by Congress under the Older Americans Act, our nutrition programs have been at the forefront of tackling social isolation. In fact, the recent evaluation of our Older Americans Act nutrition program indicated that older adults living alone who receive meals, showed reductions in feelings of social isolation. Social isolation is an especially important topic for us at ACL, because as one ages, there are many changes that occur which can often trigger this issue. It’s estimated that nearly 20% of older adults 65 and older are socially isolated. Opportunities to identify and address social isolation are present throughout the work that we do at ACL. We know that persons with comprised health and disability are at high risk of loneliness and social isolation. These individuals may not engage with families, friends, neighbors or peers due to barriers when it comes to speech or hearing impairments, inadequate transportation, and settings that are just simply not accessible. We also know that social isolation and loneliness have a detrimental impact on one’s health and well-being. Researchers have suggested the health risks associated with social isolation can be compared in magnitude the well-known dangers of cigarette smoking and obesity.


According to a report by the AARP public policy institute, and Stanford University, social isolation among people with Medicare is associated with an estimated 6.7 billion dollars in additional Medicare spending each year. That’s comparable to additional program spending for people with chronic conditions like high blood pressure. Several studies have found reductions in loneliness and improved social well-being with programs funded through the Older Americans Act. For example, one report shows 93% of congregate meal participants were socially active, and were satisfied with their opportunities to spend time with other people. We’ve also learned the typical congregate meal participant does not experience loneliness. Only 7% of congregate meal participants screened positively for depression, and 81% of home delivered meal participants reported satisfaction with their opportunities to spend time with other people.


So social connection is also enormously important for our veteran population, pivoting slightly. A population that we know is at a high risk of suicide. To bring the expertise of the aging and disability networks to the service of those who have served our country, ACL and the Veteran’s Health Administration, VHA, have partnered to build a veteran directed care program. Since 2008, this collaboration has helped veterans with disabilities of all ages, and their families receive needed social supports and services in their own homes and communities. The ultimate goal of course is a nationwide home and community based long-term services and supports program that allows veterans more access, choices, and control over the care that they receive. We have combined the hands on experience and skills of ACLs, networks with a commitment and resources of VHA, to provide veterans with an unprecedented additional opportunity to avoid nursing home placement and remain independent in the community. As of August, the program is serving 2,133 veterans across 35 states and the District of Columbia and Puerto Rico. At the same time, 79 Veterans Affairs Medical Centers or VAMCs have partnered with aging and disability networks.


Another where ACL, through our core mission of promoting community and connection, continues to lead, is in the application of research and technology to promote the quality of life of older adults and people of disabilities. We have a research division at ACL, very proud to say. The National Institute on Disability, Independent Living, and Rehabilitation Research, or NIDILRR.  NIDILRR currently invests $20 million annually in technology research and development for individuals across the lifespan, with functional, sensory, and mobility issues. Since 1999, NIDILRR has a proud history of funding technological innovation that has led to increased social participation and community integration, including ensuring that the development of web browsers include accessibility features. Developing the principles of universal design that are now widely used nationally and internationally when making age-friendly spaces. And also developing clinical and medical interventions for us in the real world, such as portable dialysis machines. We regularly talk with industry on issues like data and service standards, accessibility, and usability, and the particular needs of older adults, and people with disabilities. More recently, NIDILRR has been funding efforts to develop mobile telehealth tools for use by people with disabilities and their healthcare providers. For example, we are supporting grants to researchers at the University of Pittsburg who are developing two new telehealth and telerehabilitation tools. One is a mobile health software platform to support wellness and self-management among people with disabilities called iMHere 2.0. The second is an interactive telehealth platform designed to support various telehealth, and the telerehabilitation services to rural clinics or directly to people with disabilities at home, or in our communities, and that one is called Visitor 2.0.


So as you can see, ACL is a leader in advancing a spectrum of community and technology-based solutions to major challenges to the health and welfare of older adults, persons with disabilities, or families and caregivers. As healthcare in the United States is undergoing rapid change, and as a population of older adults and persons with disabilities continues to grow, so to will the demand for resources from community based aging and disability organizations. ACL is committed to working with public and private partners to help the aging and disability networks we support, meet this challenge. It is going to not only require continued investments from Congress and programs that we deliver, such as the Older Americans Act, but it’s also going to require the commitment from the private sector and healthcare industry. We need their commitment to work with community-based organizations, to fill the gaps in prevention and care when it’s clear that a clinical intervention won’t deliver the best results for the patient, and certainly will not be the most cost-effective.


So the fundamental idea is this:  When services from community-based providers and healthcare entities are well integrated, consumers win. Thanks again for convening this briefing, and for your series on Aging in America. I look forward learning more of the suggestions, as well as the practical policy and programmatic solutions that your participants propose. ACL is willing, ready and able to provide public/private partnerships, support for the great work that we do in sharing our common goals. Thank you.




SARAH DASH:   Thank you so much, Mr. Assistant Secretary. So again, in the sort of switching up the Alliance format, we have time for just a few questions. Kind of noon fireside chat, if you will. And — to get into a little bit more depth on your remarks, and then we’ll get to our panel. So thank you so much.


In your remarks, you really made it clear the importance of the linkages between the community services and supports, the clinical setting. You talked about a number of kind of initiatives that you have with other agencies. Can you talk a little bit more about those? How does the Administration for Community Living work with the other agencies in the federal government? And if you want to talk about the state level too, that’s fantastic.


LANCE ROBERTSON:  Very good. Quite a complex question there with lots of opportunity to kind of unwrap that. Again, thanks so much to everybody for being here. Now it’s an opportunity to go off script from the lawyer approved talking points, and really kind of share with you, I think, from my perspective, some exciting things that are happening, and I will say to Sarah’s question, really what just inspires me each and every day, is the opportunity to better partner across federal government. That opportunity, of course, has always been there, but as many of my colleagues in the room, and others that work every day with me know, I believe that’s where the secret sauce is at. I think it’s more about, how can we work together more effectively to produce an outcome that is better for America. And  you know, when I think about the $1.3 trillion federal agency that is the Department of Health and Human Services, there’s a lot of opportunity just within HHS. So at ACL, we have really put emphasis on how do we create stronger relationships with fellow sister operating divisions like CMS, and FDA and HERSA and Sampson and Indian Health Services, and really appreciate their mission, their goals, where their resources are directed, and how we at ACL can help support that, but in return knowing that it’s going to ultimately help us achieve our mission. So one question we often get is — and maybe it’s around reauthorization, or maybe it’s just around how do we serve this growing number of people who are older and living with a disability? You know, the reality is it’s not an answer that is, fix simply with more money. While I think appropriations is always a part of every valuable conversation, to me it’s about how do we leverage the existing resources and how do we make sure that we are partnering within HHS and across the federal government? And if time allowed, I would love to talk more about some of those partnerships, because they are exciting. Whether it’s with the Veteran’s Administration, which we referenced. The VA work is phenomenal, and is really gaining a lot of momentum. To some of the things that we’re doing, say for instance in the elder justice space. We have, for instance, the honor to chair the Elder Justice Coordinating Council, which really is a federal body consisting of 14 different federal agencies, all committed to moving the needle, and positively addressing elder justice. And again, that’s just one example, Sarah, of a lot of what we do. But suffice it to say, in my role as administrator, I really make sure that that remains a priority. It’s about building those relationships, and moving effectively toward common goals, and leveraging existing resources where we can.


SARAH DASH:  You mentioned your partnership with the VA; I understand you’re a veteran yourself? Is that correct?




SARAH DASH:   The United States Army.


LANCE ROBERTSON:  Yep, go Army. Beat Navy tomorrow!


SARAH DASH:  If you could wave your magic wand, besides winning the game, what would you hope to accomplish even further in terms of that partnership with the VA?


LANCE ROBERTSON:  Great question. So really, I think in just being honest with you, you know, both as a veteran, but also as somebody that’s worked in social service space all of his career more or less. What really has been both exciting, but a bit puzzling to me is, as I think in the last 10 years, as the Veteran’s Administration has gotten very serious about serving veterans in a setting of their choice, and wrapping good services around them, we all naturally understand that’s sort of our mission in charge each and every day, and has been. So I think in conversations we’ve been having with the VA and helping them build their veteran directed care program, it’s just such a natural fit for us. So I think as we try to — I’ll just say, bring up to speed the Veteran’s Administration on how we take care of people in a home and community-based setting, they can then turn to us, rely on us, because of our track record, because of our expertise, because of the networks that are already in place. So it’s an example, I think, of a real win-win that is happening quickly, and it’s because of, again, both the experience and the bandwidth we bring to the conversation, and coupling that with their desire and resources, again, I think it’s going to continue to prove to be a very valuable thing, specifically for veterans. But again, as we all know, when it comes to those needing care and support to remain in the community, whether it’s a veteran or not, that sort of formula is pretty similar. So again, it’s how do we best leverage their needs with what we were already capable of doing, so that we can further advance the needed care for veterans? And obviously I know we are all very, very committed to those that serve our country in that line of work, and how do we make sure that as they honor us, and protect us, and preserve our rights, that when they come home and need assistance, we are right there to help them, and honor, again, the commitment they’ve made to our country.


SARAH DASH:   One more question:  You’ve referenced this wide network of community services, and folks who are really delivering long term services and supports. Can you talk a little bit about — we have such a big country of course, and we are going to hear later today from an urban perspective.  Can you talk a little bit about the rural needs and how does that play out?  Is there enough capacity out there to really meet the need?


LANCE ROBERTSON:   Well, I mean — thank you, Sarah, that’s certainly of course a big issue that, as I look around the room, there are a lot of experts in this room, and what encourages me, is knowing that each one of these colleagues every day are trying to bring to the table some innovative solutions. And when it comes to the issue of serving people in rural spaces, that is and has been a challenge. Certainly, I think some of the more recent conversations around innovations of course embrace technology. It involves bundling of services. There are various things that we can probably do that — that I know are probably around the corner that’s exciting. You know, coming from Oklahoma where a lot of our service recipients were in rural areas, I face that every day in my decade as a commissioner of aging services, and really trying to appreciate, how do we make sure somebody in the panhandle of Oklahoma has access to services that they need to remain in their community? And sometimes you just got to get creative, and you’ve got to figure out, okay, that may not look exactly like some service delivery models, but those opportunities are there. And then just a few months ago, having an opportunity to go out and visit some villages in Alaska, which aren’t rural, they are frontier. They are way out there. And talking with some of those residents about, wow, and those tribal members about what would that service delivery package look like? Again, I think all of us sensibly lean towards things like technology and some of the other opportunities, but acknowledging that sometimes there will have to be a bit of a morphing of how we offer the care to some of those individuals. It does present its challenges, and there is silver bullet, but I do know that we acknowledge and recognize that — when we talk about a person-centered care plan, we talk about conversations where that consumer needs to be driving the conversation, it is about doing all that we can to again support that. And I do know that the Department of Health and Human Services, thankfully we have the secretary involved in that, because he acknowledges if we are going to transform the healthcare system, it’s not just in urban settings. That involves everyone in every corner of the country. So some of the resources that he’s bringing to this conversation excites me as well. Yeah, tough question. One that we’re not going to fix necessarily tomorrow, but I think we have a lot of opportunity to move forward.


SARAH DASH:  Well, thank you so much. Unfortunately we are out of time for this portion, but I want to — again, please join me in thanking Assistant Secretary Lance Robertson. Thanks.




I am now going to call up our expert panel, which is going to shed even more light on this conversation. So please come on up, to our panelists. And just while they are joining us, I just briefly want to explain kind of how the question and answer session is going to work. We’ll have time for probably just a few questions from the audience. We will have mics on either side of the room, and you have a green card, so if you have a question, please feel free to write it down. So I’m going to take my seat again, and introduce our panel, thanks.


Now, this is what’s going to be more like a regular Alliance briefing, for those of you who are familiar with it. So I’m going to very briefly introduce our panelists, and then we’ll get right to it. You have longer biographies, as always, in your folders.


Today we are going to hear from Dr. Thomas Cornwell, the founder and Chief Executive Officer of the Home Centered Care Institute.  Dr. Cornwell has made over 33,000 house calls in his career. That’s a lot of miles. And in 2012, he created the Home Centered Care Institute and National Education and Research organization, focused on expanding house call programs, and the workforce, nationally.


Next, we will hear from Sabrina Smith, who is the Chief Operating Officer for the American Telemedicine Association. She also briefly served as the organization’s interim Chief Executive Officer. Dr. Smith has 20 years of cross-industry experience in healthcare, academic medicine, and non-profit management. Before coming to ATA, she held leadership positions at the Regulatory Affairs Professional Society, and the American Academy Physician Assistants. Welcome.


So that’s kind of our clinical and healthcare side of the panel. We really didn’t mean to divide you up. But we’re then going to hear from Lindsay Goldman, who directs the New York Academy of Medicine’s work in healthy aging. She has 16 years of experience in program development and administration, aging services, philanthropy and social policy. Lindsay oversees Age Friendly New York City, which is the Academy’s partnership with the city council and the Office of the Mayor, and she serves as the Academy’s liaison to the World Health Organization.


Finally, to help us bridge this link between the community and the clinical, we are going to hear from Whitney Austin Gray, who is Senior Vice President at Delos. Whitney brings over a decade of expertise as an international leader in the intersection of health and built environment. She leads the Delos Insights Team, focused on conducting industry research and supporting industry adoption of healthy building practices. Whitney also led the development of the first case studies focused on the well building standard, which she will discuss more in her remarks. I think this might be the first time we actually talk about architecture on an Alliance panel. I’m so excited to hear from you.


So with that, let me now turn it over to Dr. Cornwell, and feel free to make your remarks up there.


  1. THOMAS CORNWELL: Well, thanks so much to the Alliance, as well as to the sponsors for allowing me to speak today on aging in America; is homebased primary care too good to be true?


I want to start with the story of Elisa who was born in Germany in 1921. I was called up by social services, that you heard about from Mr. Robertson, to see her, because of multiple hospitalizations. She had over ten in the prior six months for things like her heart failure, diabetes, she had pressure sores, because she was always in a wheelchair. She had peripheral vascular disease, that you could see because of her amputations. And because of all of these admissions, the hospital said to her, you are no longer able to care for yourself, you have to go to a nursing home. Well, she refused, and I was called out by Social Services. And what I learned on my first visit, was that part of the reason why she had these amputations, was because of damage done by the cold winters in the Nazi prison camp. She was also not able to have children because of what happened in that prison camp, so she had no one to care for her. Well, bringing her quality home-based primary care, she couldn’t even get out to a doctor between the hospitalizations, because her home was not handicapped accessible. And so we brought great primary care to this patient. We got her diabetes under control, we got her heart failure under control, with the help of home health and getting her a hospital bed so that she didn’t have to sleep in wheelchair. We were able to heal her pressure sores. She got so much better, that we were actually able to arrange for her to go out-patient rehab and get new prosthesis, so that she could actually walk again, get out of the hospital some, and for the first time, get into her bathroom that she wasn’t able to with her wheelchair. Over the next eight years, she only had two hospitalizations, and throughout her care, we worked with Social Services, as well as Home Health.


It really takes a village, as you’ve heard, to take care of these complex patients. You heard about that by Mr. Robertson, you’re going to hear about it from our other speakers. But I see outcomes like this all the time, that the sickest patients in society are not getting the primary care that they need, and we bring it to them. We improve their quality of life. We improve the quality of life for their caregivers, which is a whole other topic. But we also reduce healthcare costs by enabling them to age at home, and avoid hospitals and nursing homes.


One of the things I just want to emphasize is, home-based primary care is quality primary care. High touch primary care done by doctors, nurse practitioners, and physician assistants. But we now have high tech capability. On my cell phone, within 30 seconds, I can get an EKG. There is apps for doing things like vision testing, medication databases. We can do portable lab tests in the home, as well as draw blood in the home, and spin it in our car with portable centrifuges that plug into your cigarette lighter. X-rays and ultrasounds can be done in the home. And so while this is high touch primary care, we do have the high tech capability of truly doing quality primary care in the home. And Sabrina is going to be talking about telehealth, that the future is just going to be so much more impactful, as we incorporate that into home-based primary care.


So I gave you an anecdotal story of the incredible value of this, but we also have good data. And the initial data that really impacted our nation, came from the VA’s home-based primary care program. The home-based primary care program is the largest program in the country. It’s in all 50 states. And in addition to home health and Hospice, they send out doctors and nurse practitioners, mental health workers, social workers, and they have pharmacists on their teams to really surround these veterans with great care. But that great care costs $11,000 more in the home. And about 13 years ago, the VA was told you need to cut the program. You are spending 460% more than usual care. Tom Edes, whose been a champion of home-based primary care, and other things in the Veteran’s Administration, asked his superiors for some time to look at all the cost data. They went back to 2002, and I think what they found even surprised Dr. Edes. They found an 87% reduction in the use of nursing homes. 87%. A 63% reduction in hospital costs. An overall savings of $9,000 per veteran, and when you multiple that by the 11,334 vets in the program, it came out to $103 million savings by doing what the veterans wanted, giving them more care in the home. It also has the highest patient satisfaction. And so with this being so wonderful, why isn’t it more prevalent? Is it too good to be true? And the reason why it is not more prevalent, the main reason is fee-for-service. And you heard again from Mr. Robertson that we have this fee-for-service system that rewards volume, not results, and house calls is a very low volume, but high value service. And we have seen now, Medicare is aligning payments to enable aging in America at home. The Independence at Home legislation is one of the examples where it had great outcomes, and in the first two years, saved $33 million on about 15,000 patients. And we have now taken that learning from independence at home, which has been extended now another two years, and have proposed a new complex chronic care track that’s a part of the comprehensive Primary Care Plus program. We can maybe discuss that more if you haven’t heard of it, but it’s a large Medicare demo of about two million patients, but a new complex care track that would target these high cost disabled, or chronic illness patients. It would provide payments that would support this care, but also had shared savings and take on risk. There would be flexibility in the terms of waivers for site of care for doing innovative telehealth that we’re going to hear about, but also some flexibility with nurse practitioners and physician assistants to allow them to order home health. And finally, it would incentivize quality and outcomes so that the cost savings could actually be a part of paying for the program.


So I really appreciate the people in this room, and the organizations. For me personally, Health is Primary has been so supportive of the independence home and home-based primary care, along with others in the room, and I look forward to working with you, and to advance home-based primary care, as well as age friendly communities in our country. So thank you so much.




SARAH DASH:   Thanks, Tom.


SABRINA SMITH:  Well, good afternoon. And I want to thank all the previous speakers, because they really did queue up this presentation today. And I want to thank all of you for being here today, listening in on this session, because that means that you care about the issues that we’re discussing and it’s going to take all of us to address all the issues.


I personally am very inspired about the changes that are taking place in healthcare. Over the past decade, we’ve had major and significant advances in healthcare technologies, creating a new digital culture that we can begin to build up, and to release new innovative strategies. We have artificial intelligence that many of you have heard about, we have predictive analytics and genomics and precision medicine, and last but not least, we have telehealth. But it is this new framework that is so absolutely interesting, because it gives us an opportunity to redefine our understanding of healthcare delivery, and even the type of healthcare that we are providing to our patients. And recently, and I think as Tom as pointed out, we are starting to engage with our patients very differently. We are able to offer them quality affordable services at a lower cost that’s more convenient to them.


So let’s look at some of the facts. We talked a little bit about the cost of healthcare, and telemedicine is playing a very important role in this process. As our previous speaker and assistant secretary pointed out, that age group of 65 and older is growing, it will continue to grow. We are investing a lot of dollars into long-term care. And while a lot of us would like to age in place, and not have to go into a long-term care facility, it may happen. And that’s not to say that it’s bad, but how can we effectively engage and utilize our long-term care facilities?


So let me share with you a case study, and put this into context a little bit. The Medicare program currently is paying up over $100 billion, and that is expected to continue to grow. And that just kind of demonstrates to you the magnitude of the dollars that are going into the system. So what can we do with telemedicine? Well, I think there’s a lot we can do. First of all, telemedicine — and we have several case studies where telemedicine is preventing the rehospitalization of patients. And that means within that 30 days, they are going back into Emergency Department, and having to be re-hospitalized. And why is that? Again, a lot of these facilities do not have 24 hour coverage. They do not have access to a physician that could actually determine whether or not the patient needed to be readmitted, or could wait. And looking out for the patient, they naturally make the decision that they need to be transferred back into the hospital setting. A lot more expensive, it’s inconvenient for the patient, it’s inconvenient for the family. And so that’s why it’s so important, where telemedicine can really step in and make a difference. And a lot of institutions have done that. You can have access to a provider 24/7. They can make the evaluation right there on the spot. And then they can really work with the family as well, and I think sometimes we forget about the strain that this puts on the caregiver, if they have a family member that’s in a long term care facility.


Tom showed us a demonstration of some wonderful new gadgets, and if I knew he was going to do show and tell, I think I would have done the same thing. So that means that if you have an opportunity to come to an ATA tradeshow, there are literally hundreds and hundreds of tools and resources that are in the market, in a variety of settings. But I think in particular, there are some areas where seniors are going to benefit the most, and that is with mobile apps, both for them in their disease management, but also for their caregivers, informing them whether or not — maybe mom or dad took their medicine or didn’t take the medicine. So really helping with management of the patient. And then remote patient monitoring. So you don’t necessarily have to leave the home and go to a long-term care facility, you can actually be monitored at home with a team that is looking and monitoring all the aspects in catching and preventing rehospitalizations. And then senior living solutions, and our team here is going to talk a little bit about that. There are innovative things that are happening with Smart Cities, and with space that you could only imagine. And then on demand urgent care, I think that’s the most critical, especially when what we were talking about, in the urban settings, where you may not have access to a specialist or care. Really having that ability to connect with a healthcare provider that is going to ensure that if you do have a stroke, that we can handle it right there on the spot. And again, I think for seniors living in a rural environment, it’s even more critical. And then care and case management is going to start to look very different than it has in the past. And so I think there’s opportunities there for seniors, as that field develops and matures.


So what are the challenges? With any transformation, there are challenges, and that’s okay, because I think if we pull our resources together, recreate partnerships, we can address the many challenges that do exist. So interoperability. When you are in an acute setting, and you may have post-acute, you may have a long term care facility, it’s really important that we can — our systems can talk together, and that we can integrate our data. And so that’s an area where we have lots of issues at this point to fit everything into that central EMR, where doctors can really have a 360 view of the patient. And then the area is again, unified data and data measures and metrics. With telemedicine, it gets a little bit tricky, and so we want to ensure that as we incorporate telemedicine into the healthcare delivery system, that we know the impact that it’s having on population, health and management. And we don’t want it to be overburdensome, but we also want to make sure that we’re doing the right things for the patient at the right time. And then organizational know-how. We work with hundreds of large academic medical centers, healthcare systems, small independent hospitals, critical care access hospitals; they want to be able to bring on telemedicine. And so what is the know-how? How do we do it? How do we do it effectively? And that leads to the discussion on workforce, and I believe that Assistant Secretary brought that up. What does the workforce look like in the future, given the digitation of medicine? And so we want to ensure that we are informing our nursing staff, our LPNs, and other groups, appropriately, to lead clinical transformation efforts within their hospital settings. And then technology literacy. This is more consumer facing.


I think about my mom, who is 88 years old, I’m lucky that she lives with me. Now, take it for granted I work for the American Telemedicine Association, so of course I’m going to complain about work every night, correct? But I do talk about telemedicine, and so she is a Kaiser patient, and Kaiser was working with her appropriately, and they were going to set her up for a telehealth visit. Now I thought I had done my due diligence, since I do talk about work every single day. And she was like, no, I think I’m going to go to the Emergency Department. Now, I’m thinking, you don’t need to go to the Emergency Department. I’m trying to talk her down off the ledge there. But she insisted on going into the Emergency Department and she was handled correctly. Then within a matter of hours, Dr. Oz was on TV. You know where I’m going with this, right? And so she comes to me and she goes, “There’s this wonderful new thing, Dr. Oz says it’s called telehealth.” Really? So maybe we should all go out and hire Dr. Oz.


But it really brought to the forefront that when we’re working with our patients and our family members, and as clinicians and healthcare providers, and payers, we may know what this stuff is, but does the average person? And so I think we need to spend some time on community preparedness and community literacy. So that they’re appropriately engaging with our system, and they understand exactly what that means. And I would probably emphasize that even more in some of the rural environments that have less technology in their day-to-day settings. And then connectivity, we talked a lot about that. That gets a little bit tricky. There’s lots of efforts to ensure that we have broadband connectivity. It’s on the forefront of everyone’s minds. But in some cases there is some geographic challenges in actually implementing broadband. And so we have to be innovative, and we have to be clever, and we have to not assume that what fits in an urban setting, is going to fit in a rural setting. And so we have to be creative with the way that we use apps, the way that we set up data and clinical hubs, because broadband connectivity just may not be possible in some areas. And then policy barriers — and Tom touched a lot on this. It’s a big lever, right? Individuals don’t want to provide things that they don’t get paid. I mean, that’s just common knowledge. But I think that we can approach some of the policy barriers. Together we need to. Reimbursement is just one of those areas. Licensure is another. And there is a few that I’m not going to step into that policy arena, because I’m not a policy expert, but policy is a barrier, and one that we all need to work together to solve.


That is it for my presentation. Looking forward to further discussions.




LINDSAY GOLDMAN:  Good afternoon, thank you so much for inviting me. At the New York Academy of Medicine, we are dedicated to ensuring everyone has the opportunity to live a healthy life. In 2007, we initiated Age Friendly New York City, as a public/private partnership with the city council and the mayor’s office, working to maximize the social, physical and economic participation of older people. Today, I’m going to talk to you about age friendly communities where we’ve had successes in New York, where we still face challenges, and how the federal government can help. But I’m also going to start with a story.


This is Hank, he’s 88, and until recently he worked part time as an optometrist. To get to work, Hank took the subway, which was a little less than half a mile’s walk from his apartment, and like 80% of New York City subway stations, the station does not have a elevator. Hank has COPD and heart disease, which make it difficult for him to walk long distances. Luckily for Hank, his route was in a Safe Streets for Seniors target area, where improvements were made by the Department of Transportation, resulting in a 16% decrease in senior pedestrian fatalities, city wide. These improvements include mitigation measures at dangerous intersections, new specially designed benches, thousands of them, and bus shelters with seating and transparent walls. The new benches enabled Hank to work for two additional years, because he could stop and take a rest when he struggled to breathe on this way to the train. Working for those two additional years kept him intellectually stimulated, physically active, socially engaged, and financially secure.


Consider Hank’s case at a population level, and the benefits associated with something as simple as an increase in public seating, funded through a $4.5 million grant from the federal transit administration. Health is 80% determined by social and environmental conditions. So our goal is create a better fit between the person and their environment, which can result in greater choice and enhanced quality of life. A journalist recent asked me, “What’s the next big story in aging?” Well, for a journalist, every story is an aging story. There is always an aging angle, and the same holds true for policymakers. All policies affect older people. In New York, Governor Cuomo recently issued an executive order requiring all state agencies to consider health and aging in their planning, programming, procurement and contracting decisions. We need political leadership like this to elevate the issue of aging, to make improvements to publicly controlled services, and to help galvanize private sector action and investment. He upcoming reauthorization of the Older Americans Act may be a good opportunity to consider funding for age friendly community planning, and implementation, to advance the spread and scale of the movement throughout our country.


Age friendly communities work to regularly solicit feedback from older people, use this feedback to reduce barriers to participation, and inform the public about available resources. Technology can streamline this process, and facilitate two-way communication in real time. For example, we’re teaching older people to use the city’s 3-1-1 app to report on dangerous neighborhood conditions like lighting out in a park. But we need greater support for technology training programs to address significant disparities in digital access and literacy by age, race, income, and education. Some communities are effectively leveraging economic development dollars to improve the quality of life for older people. For example, the Adirondack community of Saranac Lake is using six million of a $10 million downtown revitalization grant from the New York Department of State, to redesign this historical theater. Older people will enjoy increased access to arts and culture, which we know is good for health and social cohesion, and the project will create jobs, and boost local tax revenues. However, what we don’t know, is whether this will result in employment opportunities for older people, because ageism remains rampant in the workplace. And this speaks to the importance of Title 5 of the Older Americans Act, the Senior Community Service Employment program, as well as the need to incentivize age smart employment practices within the private sector.


As some of the previous speakers said, most people prefer to remain in their homes as they age, and we’re transitioning to model where the locus of care is in the home and the community. But you can’t access home and community based services if you don’t have a suitable home environment. Housing affordability and accessibility are by far the biggest challenges for older people in New York City. Over the next eight years, the city has committed $150 million to conduct accessibility audits and make necessary improvements so more people can age in their homes. Using a toolkit developed by the New York City American Institute of Architects Design for Aging Committee, this program is estimated to help 30,000 households. But there is still an additional 200,000 people on the waitlist for affordable senior housing. Funding to support the HUD section 202 supportive housing for the elderly program, including both capital and supportive services, is essential, as this population rapidly grows over the next 20 years.


Finally, we need good data to create equitable and age-friendly communities. This is a map from ImageNYC; it’s our open-source interactive map of aging. And this map shows the projected population change for people age 70 and over, from 2010 through 2030, in neighborhoods throughout New York City. Everything green represents an increase, with the darkest shade of green indicating the greatest increase. The little pink buildings represent adult day programs for people with dementia. The Rossville Woodrose neighborhood of Staten Island projects 187% increase. Many of these people will live past 85, and the only adult day programs are few and far between. What resources will these people need, and where will they need them? A fair, accurate, and reliable 20/20 census count will enable us to prioritize investments in infrastructure and programming that will optimize the health and well-being of current and future aging populations.  Thank you.




WHITNEY AUSTIN GRAY:  Hello, good morning. When we look at aging — of course you start aging from the moment that you’re born, and aging is not only about the old, it’s not only about that one moment where they need care. And so I want to encourage you, as we explore the role of the built environment, and the physical environment, to consider this entire span of continuum of care. So the built environment is going to impact your primary care — this is where you spend a lot of the time — and of course any of the post care when you return to the home. And we know — I think the discussion has been really relevant today, and timely, around including the built environment discussion. Too often we’re not at the table. It’s already there, it’s already happened, and now we focus more on the care delivery than we actually focus in the infrastructure behind where people are living and working, and spending their lives. And why is it so important that we look at the built environment? We spend 90% of our time indoors, so that means if you’re 40 in the audience, that’s 36 years of your life. If you are 100, that’s 90 years. So you are with the highest exposures in the built environment, or what you breathe, what you eat, what you’re exposed to. Your circadian rhythm, sleep cycles, and even who you connect with, how often you connect with them, and how often you spend community.


So what’s happening with the generation that’s aging in the built environment, and what role is this playing? Well, the majority of people that are over 65, 90% report, “I want to stay at home, I’m not planning to go anywhere.” We could argue that of course the recession of 2008 made people hold on to their McMansions longer. We are seeing stats come around, kids choosing to live with their parents longer. For a variety of reasons, people are hanging on to these large homes, they are not transitioning, nor choose to transition into retirement homes. And I think we are all very aware here that there is a lot of stereotypes and ideas around connotations.  What is a retirement home?  Is this the end of life? Or is this the second part of life? And we see Boomers redefining this. In fact, in the last 16 years, we see the number of communities with the majority of the population being over 50, having tripled, particularly in the north and the western states. So for those that do transition into continued care retirement homes, or retirement communities, we really see this being very small right now, as a sliver of the population, but of course this is expected to grow. I work deeply within real estate, we want to find those trends, capitalize on those trends, and I would ask you today, is there enough regulation and market drivers to inform the building of CCRCs, retirement communities, for the future of these generations. Whether they plan to stay in place, or whether they plan to move.


And of course, these are the numbers, this is the industry, and a lot of real estate developers are looking directly at these numbers, capitalizing understanding that this industry is absolutely here. So when we look at this American spending on continued care retirement communities, in 2013 it was 149 billion. This is anticipated in 2026 to be 261 billion. And what’s happening inside of these investments? I suggested that it might not be the retirement community. In fact, we are seeing this idea that maybe we need a rebranding campaign, because retirement is end of life. So second part of life? Maybe that’s a life planning community. We are seeing changes in that all of a sudden, this is not just for the old, this is truly for the “aging”, which means that your child, who is in their 70s, with a parent that’s in their 90s, chooses to move in with you, because they don’t really want to shovel the front doorstep every day in winter, and they are spending most of their time visiting you anyway, so they might as well just move in with you.


We are seeing in Urbandale, Iowa, for example, college students being paid parts of their living and board to spend time and actually live in the nursing homes, providing music therapy. So these are the trends that we are looking at, aging diversity. And of course I love seeing these — looking at childcare communities right next to retirement communities. And Japan has really been looking at this idea particularly around purpose. The purpose, the commitment, and the giveback to communities. And these are truly aging and living communities that are being designed. But of course there is the financing package. There is the buy-in plan either upfront, and then you lower it down to the monthly cost. This is all-inclusive benefits, but of course how you’ve saved, where you’ve saved, and how and when you plan to transition to these communities, is largely based on that financing structure as well. So if you choose to age in place, or you choose to age in a new place, these are some of the trends that we’re seeing from built environment professionals that are really leading this.


And so today, I want to talk to  you about universal design. As Assistant Secretary brought up earlier in his comments, as well as voluntary building certification systems that are drivers, but also can be enforced through policy support. And there are current bills even going through, looking at tax credits for those that are aging to be able to provide better amenities in their home, therefore, age in place. When we age in a new place, we’re going to be looking at these drivers again on volunteer certification systems, but also the diversifying of these communities. This is not putting you out in the middle of nowhere, this is integrating you into communities, into cities, and again, I need to emphasize diversity, and not homogeneity for these retirement environments. I really love this concept, if you design for the extremes, you benefit the means. This is not just designing for the aging, we talk about universal design, it’s designing for all. And there are countless examples, and we design for those that are disabled, that are wheelchair bound, that have cataracts, that are not able to be as mobile as they wish. That we are actually learning things for all. And so instead of focusing so much on designing for only the aging, or only the old, I should say, we really want to think about how what we’re learning about as aging population, can actually benefit all infrastructure being developed. These are all examples of ways that we can bring this in to modern environments that are being built every single day in the U.S. And universal design is heavily encouraged, it is exciting.  I was recently in Norway — in 2025, they will put forward universal design features in all of the following different amenities, as well as online and available resources. So they are deeply investing in universal design. And of course our neighbors to the north, investing in aging at home amongst many examples, are on universal design.


I work very closely with the WELL building standard. This is similar to LEED, if anyone’s familiar with environmental sustainability standards. This is a human sustainability standard. We’re in 37 countries, and lots of corners of the world, and it’s a voluntary building certification system focus on human health, and well-being. You’re not designing for the sick, you are not designing for the diseased. You are actually designing for well-being. Designing for resiliency, designing for health in place, which of course is preventative. These are all the categories that we focus on with the WELL building standard. And of course we have to look at the technology in place. Once we design these communities, we have to make sure they are operationalized to be healthy. So this is not only looking at when there is an episode of care. But preventatively, what is the air quality, what is the sleep rhythms, how do we understand how to better orchestrate a healthy thriving home for all of those that are aging? This is just a minor example of sleep cycles and light. Many people have no idea they have actually evolved to not be able to detect differences in light quality, tends to show up in your sleep, it tends to show up in long term issues around certain cancers that are more prevalent around shift workers and those that don’t receive the right amount of light. It’s also deeply connected to issues around dementia and mood. This is an area you will only see more research coming out of, is light, light exposure and rethinking about how our built environment can support that.


In conclusion, I hope to convince you that the real estate trends here are moving quickly, rapidly, and they are not looking behind them very often. And actually standardizing some of these practices, or even reaching out to some of these voluntary practices to say, how can we really design for the future of aging, and the future of well-being, and not just a disease? I think the WELL building standard is but one of these examples, however any of these types of voluntary programs do require funding and support. So really encourage that we look at some of these programs, whether they are looking at market and regulatory incentives, you know, mortgage loan structures. Fannie Mae has a really interesting program on healthy homes, and they are looking to incentivize voluntary building standards, and of course, really re-thinking about the investment in place proactively, being able to be designed for health and aging for all. Thank you.




SARAH DASH:   Thank you, this is a terrific panel. We have about 15 minutes left in the briefing, time for some Q&A, so I want to invite anyone who has a question to stand at the mic, or hand your green card to one of our staff members. And while you’re kicking it off, I want to bring up the role of Medicaid, because we haven’t had that conversation. We’ve talked about long-term services and supports the Medicaid program has for some time, sort of been involved in this rebalancing, this effort to move from nursing home to home and community based services. So I want to ask the panel, can you talk — and maybe I will start with Tom — can you talk about how can these efforts that you’re talking about, kind of support the Medicaid efforts to transition to HCBS?


  1. TOM CORNWELL: You know, that’s a great example, because it really shows the impact that policy can have on aging at home. I have been doing this long enough that I know in 1983, if you needed help with long term support and services, one percent of the dollars went to home and community based services. 99% went to nursing home care. So basically you had one option — nursing home. That has steadily reversed over the years, in part because of, Money Follows the Patient. But I think the latest data in 2017 was that 57% now goes to home and community services. Some of the things you heard about Mr. Robertson, and 43% goes to nursing home. And the problem with that, is as we are literally taking patients with Money Follows the Patient out of nursing homes, and putting them into the home, they then don’t have the care if they can’t get to the doctor’s office. And so we have to give them more than just the home and the support, we also need to get the healthcare in there.


SARAH DASH:  Does anyone else want to comment?


WHITNEY AUSTIN GRAY:  I think I’d just encourage — you this hyper focus on the delivery of the caring giving episode, as compared to the entire continuum of care that’s provided with Medicare, and issues like mold in the home. If you are aging in the home, and you are exposed to mold, and you display a certain respiratory ailment, and the physician has no idea that this is what’s occurring in your home, that’s an issue. So what are you being treated on? So I think when those Medicare dollars go to only the episode of respiratory issues and asthma, and do not go to actually some of these homecare and assessment, what Lindsay was speaking about around accessibility in the home, and actually visiting some of these environments, you continue to see this recidivism on the same issue, because you’re not taking care of the actual problem. So making sure these allied health professionals, which I would include designers as allied health professionals, are also really part of this care model.


SARAH DASH:   I want to encourage anyone who has a question to come ask it, but you know, we have a lot of healthcare leaders here in the audience, and there has been a lot of talk about that need to move beyond healthcare and address these so-called social determinants of health. So how can the healthcare system do a better job? What are the limits and what are the possibilities in terms of doing things like the home assessments, the built environment, et cetera?  Anyone have any –?


SABRINA SMITH:  I think you make a point. When we were talking earlier about the workforce and how that’s changing, and really bringing that into part of the discussion when you have maybe patient navigators, or those that are taking different types of clinical assessments, as part of the assessment. What does the home environment look like? Maybe they should be making visits there, and that should be part of the experience, so you really have an understanding of what’s going on with the patient. And so I agree with you, I think that we need to reframe and relook at the workforce and the competencies that are needed, as we are looking at tackling some of these very intricate issues.


  1. THOMAS CORNWELL: And that’s where I think anyone going into the home, not necessarily a doctor, but a nurse or a handy person — I had a patient that had been having chronic leg wounds, and when I finally did a house call to her, there was two to four feet of garbage everywhere in her apartment, and no place to even lie down, which is why her legs were swollen all the time. And so again, seeing it obviously can really help in terms of seeing the refrigerator, is it empty? Is there a food scarcity? And obviously going to the home can help you with that.


LINDSAY GOLDMAN:  I would just add that I think healthcare certainly has a huge role to play, but so do all of the other sectors, and so I think there are certainly healthcare dollars that should be going to community-based services that address the social determinants of health. We also need to think about other funding streams. And increasingly, I think we’re starting to see that. So I gave the example of the $150 million commitment to conduct accessibility audits in individual units and common spaces, that money is coming from the Department of Housing, Development and Preservation. That is money for refinancing, for rehabilitation of existing housing. And so they’re going to be rehabilitating those buildings anyway, why not use that opportunity to make the building more accessible? To make the common space more inclusive, to promote cohesion within a building. This is really about leveraging public dollars, and breaking down public funding silos, so that any time there is some kind of major allocation or appropriation, for example, parks, there is a lot of money put into restoring New York City parks. We are very into park equity. And so now we’re looking at, okay, what are the features of a truly inclusive park? How can we ensure that this new green space is well integrated into the community, and can be used by people of all ages and abilities?


WHITNEY AUSTIN GRAY:   I would add, on the side of innovation, I love these comments. The idea of the health coach, right? We’ve seen those come from the frequent flyer in the Emergency Department, where a health system is like, we will assign you someone who will be regularly checking in and monitoring. Right? But let’s go beyond just saying, how are you managing this one care episode, to really talking about these other components of well-being in their life. And I love to see this health coach trained to understand resources around where to live, and how to live, and access and issues that Lindsay is referencing, to even be able to tap into these resources of how to find a health home, or what a healthy home even looks like. The majority of Americans want one, but have no idea what it looks like. So I look at this analogy — and pension funds turning over to retirement funds. The pension fund was totally managed, the retirement fund is up to you to manage. Interesting seeing what health, and how this is changing for a certain — you know, work policies where we have those 65 and older still at work environments, and maybe now being pushed to manage their health in ways that they never have before, instead of waiting for the problem to occur. Thinking about these health coaches as maybe being those people we turn to initially that can help us be able to navigate the healthcare system, that are informed around social determinants of health to understand your diabetes. It’s not about the treatment of the medical care, as much as it’s about the next meal you’re going to get, and can you pay for it. Right now — and this was a great conversation — Sabrina, we were talking about, how will we educate this “health coach” of the future that knows all of these resources? That will make sure to be able to get you that upfront care.


SARAH DASH:  We have a question at the mic. If you could introduce yourself and ask your question.


AUDIENCE MEMBER:  Hi, Shauna Koss, I’m with LivePac, which is a platform for caregivers and their families. I’m really building on this conversation, which is, if social determinants are driving anywhere from 60 to 80%, we definitely want to see collaboration, but is there a risk in medicalizing, or embracing these activities as part of the medical model, as opposed to really, not only investment streams, but really a shift consistent with all of the other developing countries on full investment on social services and community base needs. Perhaps one of the models that’s most interesting as we see mergers, that impact certain communities, taking a portion of those mergers, and these have been voluntary, but potentially it could be incentivized to invest in the communities that are impacted and not in the health model, but in the community based services model.


  1. THOMAS CORNWELL: I would just like to say that when we started the Home Centered Care Institute to advance home-based primary care, we could have called it anything. We could have called it the House Call Institute, the Home Based Primary Care — we called it the Home Centered Care Institute, because we are a small part of what is needed. We’ve been missing — we haven’t been to the table, and so I completely agree with you in everything that has been said, but the problem is that these are the sickest patients in society that are homebound. They need that component, but we need to put significant dollars into supporting them being there. And it’s not a medical model, it’s a social model. It is a social model to keep them home, not a medical model.


WHITNEY AUSTIN GRAY:   I couldn’t agree more. I mean, I think that moving away from the term “health” for too often has meant disease, right? Is really thinking about the social model. We clearly have some leading examples in more socialized countries, where they are looking at the care up front preventively and how that’s going to impact, of course of the value and the end. When it comes to, you know, choosing the location that you’re going to live, I really — think about some new models here, right? So we have naturally occurring retirement communities — how are we educating those that choose to age in place, around maybe even being able to help neighbors, or be able to train in preventative health strategies? I mean, this can be as simple as finding your neighbor before a fall, or being able to detect if there is a problem. Why does it have to be a health provider that’s doing that? And I don’t think we look enough at training our own resources within some of these aging communities to be community social providers for each other, even. So I think there is quite a few innovations that can clearly be a part of that model. I couldn’t agree more. This is not only on health, this is definitely a community model.


SARAH DASH:  We have a question on a card that I just want to get to before we wrap up. It’s a question for Dr. Cornwell, but open to the panel. Could you speak a little bit more to the chronic care track of the independence at home program and perhaps that’s a question about the CPC Plus piece that you talked about. Could you kind of say a little bit more about kind of where we are with that, and where it might be going?


  1. THOMAS CORNWELL: Right. And maybe Eric and Ray — can you stand up a second? Ray actually was part of the ones that actually wrote what was presented to CMS, and so CMS is very interested in what these two have been working on, along with a group of us. But again, it’s taking the learning — Eric DeYoung is the President of the American Academy of Home Care Medicine. He has been the chair of the public policy committee that has taken [unintelligible] practice, one of the 15. And so he has a ton of experience, and he’s taken the learning, along with [unintelligible] to create this — why don’t you just — I’ll stop talking. You guys are the ones.


AUDIENCE MEMBER:  Thank you, Tom, and thanks to the panel and Sarah for a great panel. So the CPC Plus track that CMS is working on right now in CMMI, which the Academy has provide some input on, and provider framework, is basically an idea of rewarding team-based primary care, rewarding medical services, but also social services and a whole interdisciplinary team and giving enough money, frankly, to grow primary care for the most sick complex elders in Medicare. And it would be a new payment model, which is kind of learned from IEH, but involves PMPM, plus some flat fee, perhaps for visits, plus shared savings. So it’s rewarding results for practices that are willing to take on the most sick, most complex patients in Medicare and do good primary care at home or from the office, but as long as it’s team-based care that keeps folks where they want to live. And Ray has helped kind of device the structure of that CPC Plus framework that we are working on with CMS, so he may have one or two words to add.


AUDIENCE MEMBER:   The only thing I will add is that it also includes voluntary alignment from patients, and the other piece that is important, is the quality aspect, which is extremely important. The quality measures that are included, which we’ve been working very closely with CMMI on, which is important, and also came from the learnings of independence at home.


AUDIENCE MEMBER:  Can I just add, the number one quality measure that we decided to propose was percent of days spent at home. That’s what we are proposing to CMS is the number one quality measure.


SARAH DASH:  So we are out of time, and I think we could talk about this for another couple of hours probably. Hopefully the panelists are available to answer your questions, if you sill have questions after the panel. I want to invite you to keep an eye out on our programing for next year, which is going to focus on social determinants of health, and on this question of value and innovation and what does it really mean for an aging America, as well as for the rest of the American population? If I could take the liberty, while you are leaving, just to remind you to fill out your blue evaluation form, because we care about quality metrics too. But I just want to ask each of the panelists, if you could, just to take like 30 seconds to say if there is one thing that you hope that policy makers kind of take away from this conversation, what would that be?


SABRINA SMITH: I’ll go first. I do want to take us back for just one moment with my opening comments, and I think it speaks to the question that came from the back, is that we do have an opportunity to redesign what this looks like. We have all of the tools, we have new information that we didn’t have before, and it’s really going to take all of us working together. So I would say for policy makers,  you have a lot of programs that are overlapping, they are contradicting one another, there are spin-offs and it really does take the available funds that are there, and just totally disseminates them, just dilutes them too much. And so really thinking about, we can design this new system, and we speak about healthcare because all of these social determinants and these other issues end up into healthcare, right? And so that’s why we’re having that discussion. But it’s on all of us to work together and to figure that piece out, and we’re all part of the solution. And so agencies and policy makers, let’s figure how we can work together to put those funds to better use.


  1. THOMAS CORNWELL: One of your resources is something called the Perfect Storm, and it’s seven pages, and it goes over the data on both the CPC Plus program, as well as the advantages to home-based primary care. But one of them that we discussed a little bit was just, 25% of Medicare dollars goes to cost in the last year of life. And that’s another huge thing that home-based primary care sees these patients way up stream; about 25% of our patients die a year, 75% die at home. 74% are on Hospice much longer than the national average. It’s another aspect that we didn’t talk about, but it’s not just aging at home, it’s also dying at home, if that is your wish.


LINDSAY GOLDMAN:  To truly reap the benefits of this new longevity dividend that has given us this growing, aging population, we need to keep people engaged in public life as they age. In order to do that, to know how to keep people engaged in public life, we need to know who these people are, we need to know where they live, we need to know what they need. And in order to know that, we need data. And so I will reiterate my point that we are in desperate need of a fair, accurate and reliable census count.


WHITNEY AUSTIN GRAY:  I would add that today is a bit about the innovation, right? So pushing and pulling. And I think a place where we can really use you to be able to define what is a healthy aging community? There is lots of definitions, there is a lot of variety out there, there is not an actual enforcement as to what that looks like. Whether you use voluntary standards like WELL, or others to be able to pull people into this, and then hopefully also push them with some incentives to be able to actually drive a definition of a healthy living, so that we don’t have 5,000 different definitions that do not actually equate to a healthy place.


SARAH DASH:  Thank you so much to all of our panelists, thank you once again to those who have supported today’s event and the entire series. Thanks to all of you for being a part of the Alliance audience, and I wish everybody a happy holiday season, and healthy. Thank you.