HEADLINE-HEALTH | Elderly Safety net-Can the Safety Net be Age-Friendly?
Can the Safety Net be Age-Friendly? How to Address Its Important Role in Caring for Older Adults with Geriatric Conditions
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Abstract
The safety net, a collection of public hospitals, federally qualified health centers (FQHCs), and publicly funded community-based healthcare entities, provides essential care to middle-aged and older adults with geriatric conditions. The role of the safety net for these adults will intensify over the next two decades with the growing numbers of middle-aged and older adults with adverse social determinants of health and premature geriatric conditions. The foundation for addressing their needs is to detect geriatric conditions and then focus care plans on the impact of these factors on function, which predicts mortality and quality of life more than chronic conditions alone. To detect geriatric conditions in safety net populations, the Age-Friendly Health System (AFHS) framework offers an evidence-based focus on the 4Ms: Mentation, Mobility, Medications, and what Matters. Further incorporating geriatric care models that target the 4Ms and are adapted to safety net populations will enable age-friendly care that optimizes health and addresses what matters to older people.
Memento Maxima Digital MarketingThe safety net, a collection of public hospitals, federally qualified health centers (FQHCs), and publicly funded community-based healthcare entities, is an essential component of our health system for low-income and uninsured people. It is often thought to be the place for marginalized and vulnerable populations, the working poor, children, and women of reproductive age. Most people do not realize that the safety net also provides essential care to older adults (typically defined as 65 and older) and those that may be younger but experiencing geriatric conditions, like dementia or frailty.
The role of the safety net for geriatric care will intensify over the next two decades as older adults begin to outnumber children in our society. While older adults or certain adults with disabilities can get Medicare insurance, that does not translate into them leaving the safety net. They may be more comfortable with healthcare there because of accessibility, language and cultural concordance, or coordination with other desired services, such as substance use treatment or supportive housing. For many, Medicare’s growing premiums and deductibles leave high out-of-pocket expenditures to patients that are difficult to cover outside of the safety net.1 There are an increasing number of studies that those in later middle-age (45–64 years old) who have experienced adverse social determinants of health prematurely develop chronic illness and therefore experience geriatric conditions at earlier chronological ages; and these are the adults more likely to be seen in a safety net setting. We explain this more below and how the needs of these patients can be met with high-quality geriatric care.
THE SAFETY NET WILL SERVE MORE PATIENTS WITH GERIATRIC CONDITIONS
The safety net can expect to see more older adults because of the increasingly diverse racial and ethnic diversity of older adults along with economic disparities often seen in these minority populations.2 These characteristics increase the likelihood that these older adults will seek care in the safety net, e.g., because of limited English proficiency, an array of cultural backgrounds, gender identity, sexual orientation, race, and ethnicity. 3–6 Older adults are the only demographic for whom the poverty rate is increasing, a factor contributing to the growing number of older adults experiencing homelessness, often for the first time in their lives. 7, 8 Even with Medicare insurance, adults seek care in the safety net. From 2006 to 2010, almost 20% of visits in safety net primary care nationally were by Medicare-insured adults. 9 These adults were more likely to be Black or Hispanic, have multimorbidity, experience polypharmacy, and be from neighborhoods with high rates of poverty than those who go to non-safety net sites; almost a third of safety net patients were dually eligible for Medicare and Medicaid. 9
In addition to the growth of older adults in safety net settings, it is important to note that geriatric syndromes do not only affect those 65 and older. Those adults with adverse social determinants of health or chronic illness in their 50s and older demonstrate a higher prevalence of geriatric conditions such as functional impairment, urinary incontinence, frailty, falls, and dementia than the general population (see Table Table11).10–15 For example, the population of people living with HIV (PLWH) is growing older, such that in San Francisco two-thirds of PLWH are now 50 and older, the ages at which geriatric syndromes are more prevalent in this population.16 The aging trend also affects jails and prisons, where the population is aging at a faster rate than the nation and has geriatric syndromes, such as frailty and cognitive impairment, starting in middle age.13, 17 Incarcerated persons along with those living with HIV are often served by safety net healthcare programs, such as public hospitals and federally funded programs.
Table 1
Geriatric Conditions in Adults 50 and Older with High Burden of Social Determinants of Health
| Population | Increased prevalence of geriatric conditions | Sample characteristics and comparison group |
|---|---|---|
| Older adults chronically experiencing homelessness | Frailty
Functional Impairment Mobility impairment Cognitive impairment Depression Visual impairment Hearing impairment Urinary incontinence |
Population-based sample, comparison to general population.
Adults age 50 and old |
1,2 Christine Karen Cassel, MD,1 and Christine Seel Ritchie, MD, MSPH3
