Eldercare Voices is an occasional feature of the Center’s monthly newsletter, Health Innovation Highlights, inviting guest commentators directly involved in care delivery to older adults to share their perspectives from the field. This is the first in a special series of interviews on their experiences with older adults during the pandemic.
Interview with Nancy Wilson, MSW, Adjunct Associate Professor at Baylor College of Medicine
Nancy is a gerontological social worker with over four decades of professional work and leadership in advancing interdisciplinary models of integrated community-based service delivery to elders and families coping with chronic illness including depression, dementia and anxiety. She is currently an Adjunct Associate Professor in the Department of Medicine-Section of Geriatrics and the Huffington Center on Aging at Baylor College of Medicine in Houston, Texas.
Center: How are the older adults you work with doing? And, how are you doing?
Nancy Wilson: Well, my direct engagement with older adults is primarily through our Baylor partner, BakerRipley, an agency that provides services throughout the communities in and around Houston. The older adults I work with are primarily those with dementia and their family caregivers. They are struggling. These are older adults who typically come to a dementia day program while their family caregiver goes to work or gets a break. But they've largely been quarantined at home. While for some, this has just meant a discouraging loss of routine, others have lost much more. Some no longer speak and/or are less mobile because, quite frankly, if you don't use it, you lose it. Family caregivers are totally stressed. They get no breaks, and they are witnessing their loved ones’ decline. Where I am, the caregivers are predominantly women who are handling both remote schooling of their children and care for the older adults in their lives. Others are the spouse of a person with dementia, and are facing their own health worries as older adults.
As for me, I'm a big believer in the need to take care of ourselves. I'm a member of the older adult population myself. While I want to jump in and help all the time, I have to make day-to-day decisions on risk, and that is wearing. I try to consistently ask myself “what's the next right, safe thing to do?” That helps. I also try to maintain routine physical and social engagement. I even walk up and down the driveway while on phone calls to keep moving! I think we've all had to learn how to be creative and be safe.
Center: What do you think older adults most need right now?
NW: There is great variability, but, here, we have huge economic needs. I'm talking about fundamental issues like housing and food insecurity. We also have a large uninsured and underinsured population. Families face hard choices about paying for medicines or food. Many agencies have worked hard to sustain supportive efforts, but it's challenging. And, anything that affects the family affects the older adult. So many households are interdependent and intergenerational and we need to provide them with economic support, as well as access to health care in order to help the older adults living there. When I make wellness calls to older adults, they ask for masks or food for their families.
We also have to be careful about ageism. We don't want older adults to have to sacrifice beyond what others are sacrificing.
An overwhelming theme for all ages is social isolation: Children miss their friends but older adults do as well. They miss seeing and hugging their family. I have realized we need to be more mindful about how many folks lack easy access to outdoor space that could allow for safe social interactions.
Center: What are you learning now that signals the direction for care in the future?
NW: What we’re learning now is that we can think differently about ways to engage people. Telehealth has been important but we have to think hard about how best to use it. For instance, tests for memory loss or cognitive change were previously conducted using pencil and paper. We’re now coming up with creative ways that don't require that. We’re also learning that when health care providers do telehealth visits, they can include family members who are doing the day-to day care. We have to pay attention to who is living alone, which family members are around to offer support. Also, we need to expand home medical care options.
I also think there are policy changes needed to support these innovations. Previously, if it didn't happen face to face, there was no reimbursement. We’ve seen changes in Medicare that allow delivery of services using virtual means. But will this be permanent? I can't imagine going back. I also think we’re seeing more direct referrals from clinicians to community-based organizations and that needs to continue. It’s not enough to simply give patients a name and a number to call.
Another area is our huge workforce challenges. We need to look at new possibilities to have "extenders" at all levels of the workforce, like Community Health Workers, who can reach underserved populations. There is an enormous opportunity to retrain our workforce and to retool how they work.
Center: What's been most surprising to you about the experience of older adults during this pandemic?
NW: It has been surprising that, as a country, we were not prepared to recognize the impact the pandemic would have on our most vulnerable older populations. Residents of nursing homes and the staff who care for them have been deeply neglected in the public policy response. This impacts community awareness and support. Community volunteers and restaurants feed medical professionals and donate masks to hospitals but they tend to overlook other essential workers, like nursing home aides. We locked down facilities so essential people and family members could not visit to help because we didn’t have adequate PPE for them.
We here in Houston live in a community that knows disasters like hurricanes and flooding, so disaster plans have long been in place. However, having to keep distance from one another changes all the usual mobilization plans and creates huge logistical problems. Older people like myself can’t just show up in person to volunteer. Even getting basic supplies like adult disposable diapers to people took lots of new logistics. And people kept asking for masks so they could safely go out because they had to shop.
On the positive side, I've been surprised at how well organizations like BakerRipley and others have been able to pivot and implement creative approaches for support, but I also know many people who were not known to social services before are still being left out.
Center: If you could wave a magic wand, what would you wish for to improve the lives of older adults (aside from an effective, safe, widely available vaccine)?
NW: I have several wishes. One would be greater recognition of the impact of social isolation and that mental health care needs continue across the lifespan. Every setting that works with older adults would not only concern themselves with, for example, whether they are being fed, but also whether they are being socially nurtured and if they are staying physically active.
Another wish is for emergency financial support for providing the direct care workforce in all settings a living wage, especially those serving vulnerable populations.
A third wish would be for greater flexibility in Medicare, in particular, to pay for social determinants of health. For example, folks with dementia don’t need one more MRI but they may need in-home care or assistance with food.
Finally, I'd wish that family caregivers and care workers in facilities would have available PPE so they can visit and hug family members and help them day to day as they always have in the past.
This interview has been lightly edited for length and clarity.