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BY: RENÉE M. HANRAHAN

Although assessing and addressing community health needs has long been an important part of American Catholic health care — since its18th-century beginnings, in fact — the U.S. Internal Revenue Service has recently institutionalized the tradition. Under terms of the Affordable Care Act, the IRS requires tax-exempt hospitals to conduct community health needs assessments at least every three years by gathering input from public health experts, providers and community members. The hospitals are required to then develop implementation strategies for addressing community health priorities.

In keeping with the tradition and in fulfillment of the requirement — and to learn more about its own clients — Via Christi Health, based in Wichita, Kan., surveyed 144 community experts in aging services and 80 residents of Via Christi Village senior communities. Potential survey respondents were selected based on their position in the community, their knowledge or experience related to providing services to the aging population or because of their hands-on experience with that population as caregivers. They included representatives from not-for-profit organizations, emergency services, government services, faith communities, Area Agencies on Aging, executives of a variety of senior communities, health care providers, caregivers, low-income housing managers and transportation providers. Community support was strong. Over 90 percent of the people invited to participate responded to the interview request.

The 80 residents of Via Christi Villages' independent or assisted living communities participated in one of nine focus groups organized for this research effort. Participating seniors either volunteered or were selected because they were members of residents' councils.

The purpose of this aging assessment was threefold:

• To examine health disparities affecting the elderly and their families in our ministries' service areas
• To research the awareness of the general public about programs designed to assist the elderly in living as independently as possible
• To identify gaps in services provided and/or delivered for the elderly population who may be vulnerable and poor

Additionally, Via Christi Villages hoped to learn from its residents how it might better meet their needs.

Via Christi Villages serves more than 1,300 residents in its 12 senior communities and programs in Kansas and Oklahoma. The level of care ranges from independent living apartments/condos to skilled nursing home beds, including memory care units. Senior communities are located in Hays, Manhattan, Pittsburg and Wichita, Kan., and in Ponca City, Okla. Via Christi Health, as the umbrella organization, provided the financial support and staff leadership for the interviewing process, although members of Via Christi Villages (VCV) were also invited to join the research effort.

The assessment began with a review of 2010 U.S. Census data, county health rankings, followed by the one-on-one interviews of about one hour each and — with residents of VCV facilities — focus-group discussions. The data collected from each VCV market was merged into one large data set to get a larger view of elderly needs in the state of Kansas. In the final report, responses were broken down into geographical areas to allow Via Christi leadership an opportunity to address each community's specific needs and to take advantage of community assets identified by respondents.

We developed two sets of questions, one set of open-ended questions for community leaders and other community residents; another with a mix of yes/no questions, multiple choice and open-ended questions for residents of Via Christi Villages, including its independent and assisted living facilities. (See sidebar for interview and focus group questions.)

The top two health care needs related to access — a shortage of primary care physicians and of transportation services — were not all that surprising, given that primary care physicians limiting their Medicare and Medicaid patient load is a national concern, and lack of affordable and timely transportation, especially in rural areas, continues to be a challenge for all program providers. Both issues had been identified in earlier community assessments conducted by Via Christi Hospitals. Additionally the survey found:

• 45 percent of the survey interviewees would like to see some form of case navigator assigned to seniors who suffer from multiple chronic conditions, especially if one condition is diabetes.
• 40 percent of the interviewees suggested that adult day care time has come for families who are struggling to balance jobs and aging parents. They believe that both Medicare and Medicaid need to assist these families by paying at least the hourly minimum wage to an adult day care provider.
• 80 percent of all survey participants believe that Medicare revisions need to be made, especially to Part D, so that the elderly themselves have a better understanding of what is covered and are in a better position to make choices to fit their individual needs.
• Less than 25 percent of those interviewed (non-residents of Via Christi Villages) had made out a final will, signed an advance health care directive or assigned a power of attorney to another individual, even though many of them worked in the aging field or dealt professionally with death and dying issues daily.

The aging assessment revealed that professionals are aware of numerous available services, but it recognized that the elderly and their family members have difficulty connecting with them unless they are given assistance. Coordination and communication between providers is desperately needed. For elderly who are homebound and lack transportation options, providers need to take advantage of technology to improve health care delivery. Medical students need to be incentivized to go into geriatrics to better assist the growing aging population with pain management, macular degeneration and chronic disease management. Cultural competencies should include sensitivity to the skills needed in dealing with older adults.

In addition to what we learned from our primary research, we identified some important information about care for the elderly in our state. For example:

• Approximately 5.2 percent of Kansans over the age of 65 live in nursing homes, far more than the national average of 3.8 percent
• Kansas ranks second in the country in terms of per-capita number of nursing home beds
• Out of 105 Kansas counties, 85 of them exceed the 3.8 percent national average in the percentage of senior citizens living in nursing homes
• At the time of the research, 9,900 nursing home residents in Kansas were in Medicaid beds
• The average monthly cost per resident in a long-term Kansas care facility is $3,600

In our conversations in focus groups with the 80 Via Christ Villages residents, one finding was not surprising: Not one person misses doing housekeeping, laundry, lawn mowing or house maintenance chores. Some women, though, did report missing holiday baking, working in their flower gardens and shopping.

The men were more inclined to miss gardening, driving their cars and tinkering in the garage.

The seniors said they love the security of living with others; several indicated they no longer worry about falling and not being found for days.

"Living here has been one of life's rewards, as it is clean, safe and friendly," said one.

Other responses included:

• "I like living here at VCV because I no longer have to worry about when to take my medications. I no longer worry about getting to the store to buy groceries, or worry about taking care of myself on days that I don't really feel well. I find I spend more time visiting with my new friends, watching TV and sitting out on the front porch when the weather is nice."
• "It's comforting to know that, should I need assisted living, I don't have to change facilities. That was one of the attractions of moving into Via Christi, as it offers more than one level of care."

One surprising finding from the community leaders' survey was an apparent growing problem of gambling among seniors. Seniors interviewed on-site at casinos on two occasions related the interest among seniors in gambling to boredom. (See sidebar)

Residents of the Via Christi senior living facilities also highlighted boredom as a problem. Many said they are bored by traditional art and craft classes, book clubs, chair exercises, board games and TV movie nights. In their place, seniors said they'd like to see more outings (ironically, including trips to the casinos), shopping trips, more happy hours, baking classes and recital nights for resident musicians.

One lady declared, "If I see one more rerun of 'The Lawrence Welk Show,' I'm going to be sick!" Another respondent said, "For folks like me, who were active in life and accustomed to going to music theater, the art museum or the symphony, sitting in a room with unattended puzzles, a few pictures on the wall and a small radio is neither fun or fulfilling."

Regarding finances, over 95 percent of the elderly residents interviewed were concerned — and many were fearful — of any discussion about cuts in Social Security. While this question was not specifically asked, seniors volunteered this concern as one they wanted to share. Additionally, nearly all Via Christi resident respondents and over half of the community leaders interviewed thought that health care coverage for the elderly needed to include some dental and vision exams and treatment.

One interviewee stated: "If Medicare paid for an annual eye exam and bought the necessary corrective lenses, there might be less traffic in the ERs due to fewer falls."

Last but far from least, the senior residents indicated that they want to talk about their death, be assured their final wishes will be granted and that their family will be OK once they are gone. Their biggest fear is becoming a financial and emotional burden, so being able to freely talk about death gives them peace and hope for those they leave behind.

Personally, as the Via Christi staff member conducting all of the interviews and leading the focus groups, I came away with a strong sense that our elderly residents very much want a continued two-way dialogue. All said they understand the cost of providing more services and recognize they can't have access to all the things they once loved. However, they have a strong need to talk and know that others will listen.

Further, the assessment offers an opportunity for those in our communities and the staff at Via Christi to make a difference in the lives of elderly persons and to collaborate with others in doing so. Those involved in the community and at Via Christi may find there is some "low-hanging fruit" that can be selected to better serve seniors' needs without adding much cost. Many people would be willing to donate electronic games and challenging puzzles to senior facilities to help stimulate active minds. (Many of the puzzles I saw lying around would hardly be challenging to middle-school youth, so it's no surprise that seniors would find them boring.)

It's hard for a past hunter who was used to shooting wild turkeys, rabbits or deer to enjoy sitting through an art class making beaded jewelry. Likewise for a woman who loved to bake, especially around the holidays, it is hard (and somewhat depressing) not to be able to whip out her favorite recipes and start baking when she smells the scent of cinnamon and ginger in the air. We, as a ministry, need to see how best to reach out to these folks with their unique gifts in a way that is both engaging for them and cost-effective and practical for us. It takes time and creativity but it isn't unrealistic.

The survey report has been shared with the Via Christi board. Pending board approval, the next steps for Via Christi is to use the findings of this assessment to identify priorities, develop action plans and — once implemented — measure outcomes.

The survey results are expected to be available in fall of 2012 at the Via Christi website: www.via-christi.org.

RENÉE M. HANRAHAN is director, community benefit, Via Christi Health, Inc., Wichita, Kan.

CASINOS: RECREATION WITH A RISK

The June morning is breathtaking where I'm standing — 65 degrees, a breeze, birds chirping in the sunlight. I look around and see silver-haired ladies and gentlemen, some walking slowly with canes or walkers, some in wheelchairs, several pulling portable oxygen tanks. But they're all smiles. Where are they headed?

If you guessed a senior center or a medical facility, you would be wrong.

It's senior month at one of the area casinos, and from 7:00 to 11:00 a.m. on Tuesday, Wednesday and Thursday mornings, seniors are taking advantage of the free continental breakfast and time together with friends and family. To sweeten the deal even more, the casino is throwing in $10 of free gambling money. Life is good, but it's about to get better, they hope.

Or is it?

The casino's marketing campaign is inviting, and in many respects, a morning outing to a casino can be fun. For most seniors who engage in this social opportunity, the casino is a pleasant, safe and at times exciting place to be, and the staff is friendly, courteous and always welcoming to customers, regardless of their age.

But according to some who work with seniors, casino visits also can bring serious challenges, even heartache.

Between April and December 2011, Via Christi Health conducted a health needs assessment in locations where Via Christi has senior communities, including the Kansas cities of Hays, Manhattan, Pittsburg and Wichita, and Ponca City in Oklahoma. Among the findings came an unexpected and troubling concern: an apparent increase in gambling addiction among the elderly living in the Pittsburg, Kans., and Ponca City, Okla., areas. Both communities are within easy reach of Oklahoma gambling casinos.

In Ponca City, over one-third of the community leaders interviewed identified gambling addiction as a community problem — and not just for seniors. Within a few miles of Ponca City, there are seven casinos; combined, these casinos house nearly 3,300 slot machines which take bets from a few cents to $75 for each "hit" (or handle pull). Five of these casinos are open 24 hours a day, and most host at least a single senior day per month, year-round. Some provide transportation to and from neighboring communities, making the casinos an easy and convenient destination.

Some of the interviewees shared stories about financial problems experienced by seniors whose losses at the casinos meant they failed to pay their mortgage bills. Other interviewees shared concerns that some of the elderly on their case-loads were regularly foregoing prescription refills so they would have a few extra dollars to play.

Because there are no symptoms present, gambling is referred to as the "silent addiction," and talking about it helps to raise awareness. The Ponca City Senior Center reported hosting a gambling addiction presentation in 2011 to educate seniors and their caregivers about the dangers associated with gambling.

I decided to do some observing, so I visited two of the largest casinos near Ponca City. There, I found that seniors generally represented 80-90 percent of the clientele between the hours of 8:00 a.m. to noon. After lunch, I noticed the proportion of seniors dropped, and between 4:00 p.m. and 9:00 p.m., it fell to less than half.

I chatted with some of the elderly gamblers, and they reported that their outings afforded good opportunities for socialization — especially when they didn't stray from the penny machines. Some couples suggested that the casino is a great meeting place for area retirees and makes for an enjoyable outing when family and friends visit from out of town. One gentleman said he meets with his brother and sister-in-law at one of the casinos on the first Tuesday of the month for lunch and a few hours of fun. Before the casinos were built, the brothers only saw each other over major holidays.

As part of our community assessment, I asked community leaders who work with seniors, and the seniors themselves, to tell me why they thought casinos represented such a big attraction compared to other activities offered them.

In a word, seniors are bored.

Some of the elderly in the aging assessment focus groups, as well as seniors I spoke with in the casinos, indicated that most of the activities hosted by senior centers and churches are "too bland — not exciting." A couple of recently widowed women said they had attended a few of the senior lunches and found the speakers interesting. But going to the casino invigorates them. Why? Because they're surrounded by people of all ages who are having a good time.

They enjoy watching people win, even if the wins are small. The whooping and the hollering from big winners are exciting, and everyone around them joins in the celebration. They enjoy the camaraderie that develops among strangers who, for a couple of hours in a safe and comfy place, can talk about nearly anything while hoping for the big score.

The focus groups in our assessment indicated those living in independent or assisted living share some of the same feelings. They too, get bored with the traditional activities offered in senior communities and desire more interactive opportunities with people of all ages. Some who are not living close to relatives rely solely on the socialization brought into the facility to cheer them up and entertain them. They feel that most activities are geared toward nursing home residents, and they are craving more.

The purpose of this article is not to point fingers at states that run lotteries to balance budgets, or at casino owners, but rather, to build awareness that some seniors may be particularly vulnerable to gambling addiction. Finding solutions will require a concerted effort by gaming operators, senior services and mental health care providers, families and the vulnerable persons themselves.

— Renée M. Hanrahan

QUESTIONNAIRES

Below are two sets of questions used by Via Christi for its assessment of community needs. The first set was used in interviews with community leaders and others who work with seniors in the community. The second set was asked in focus groups with participating residents of Via Christi Village.

HEALTH ASSESSMENT QUESTIONS

1. What works in your area regarding health access for the aging population? What doesn't, and what are the health access gaps?
2. Are you aware of (or a part of) any community coalition or group working on issues related to health access for the aging population? If so, what is it, and what is the primary mission?
3. Are you aware of any coalition that is cross-sharing IT data or grants to improve health access for the aging population in this area?
4. What would you like to see changed in terms of health access services for the aging?
5. Whom or what organization do you see as primary leader in this community making a difference in health access for the aging population?
   (After selection) Why did you select this group, and what measurable impact have they had or achieved in the last year?
6. What do you think Via Christi Village could do to really make a difference in health access for the aging population?
7. Who has the best community outreach programs in providing health care to the aging population in this area? What programs are they providing and what are their outcomes?
8. What do you see your role (or organization's role) to be in the care of the aging population?
9. What plans are you making for yourself and/or your loved ones in terms of health care in your aging years?
10. How likely are you to move into an independent/assisted living facility?
11. Who else in your community should I be interviewing for this aging assessment?
12. What one question did you think that I would ask, but didn't?

QUESTIONS FOR VIA CHRISTI VILLAGE FOCUS GROUPS

1. Do you have family living in the area? Yes/No
2. Did you relocate to this area to be closer to family? Yes/No
3. Did you receive Meals on Wheels before moving into Via Christi Village (VCV)? Yes/No
4. How many years post-retirement did you live independently before moving into VCV?
5. Whose decision was it for you to move into VCV? (Resident's only, family only, both resident and family or other)
6. Which of the following statements were true reasons for you to move into VCV?
   1. To be closer to family/friends
   2. Needed some assistance with housekeeping chores
   3. Needed housing suitable for an older person
   4. No longer able to shop for groceries, medications, etc.
   5. Found it difficult to travel outside of my home
   6. Wanted more socialization opportunities
   7. Felt pressure to move into VCV to avoid burdening family/friends
   8. Other?
7. Now that you are a resident in VCV, do you feel
   9. Moving in was the right decision for you?
   10. Safer in terms of having access to needed services?
   11. You have plenty of socialization opportunities?
   12. Other?
8. Since moving into VCV, how do you rate your overall health?
   13. Better than what it was before
   14. About the same as before
   15. Worse than what it was before
9. What do you miss most about living independently?
10. What do you miss least about living independently?
11. What one thing would you tell others to think about before moving into an assisted living facility?
12. What's the biggest concern you have about living in VCV?