Iona Duckett, 77, first began noticing issues with her eyesight a few years ago. Everyday tasks such a reading, driving, and even her crocheting hobby started to become more difficult. She went in for a regular check-up, and her doctor discovered that she had macular degeneration, also known as age-related macular degeneration.

“My mother had it,” Iona says, “And it can be genetic.”

As a result of this issue, Iona’s vision steadily failed. “I’m legally blind now,” she says. “I can’t read my Bible, I can’t crochet, all the things I used to enjoy. And I can’t drive either. I’ve been driving since I was 16, so now that I can’t, it’s real hard. I’ve lost my independence.”

Struggling not only with her medical issue but also with a feeling of losing control, Iona turned to the team at Hudson Headwaters Health Network for support.

“As people live longer, we’re seeing higher and higher rates of chronic conditions, such as high blood pressure, high cholesterol, and diabetes, leading to acute outcomes, such as stroke, heart disease, and respiratory illness,” says Dr. Danushan Sooriabalan (Dr. Dan for short), a primary care physician at Hudson Headwaters Health Centers. “Often, we see mental health issues like depression and cognitive impairment accompany these acute conditions, as patients become more dependent on others and more socially isolated.”

A nonprofit system of 18 Federally Qualified Health Centers (FQHCs), Hudson Headwaters is at the forefront of working with patients like Iona.

Hudson Headwaters is the sole medical provider for more than 80,000 patients across much of upstate and Northeastern New York, a rural, medically underserved region with a high population of older adults. Their team is leading the way in working with the region’s aging communities by putting into place a model of care that not only treats root cause issues, but also addresses the ripple effects of those issues. And as a mission-based operation, Hudson Headwaters strives to provide care to everyone, regardless of income or insurance.

Addressing the layered medical needs of older adults

Farther south, Francisco Liriano, 81, is a patient at The Center for Healthy Aging at Urban Health Plan in the Bronx, another Federally Qualified Health Center, with more than 10 clinic locations serving low-income communities across New York City.

“When I came to Urban Health Plan, I was starting to feel my age in my body,” says Francisco. Originally from the Dominican Republic, when Francisco first arrived in New York, he was diagnosed with high cholesterol. “I was living with my son, and I didn’t have a lot of choice over the food prepared at home. I didn’t have healthy food options. Eventually, I ended up having a heart attack, and I needed open heart surgery.”

Urban Health Plan, like Hudson Headwaters, is focused on building a collaborative network of services to better serve the aging population and address their layered medical needs.

“We take a team approach,” say Dr. Vanessa Solar Alvarez (Dr. Solar), a primary care physician at The Center for Healthy Aging. “When a new patient comes to see us, we spend 2-3 hours getting to understand them. In their first visit, they will see the nutritionist, the social worker, the pharmacy, even case workers if needed, and then the doctor. We do this so we can create a comprehensive evaluation of everything they have going on. Then we can better address all their health challenges.”

With Francisco, that means that along with the comprehensive care he’s received to better manage his heart condition, and the support he is given for maintaining a healthy diet, he also receives care for the social isolation he experiences in the United States.

“In the Dominican Republic, I was surrounded by family,” says Francisco. “Here, everyone lives locked up. Everyone is working all the time. There is less time with grandchildren. I was feeling depression, I was feeling lonely.”

On top of the regular visits that Francisco has with his primary care physician, his cardiologist, and his gastroenterologist, his social worker at The Center for Healthy Aging also connected him to a therapist and a psychiatrist. “I take medication for the depression now,” he reports, “and it has helped.”

Like Francisco, Iona at Hudson Headwaters also struggled with depression as she lost her vision. “I had trouble eating and sleeping,” she says. “I wasn’t my old self. Most days, I’m home alone, all day. My kids come to see me, but they are also busy with their own lives.”

Hudson Headwaters, like Urban Health Plan, seeks to address the needs aging patients have beyond office visits, through the role of Care Managers.

“Our Care Managers are our eyes and ears with the patient, once they leave our offices,” says Dr. Dan at Hudson Headwaters. “They stay in close contact with patients. They help them get to follow-up appointments, they help them with transportation issues, they help with medication issues, they help with financial issues, and connecting patients to social services. Depending on how complex the case is, our Care Managers may be in daily contact with patients.”

“For us, it’s about aging well. Ideally, we want to see our patients maintaining all the things they love to do. And we want to see them staying active, eating well, and being surrounded by the people they love.”

Dr. Vanessa Solar Alvarez
Urban Health Plan

Iona’s Care Manager, Debra Shay, a registered nurse, has been instrumental not just in helping Iona get to her doctor appointments and manage her medications; she has also been a much-needed social connection.

“When she calls me, it brightens my day,” says Iona. “She likes to listen to my jokes; she tells me to smile.”

“I also pay attention to symptoms that Iona might ignore, health-wise,” says Deb. “For example, a few weeks ago Iona told me about something that was bothering her physically. And I’ll say, ‘This sounds like something you should see Dr. Adams for.’ So issues that she might let slide, I pick up on and we make an appointment.”

“She’s also helped me with my medication,” says Iona. “I had a hard time seeing the medication, knowing what day was when, when to take it. Deb got a local pharmacy to deliver my medication in bubble packs, so it’s a lot easier to sort. She also set me up with a daily check-mark system, so I can remember what I took, and when.”

Managing the ‘polypharmacy’ issue

The issue of medication is a big one for the aging population. Krissia Funes, the clinical pharmacy specialist at Urban Health Plan, says that “polypharmacy” – the use of multiple drugs for one patient – is one of the scariest things that she sees.

“We see patients who are on a lot of medications. They may be taking between 7-15 different prescriptions, 3-4 times daily. Some of the medicines they were prescribed 10-15 years ago, and they are no longer appropriate, but the patient keeps refilling them, and adding on new medications, plus medications that may not have been meant for long-term use. Our goal is to cut back as many pills as we can.”

One way that Urban Health Plan manages the polypharmacy issue is to have new patients bring all their medication bottles into the doctor’s office. “We go through every bottle and recycle what no longer applies. We give them back only what they should be taking, and we write the instructions in Spanish, if needed. We’ve also developed good relationships with local pharmacies, and they help us by sorting patient medication into weekly blister packs. That way it’s organized, it’s clear, and patients get one pack for every week,” says Krissia.

One of the benefits of taking these extra steps to organize patient’s medication is that, through the process, they start to take more ownership for their care. “My patients call me now, and they’ll say, ‘I just got prescribed a new medication by a specialist. What do you think about that?’” Krissia says, “I’m glad because it shows me that they are empowered. They are learning to be discriminating, and to take more responsibility for their health care. And it shows me the trust that we are building with patients.”

In 2016, the National Academy of Medicine reported that by the year 2030, 72 million people in the United States will be 65 and older. That is 21 percent of the population.

FQHCs like Urban Health Plan and Hudson Headwaters are at the cutting-edge of this trend, developing innovative coordinated care models that respond to aging patients with complex needs. Having historically served “moms and kids,” FQHCs have not required specialization or additional capacity to provide geriatric care. However, as a result of expanded access to services and health care created through the Affordable Care Act, FQHCs have seen a steady increase in their 50+ patient population, making up on average nine percent of the center’s patient population.

FQHCs serving rural communities have seen a more rapid growth of older adults being served, with patients over 50 years of age making up more than one quarter (25 percent) of their patient population.

As our nation’s health care system moves towards value-based care, integration and coordination among primary care, social and aging services will be critical to affect positive health outcomes for seniors. Opportunities for innovation and replication loom large as more solutions to support a growing aging population are sought to achieve positive health outcomes. FQHCs are positioned well to provide this support and through the sharing of promising practices, more FQHCs and other health networks will be able to expand their services to older patients.

In an effort to support and grow these unique community-based health care infrastructures, Capital Impact contributed a $6.3 million loan, as part of a $19.3 million transaction with the Low Income Investment Fund (LIIF), to provide a 25-year, fixed-rate loan to Urban Health Plan.

This investment helps to ensure that it can continue to provide high-quality care to more than 85,000 low-income residents of the Bronx, Queens, and Manhattan. The loans will be used to both build out Urban Health Plan’s flagship clinic, and to renovate the building next door.

“As a mission-driven organization, we are proud to support the efforts of forward-thinking FQHCs that support older adults to have a stable living environment in their community, adhere to a care plan, and are able to coordinate care and access to other long-term care support,” said Candace Robinson, Director, Strategy for Aging Initiatives, at Capital Impact Partners. “All of this saves the entire system money since it helps to keep these patients in low-cost settings that are more person-centered and independent.”

Similarly, national initiatives are beginning to focus on this area of innovation. The John A Hartford Foundation has long invested in creating age-friendly health systems, and the Health Resources and Services Administration (a division of the U.S. Department of Health and Human Services) is making the Geriatric Workforce Enhancement Program available in all 50 states next year.

Urban Health Plan and Hudson Headwaters are intent on helping aging patients maintain the best quality of life that they can. “For us, it’s about aging well,” says Dr. Solar. “Ideally, we want to see our patients maintaining all the things they love to do. And we want to see them staying active, eating well, and being surrounded by the people they love. We support them to do that.”

Getting back on track after a mid-life scare

For David Braley, a 65-year-old patient at Hudson Headwaters, he has been able to do just that. At about 50, he was diagnosed with diabetes, and had to have a five-way open heart bypass surgery. “It shocked the heck out of me,” David says. “I felt fine, overall. I’ve been an athlete all my life.”

David’s conditions, both the diabetes and his heart problems, require him to take extra caution with his diet. “I’ve been seeing my dietician here at Hudson Headwaters since I was diagnosed,” he says. “I see her about once a month, and at this point, I consider her a friend. She’s helped me learn how to manage what I eat, and I’ve been able to stay really active. I hike, I kayak, I bike, I play pickleball with my girlfriend. And I plan on staying active for a long time.”

The Hudson Headwaters care model not only works to help David manage his chronic conditions, but connects him to the additional support that he needs.

“A few years ago, when my marriage broke up, I was pretty depressed. Of course, I was seeing my dietician, as usual, and we started talking about how I was feeling. She was like a counselor for me. And she connected me to a psychologist at Hudson Headwaters, who also helped me a lot. When I went through the worst part of my depression, my doctors kept close watch on me.”

Both Hudson Headwaters and Urban Health Plan recognize that, as their patients age, they go through significant life changes. “We see patients who have lost their spouses, they’ve lost friends, they retire and feel a loss of their identity in the community.” says Dr. Dan. “When you add all of these changes to having a chronic condition, it affects you. All those factors play into your overall well-being.”

Meet the Hudson Headwaters staff as they explain how they provide a “layered approach” to treading their older patients.

“So today, I celebrate my life.”

Marcelina Lopez, 86, is a patient at Urban Health Plan. She lost her husband to a stroke just over a year ago. “I miss him every day,” she says. She herself has diabetes, high blood pressure, heart problems, and arthritis. She is in a wheelchair now. Most days, she moves only from her bed, to a chair, to the bathroom. “Before coming to Urban Health Plan, my diabetes and high blood pressure were really out of control,” she says. “I was hospitalized four years ago with diabetic complications, and that’s when I was referred to come to The Center for Healthy Aging.”

At Urban Health Plan, Marcelina receives coordinated care between her primary care doctor, her cardiologist, her podiatrist, and her nutritionist. “I have everything I need here,” she says, “I don’t have to go anywhere else.”

Marcelina’s nutritionist has been helping her to eat a healthier diet. “I used to be terrible at eating vegetables,” she laughs. “I would say, ‘I don’t want to eat that grass.’’ Now Marcelina eats her vegetables, prepared by her daughter, Gladys, who is also her caregiver.

“I feel a lot better now; everything is under control” says Marcelina. “There was a time, 16 years ago, when my family thought I might not live through these conditions. So today, I celebrate my life. If it wasn’t for my knee pain, I’d be hopping all over the place!”

Coordinating with caregivers is another critical element of managing elder adult care. “I always tell my patients, ‘Bring someone,’ when they come for a visit,” says Dr. Solar. “Ideally a family member, or their home health aide. We want to make sure everyone is on the same page, especially because there may be changes in the regimen. Sometimes we hold family meetings. The goal is to have a comprehensive picture of how we, the medical team, and the team of caregivers at home, can work together.”

“The family member, or home health aid, can also give us a more accurate picture of what’s happening at home,” says Krissia, the clinical pharmacist. “Sometimes a patient will report that they are regularly taking medications, and they are not. Or that they are eating well, when they aren’t. When we have a caregiver in the appointment, it helps to clarify what’s really happening at home.”

What drives the care teams at Hudson Headwaters and Urban Health Plan is the respect they have for their patients.

“Ultimately, it’s important that we always keep in mind that our patients used to be very productive members of society,” says Dr. Dan. “Our patients have done a lot for our communities. They were our garbage men, our mail carriers, our doctors and teachers and engineers and housewives. We want to respect what they’ve given by giving back, and helping them maintain their quality of life.”

The extraordinary effort that Urban Health Plan and Hudson Headwaters make to provide for their aging patients is reflected in the patients themselves.

As Francisco reports, “The staff here is very good. They are kind and respectful. The facilities are nice and clean. My high cholesterol is under control. I feel good, in spite of my years. I feel like a tree. I might not be growing any more, but I’m not about to fall over.”

Or as Iona says, “Even through my depression and my health difficulties, having my Care Manager always there for me, always picking up the phone, it helps me to know that I’m not alone, and that together we’ll make a plan.”

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