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HomeMy WebLinkAboutac-hbi-community-needs-assessmentPage 1 of 29 ALAMEDA COUNTY HEALTHY BRAIN INITIATIVE PRELIMINARY COMMUNITY NEEDS ASSESSMENT Submitted to the California Department of Public Health | February 2024 I. OVERVIEW: ALAMEDA COUNTY HEALTHY BRAIN INITIATIVE COMMUNITY NEEDS ASSESSMENT Our Alameda County Healthy Brain Initiative (HBI) Community Needs Assessment has been completed during the fall/winter of 2023-2024. It builds on the significant community- driven and County-led needs assessment and prioritization process for the Healthy Brain Initiative Road Map in 2018-2019. ACPHD staff reviewed the finding of recent, substantial needs assessments conducted by the Alameda County Area Agency on Aging (AAA, County-Wide Aging Plan, 2020-2024), the Alameda County Age-Friendly Council (AFC, 2022), the Embracing Aging Initiative (2019-2020), and the Digital Inclusion Workgroup of the AFC (2019-2021). ACPHD staff participate regularly in the Embracing Aging/Healthy Brain Initiative Workgroup and the general meetings of the AFC, which include ongoing discussions of the AAA’s efforts toward the next County-Wide Aging Plan as well as the AFC’s Strategic Plan refresh process. This initial HBI Community Needs Assessment is grounded in key informant interviews and the participation of the Embracing Aging/Healthy Brain Initiative Workgroup of the Alameda County Council on Age-Friendly Communities (the Age-Friendly Council). In addition, ACPHD’s in-house Community Assessment, Planning, and Evaluation (CAPE) unit provided a deep dive into the most up-to-date data on the prevalence of ADRD in our county and existing disparities among the older adult population. This initial Assessment has been completed by Lisa Haefele, Julie Williamson, Roxanna Guide, and Yilak Fantaye of the Alameda County Public Health Department (ACPHD). Their qualifications are as follows: • Lisa Haefele, Ph.D., serves as the Director of the Alameda County Healthy Brain Initiative, as well as the Senior Strategist in the Community Health Services (CHS) Division. She has provided equity-focused health and human service program planning and fund development for 17+ years, serving on the ACPHD Leadership Team since 2016. • Julie Williamson, MPH, serves as the Deputy Division Director of CHS and brings more than 35 years of experience in leading and overseeing public health approaches to chronic disease. She currently oversees ACPHD’s two programs focused on older adults, Care Partners and Older Adults Healthy Results, which offer, respectively, light- touch and more intensive case management to medically complex older adults. • Roxanna Guide, Epidemiologist with the Community Assessment, Planning and Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 2 of 20 Evaluation (CAPE) Unit at Alameda County Public Health Department, has 14 years of experience in epidemiology and data analysis around chronic disease, and in the past 10 years has done a lot of work on hospitalization data around chronic disease indicators such as asthma, heart disease, diabetes, stroke, mental health indicators, unintentional injury indicators, etc. Major projects or areas of expertise include work on preventative hospitalizations, Alzheimer’s/dementia, prostate cancer, asthma, heat- related data, etc. She earned her MPH with a focus in epidemiology from UCLA in 2009. • Yilak Fantaye, an epidemiologist at Community Assessment and Planning and Evaluation (CAPE) unit of Alameda County Public Health Department, has a Master of Public Health and over 10 years of experience in the field. He has been with the county for about 6 years focusing on areas of program evaluation, population health, homelessness, and drug overdose. For the planned, more detailed assessments to be completed in the Spring, including focus groups and community listening sessions, we are exploring the capacity of the ACPHD CAPE unit. If needed, we intend to secure a consultant and/or student interns to support these efforts. In total, we conducted 9 interviews with 13 individuals representing 11 organizations with expertise in geriatric and dementia work in our county. Key informants interviewed to date include: • Ben Chen, ACPHD’s Developmental Disability Council and Age-Friendly Council leadership team • Michele Burke, Director, ACPHD Older Adults Healthy Results program • Mercel Amin, Stefanie Bonigut, and Jessica Rothhaar, Alzheimer’s Association • Wendy Peterson, Director, Senior Services Coalition of Alameda County and Age- Friendly Council leadership team • Gail Belgarde, Grace Jordan, Social Services Agency, Embracing Aging Initiative, Training and Consulting Team: • Dr. Claudia Landau, geriatrician and consultant; Medical Director of Alzheimer’s Services of the East Bay; Board, Daybreak • Dr. Michael Harper and Andrea Gonzales, UCSF Geriatric Workforce Enhancement Project • Dr. Mark Johnson, UC Davis Alzheimer’s Disease Research Center: The Good Life • Karen Grimsich, Aging & Family Services Administrator, City of Fremont We have identified or invited, but not yet interviewed additional organizational partners, including Alameda County Health Care for the Homeless, Alzheimer’s Services of the East Bay, ACPHD Care Partners, Public Authority/IHSS, St. Mary’s Center, Human Good, Family Bridges, and DayBreak Adult Care. In addition, Alameda County Behavioral Health has just appointed Juliene Schrick as the Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 3 of 20 new Older Adult System of Care director and the chair of the Embracing Aging/Healthy Brain Initiative Work Group, effective February 5. We plan to meet with her soon after she assumes this new role. II. COMMUNITY DESCRIPTION Alameda County is the 6th largest county in California, and is widespread geographically, consisting of 821 square miles and fourteen cities. The County is home to 1.67 million people and is the most racially and ethnically diverse county in the nine-county Bay Area and one of the most diverse in the nation. According to projections from the California Departments of Finance and Aging, Alameda County’s older adult population (65+) will grow 194.99% between 2010 and 2060, outpacing the growth rate of California and the nation. Over the same timeframe, the population 85+ will increase by an astonishing 553.51%. By 2060, ACPHD estimates that the number of people age 65 and over with Alzheimer’s Disease and Related Dementias will quadruple to nearly 80,000. The Alameda County Council on Age-Friendly Communities (the Age-Friendly Council, AFC), a collaboration of County agencies and community-based partners, and other stakeholders, coordinates and plans for this aging population. The current Alameda County Age-Friendly Action Plan identifies these areas as the highest concerns for older adults in Alameda County: 1. Insufficient Income 2. Affordable and Stable Housing 3. Better Community Outreach 4. Safe Communities 5. Transportation This Action Plan is based on the findings of a 2019-2022 Community Needs Assessment process that included a widely distributed community survey and more than 29 community listening sessions, in conjunction with the Area Agency on Aging’s Countywide Aging Plan. During the Community Listening Sessions, participants were asked to vote on which of the domains of livability were most important among the eight that the World Health Organization/AARP’s Age-Friendly framework identifies. The Community Listening Sessions added Dementia Services and Supports as a ninth domain; this practice is in line with the Fremont Age-Friendly Action Plan and several other jurisdictions’ Age-Friendly Action Plans. Dementia and Community and Health Services were the two most often prioritized domains for discussion—demonstrating the urgent, felt need to better address ADRD as a chronic disease in the community. Regarding dementia, the Alameda County Age-Friendly Action Plan notes, “participants spoke about the high cost and limited availability of support resources, the use of volunteers and companions to provide relief to caregivers, and the need to support the caregivers more.” Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 4 of 20 III. PRIORITY POPULATIONS The Alameda County Healthy Brain Initiative will support systems-level coordination and improvements that will affect the entire population of individuals at-risk or living with ADRD, their caregivers, and their health and social service providers. Within that population, we intend to focus on: • Low-income and under-resourced populations, including those on Medi- Cal (including “Duals” on both Medi-Cal and Medicare) and/or utilizing Safety Net hospitals and clinics in Alameda County. • Pacific Islander and Black residents, who national and local data shows experience higher prevalence, as well as higher rates of hospitalizations and emergency department (ED) visits. • Those who are linguistically and culturally isolated, including Alameda County’s large and diverse immigrant population. • Unsheltered or housing insecure older adults, who make up the majority of individuals entering homelessness in our county. IV. DATA PROFILE: PREVALENCE, MORTALITY, AND MORBIDITY OF ADRD IN ALAMEDA COUNTY • As of 2020, Alameda County had a 12.1% prevalence of Alzheimer’s among those ages 65+ according to Alzheimer's Disease Prevalence Map by County. • The percentage presented by Centers for Medicare and Medicaid Services data for those ages 65+ who were Medicare fee-for-service recipients (dual and non-dual eligible) having ‘Alzheimer’s disease, related disorders, or senile dementia’ was lower but still substantial (8% in 2022). Females ages 65+ had a 9% prevalence rate and males had a 7% prevalence rate. African Americans/Blacks had a prevalence rate of 11%, Asian/Pacific Islanders and Whites had an 8% prevalence rate, Hispanics had a 7% prevalence rate, and American Indians/Native Alaskans had a 20% prevalence rate. Hospitalizations • There were 8,341 Alzheimer’s/dementia related hospitalizations in Alameda County in 2020. 3% of these hospitalizations were coded for Alzheimer's/dementia in the primary diagnosis field. For the remaining 97% Alzheimer's/dementia was coded in the 2nd-25th (associated) positions. For those hospitalizations that were coded for Alzheimer’s/dementia in the associated positions only, the top 20 primary diagnosis fields are shown in the table below. Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 5 of 20 Top 20 Primary Diagnoses for Hospitalizations with Alzheimer’s and Dementia as an Associated Diagnosis Sepsis 2166 26.8% Fracture of Femur 328 4.1% COVID-19 288 3.6% Cerebral infarction 254 3.1% Hypertensive heart and chronic kidney disease 243 3.0% Acute Kidney Failure 233 2.9% Urinary Tract Infection 222 2.7% Pneumonitis due to solids and liquids 170 2.1% Respiratory failure, not elsewhere classified 143 1.8% Other disorders of fluid, electrolyte and acid-base balance 134 1.7% Pneumonia 133 1.6% Intracranial injury 129 1.6% Acute myocardial infarction 126 1.6% Type 2 Diabetes Mellitus 125 1.5% Infection and inflammatory reaction due to urinary catheter 111 1.4% Other disorders of brain 104 1.3% Hypertensive Heart Disease 94 1.2% Epilepsy and recurrent seizures 90 1.1% Atrial fibrillation and flutter 82 1.0% Chronic Lower Respiratory Disease 79 1.0% • In 2019-2020 among those ages 65+, there were 15,131 ADRD hospitalizations, at a rate of 3391.7 hospitalizations per 100,000 population. Among Pacific Islanders, there were 163 ADRD ED visits (1.1% of total visits), at a rate of 10,616.1/100,000 population (3.1 times the county rate). Among African Americans/Blacks, there were 3082 hospitalizations (20.4 % of total visits), at a rate of 6,948.7 visits/100,000 population (2.0 times the county rate). Among Hispanics/Latinos, there were 1,414 hospitalizations (9.3% of total visits at a rate of 3,328.8 visits/100,000 population), among whites there were 6554 hospitalizations (43.3% of the total visits at a rate of 3,007.8 per 100,000), and among Asians there were 3,058 visits (16.0% of total visits at a rate of 2,465.6 visits/100,000). • 118 of the ADRD hospitalizations for those ages 65+ from 2019-2020 were among those identified as homeless (1% of total for this age group). Looking at all age groups instead of just ages 65+, we see that there were an additional 83 hospitalizations from 2019-2020 among those ages 55-64 years. Among the age group 55-64 years, people who were homeless made up 10% of the hospitalizations for ADRDs. 34.7% of the hospitalizations among those who were homeless were in the age group 55-64 whereas Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 6 of 20 for the non-homeless population the percentage of hospitalizations among those ages 55-64 was 4.7%. • Among the 15,131 hospitalizations (including those admitted to their own ED who were later hospitalized) in 2019-2020 among those ages 65+ in Alameda County, 14% were at Alta Bates Summitt Medical Center, Hawthorne Campus, 12% were at Washington Hospital, 11% were at Kaiser Oakland/Richmond, 9% at Eden Medical Center and Kaiser San Leandro, 7% at Highland Hospital and Kaiser Fremont, 5% at St. Rose Hospital and Alta Bates Summitt Medical Center, Alta Bates Campus, 4% at Alameda Hospital and 1% at San Leandro Hospital. Hospitalization Costs • Total charges for 2020 among ages 65+ were $747,254,109 for ADRD hospitalizations, with an approximate average cost of $207,736,642 (using the most recent available cost to charge ratio for Alameda County of 27.8% from 2019) (https://hcai.ca.gov/visualizations/hospital-financial-data-interactive-series-hospital-financials/). Please note that there were missing charge data for 10 hospitalizations, so this is an underestimate. The median approximate cost was $35,514. Emergency Department (ED) Visits • In 2019-2020 among those ages 65+, there were 14,709 ADRD ED visits, at a rate of 3,289.5 ED visits per 100,000 population. Note that these represent those ED visits that do not end up being admitted for inpatient care in the same hospital. The latter are represented in the hospitalization data only. • Among Pacific Islanders, there were 115 ADRD ED visits (0.8% of total visits), at a rate of 7,641.2/100,000 population (2.3 times the county rate). Among African Americans/Blacks, there were 2,838 ED visits (19.0 % of total visits), at a rate of 6,427.1 visits/100,000 population (2.0 times the county rate). Among Hispanics/Latinos, there were 1,564 visits (10.5% of total visits at a rate of 3,674.8 visits/100,000 population), among whites there were 7,194 ED visits (48.3% of the total visits at a rate of 3277.9 per 100,000), and among Asians there were 2,392 visits (16.0% of total visits at a rate of 1915.5 visits/100,000). • 81 of the ADRD ED visits for those ages 65+ from 2018-2020 were identified as being from those who were homeless. If we look at all age groups instead of just ages 65+, we see that there were an additional 57 ADRD ED visits from 2018-2020 among those ages 55-64 years. • Among the 14,709 ED visits in 2019-2020 among those ages 65+ in Alameda County, 21% were at Kaiser San Leandro, 16% at Kaiser Oakland/Richmond, 15% at Kaiser Fremont, 8% at Alta Bates Summitt Medical Center, Hawthorne Campus, 7% at Washington Hospital, 6% at Eden Medical Center, 5% at Valleycare Medical Center and Highland Hospital, 4% at and St. Rose Hospital, 3% at Alta Bates Summitt Medical Center, Alta Bates Campus, and 2% at Alameda Hospital. Hospitalizations and ED Visits Combined Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 7 of 20 • We often look at hospitalizations and ED visits together to represent a general burden of disease that we can compare by subgroups. There were 29,840 Alzheimer’s/dementia-related hospitalizations and Emergency Department (ED) visits combined in 2019 and 2020 for those ages 65+ in Alameda County, at an age- adjusted rate of 6,727.1 visits/100,000 population. Rates were highest for Pacific Islanders and African Americans/Blacks at rates 2.8 times and 2.0 times the county rate, respectively. • 2019 and 2020 showed increased age-adjusted rates of hospitalization and ED visits compared to 2016-2018 as shown below. The age-adjusted rate of visits for those ages 65+ in 2020 was 1.2 times that of the rate in 2016. • Sunol, Hayward, Union City, and Oakland had the highest rates of Alzheimer’s/dementia hospitalizations and ED visits in 2019-2020, followed by Fremont, San Lorenzo, and San Leandro. Note that Sunol has a smaller population compared to most other cities in Alameda County. As a general rule, the smaller the population, the larger any given increase or decrease in counts will affect the rate. 5588.1 5475.5 5432.6 6571.4 6879.3 0 1,000 2,000 3,000 4,000 5,000 6,000 7,000 8,000 Year 2016 Year 2017 Year 2018 Year 2019 Year 2020 Ag e - Alzheimer's/Dementia-related Hospitalizations and ED visits by Year, Alameda County, Ages 65+ Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 8 of 20 Mortality • In 2021, there were 1,013 deaths from ADRDs in Alameda County for ages 65+ (which make up 12.1% of deaths for ages 65+), and 1,025 deaths from ADRDs for all ages (which make up 9.0% of deaths for all ages). • In 2021, Alzheimer’s and other Dementias (ADRDs) was the 3rd leading cause of death in Alameda County for those ages 65+ after cancer (1,732 deaths) and heart disease (1,723 deaths). After ADRDs, there were all other causes (732 deaths), cerebrovascular diseases (732 deaths) and COVID-19 deaths (592 deaths). • In 2021, ADRDs were the 3rd leading cause of death for all ages (after cancer and heart disease). • See below the disease groups used in ranking the leading causes of deaths: All ages, 2021 4701.0 5267.9 5605.3 5825.4 5936.1 5986.4 6070.5 6098.8 6279.5 6590.2 6597.4 6727.2 7430.9 8079.9 8664.9 11260.6 0 2,000 4,000 6,000 8,000 10,000 12,000 Berkeley Dublin Castro Valley Pleasanton Newark Alameda Livermore Albany San Leandro San Lorenzo Fremont Alameda County Oakland Union City Hayward Sunol Age-adjusted rate per 100,000 Alzheimer's/Dementia-related Hospitalizations and ED visits by City/Place, Alameda County, Ages 65+, 2019-2020 Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 9 of 20 Ages 65+, 2021 • In Alameda County from 2019-2021, <10 ADRD deaths were among those ages 45-54, 32 deaths were among those ages 55-64, 190 deaths were among ages 65-74, 724 deaths were among those ages 75-84, and 2412 deaths were among those 85+ years of age. Note that identifying the true number of people who die from ADRD is difficult due to differing definitions and coding practices. In our analysis we looked at those with ADRD coded as the underlying cause of death, which excludes those who may have had ADRD coded as a contributing cause, such as some cases of pneumonia. Thus, the true burden of disease is likely higher. • The following graph shows the age-specific mortality rates by age group. The older age groups experienced by far the largest burden of disease. • The death rate for ADRDs in Alameda County increased from 2007-2009 to 2019-2021. The age-adjusted rates for males and females ages 65+ in 2019-2021 were 1.4 times 0.5 5.2 43.6 355.6 2,737.9 - 500 1,000 1,500 2,000 2,500 3,000 45-54 55-64 65-74 75-84 85+ Death Rate from Alzheimer’s and Dementia by Age Group Source: CAPE, with data from Alameda County mortality files, 2019-20121 Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 10 of 20 their respective rates from 2007-2009. • In 2019-2021, there were 3,326 deaths for ADRDs in Alameda County (1,139 among males and 2,187 among females). The age-adjusted death rates for ADRDs in Alameda County for ages 65+ were 435.3 deaths per 100,000 population for males and 523.4 deaths per 100,000 population for females. • There were 463 ADRD deaths among African Americans/Blacks. The rates for African American/Black males and females were 1.6 times and 1.4 times the county rates for males and females, respectively. There were 1,848 ADRD deaths among Whites. The rates for White males and females were 1.1 times the county rates for males and females. The chart below shows rates for other racial/ethnic groups by sex. Due to small numbers, we are unable to report out the counts and rates for Native Americans and Pacific Islanders. 383.7 450.0 512.8 510.7 523.4 315.3 384.0 425.8 436.2 435.3 0 100 200 300 400 500 600 2007-2009 2010-2012 2013-2015 2016-2018 2019-2021 Ag e -ad j u s t e d r a t e p e r 1 0 0 , 0 0 0 Death Rate from Alzheimer’s and Dementia 65+ Years, 2007-2021 Female Male Source: CAPE, with data from Alameda County mortality files, 2007-2021 Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 11 of 20 • The graph below shows ADRD mortality age-adjusted rates for ages 65+ over time. The rates for African Americans/Blacks and Whites were consistently first and second highest, respectively. The rates from 2019-2021 for Asians, African Americans/Blacks, Hispanics/Latinos, and Whites were 2.0, 1.6. 1.6, and 1.3 times that of the rates in 2007-2009 respectively, so Asians, African Americans/Blacks, and Hispanics/Latinos saw the greatest relative increases over this time period. 435.3 678.0 293.1 444.4 489.0523.4 717.5 377.9 526.4 582.4 0.0 100.0 200.0 300.0 400.0 500.0 600.0 700.0 800.0 All Races African American/Black Asian Hispanic/Latino White Death Rate from Alzheimer’s and Dementia 65+ Years by Gender & Race/Ethnicity Male Female Source: CAPE, with data from Alameda County mortality files, Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 12 of 20 Demographics of the Aging Population: Population of Older Adults: According to the California Department of Aging (CDA), the Alameda County population of those age 60 and older is 377,873. This is the fastest growing segment of the population. Race and Ethnicity: According to the CDA, most Alameda County older adults (58%) are people of color. The U.S. Census breaks this down further: Alameda County’s population age 65 or older includes 31% Asian, 11% Black or African American, 11% Hispanic or Latino, 1% Native Hawaiian and Other Pacific Islander, and 44% White. Language: According to the CDA, nearly 5% (17,525) of residents 60+ do not speak English. This does not tell the full story of the rich history of immigration and diversity in Alameda County. Today, residents speak more than 50 languages, including eight “threshold” languages that government documents are commonly translated into: English, Spanish, Cantonese, Mandarin, Vietnamese, Farsi, Korean, and Tagalog. Socio-Economic Status and Public Benefits: According to statistics compiled by the California Department of Aging, more than 10% (39,340) are considered low-income and 22.76% (86,008) are Medi-Cal eligible. Analysis by the Senior Services Coalition of Alameda County reveals that 36.2% of older adults live below the Elder Index, which measures what basic expenses cost locally, and “almost half of single older adults in Alameda County can’t cover their basic living expenses.” It adds, “People of color, women, and LGBTQ individuals … face a greater likelihood of aging in poverty.” Multigenerational poverty, especially among communities of color, means that families of the poorest older adults also face challenges in 0 100 200 300 400 500 600 700 800 2007-2009 2010-2012 2013-2015 2016-2018 2019-2021 Death Rate from Alzheimer’s and Dementia 65+ Years by Race/Ethnicity, 2007-2021 African American/Black All Races Asian Hispanic/Latino White Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 13 of 20 terms of education, income, and health that may make caring for their loved ones at home difficult. Homelessness and Housing Insecurity: As for much of the Bay Area and the nation, housing and homelessness in Alameda County are critical factors in health and wellbeing for everyone, but especially for older adults on limited incomes. Among renters, almost half of older adults are considered “housing-cost burdened,” with more than 30% of their income going to housing--and nearly one-third spend 50% or more of their income on rent. Among Alameda County’s large, unhoused population, nearly 1 in 5 experience their first episode of homelessness at age 50 or older, according to the 2022 Alameda County Point in Time count. More than 50% of Oakland’s homeless are 50 or older, according to data analyzed by the Senior Services Coalition. Isolation: Although Alameda County is spread out over more than 800 square miles, most residents live in densely populated cities and suburbs, so the CDA finds that there are very few (1,320) older adults who are geographically isolated. Social isolation may be a bigger factor, as more than 1 in 6 (17.8%, n=67,220) adults age 60+ in Alameda County lives alone. According to the Senior Services Coalition, 20.8% of those 60+ say they sometimes or often feel lonely. Health Status: More than 1 in 6 older adults 60+ say that their health is “fair” or “poor,” according to the Senior Services Coalition analysis. Many older adults, especially those living in poverty, experience multiple chronic conditions that may put them at greater risk for ADRD and complicate treatment and services for ADRD. V. EXISTING COMMUNITY ASSETS AND RESOURCES Health Care Safety Net and Clinical Services: Alameda County is fortunate to have many healthcare and social service organizations serving its diverse population, including County agencies, hundreds of community-based organizations, an independent public hospital authority, community-based clinics; and two managed care plans. Alameda County safety net healthcare institutions have a history of strong collaboration. At the same time, all are separate entities with separate data systems, separate governance, and separate strategic planning. Alameda County includes six distinct areas in the County designated as medically underserved for primary care by HRSA, which is defined as a place with a shortage of primary health care services for residents within a geographic area who are facing economic, cultural, or linguistic barriers to access to health care. Comprising more than 100 census tracts clustered along the I-880 corridor, these areas are primarily located in historically disinvested communities with large populations of Black and Brown residents. To help meet this need, Alameda County has developed a robust Safety Net for health care services, including a network of eight federally qualified health centers (FQHC) with more than 105 clinic sites and more than 1,700 providers and staff. Many of the FQHCs have Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 14 of 20 historic and cultural ties to specific communities, including Asian, African American, Latinx, and Native American populations. One FQHC, now called LifeLong Medical Care, was started by the Gray Panthers as the Over 60 Health Center in Berkeley in 1976. It remains a leading provider of health care services for lower-income older adults in northern Alameda County. The FQHCs collaborate through the Alameda Health Consortium and the Community Health Center Network (CHCN), a risk-bearing independent practice association. In addition to the FQHCs, Roots Community Health Center is a large community clinic with deep ties to East Oakland and its predominantly Black population. Alameda Health Systems is our large, integrated public hospital system, operating five hospitals and four wellness centers with over 800 beds and 1,000 physicians. Highland Hospital, its flagship hospital, is a regional trauma center and offers a full range of primary and specialty care. Highland’s Geriatric Program, which includes a Falls Prevention Center, is currently being restructured to better meet community needs. Kaiser Permanente, headquartered in Oakland, and Sutter/Alta Bates also have a very strong presence in the county. Alameda County is considered a single plan county for Medi-Cal Managed Care, with the Alameda Alliance for Health serving the majority of Medi-Cal eligible residents. Starting in January 2024, Kaiser is also providing Medi-Cal managed care to some residents. Both plans are offering a wide range of CalAIM Enhanced Case Management and Community Support Services. The UC Davis Alzheimer’s Disease Research Center (ADRC) of the East Bay, located in neighboring Contra Costa County, serves Alameda County residents. Services include assessments for adults with memory problems, including medical, neurological, psychological and psychosocial evaluations; opportunities to participate in research studies exploring cognitive and behavioral changes, caregiving and clinical trials for new drug therapies; clinical and educational services targeted to meeting the needs of the African American community; feedback for families on diagnosis following evaluation; social work recommendations for improved quality of care for persons with Alzheimer’s disease, including referrals, education, counseling and training for patients, families and caregivers; and community education programs for caregivers, health care and other professionals. The full range of diagnostic and clinical services are offered through these providers. Multiple key informants note, however, that very few primary care providers (PCPs) have sufficient training in geriatrics or in ADRD. Not many PCPs complete regular cognitive assessments on their older patients, and too few feel comfortable initiating discussions of cognitive health and diagnosing ADRD. Lack of Adult Day Health Care and Adult Day Care: According to the Senior Services Coalition of Alameda County, in the last decade, three of the six Adult Day Health Care Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 15 of 20 facilities have closed. At the same time, all of the Adult Day Care providers in the county have also closed. The remaining providers have capacity to serve only about 1,000 patients—totally insufficient to meet the need. Many of those interviewed spoke of the crisis that this lack of safe, enriching, supervised environments for older adults, including those with cognitive impairments, is causing. Ultimately, it is leading to unnecessary institutionalizations, because the lack of daytime respite and services means that for some “nursing homes become the only other option” for those who can't care for loved ones at home. This is especially difficult for adult children in the so-called “sandwich” generation, who would like to provide care at home for their aging parents but must support their own families and children. Long-Term Care Facilities: For older adults, including those with ADRD, who can no longer live safely at home, in Alameda County, we have more than 300 long-term care facilities serving primarily older adults, with a total of 14,090 beds, according to an analysis by ACPHD consultants Terry Hill and David Farrell. They include 60 skilled nursing facilities (SNFs) with 4,937 beds, 247 residential care facilities for elders (RCFEs) with 6759 beds, and 6 continuing care retirement communities (CCRC) with 2,394 beds. Of the RCFEs, about 60% are small Board & Care facilities with 6 beds or less, while 40% are larger Assisted Living facilities. Most RCFE residents are private pay, because Medi-Cal covers very few beds. In contrast, Medi-Cal covers two-thirds of SNF beds in the county. (There are an additional 279 long-term care facilities that serve primarily younger patients.) 1 During the COVID-19 public health emergency, ACPHD devoted substantial resources to understanding the landscape of long-term care facilities in the county and to supporting them in improving their infection control and prevention protocols. ACPHD and AFC Services and Resources: In addition to the new Healthy Brain Initiative, ACPHD offers two programs that prioritize older adults almost exclusively, Care Partners and Older Adults Healthy Results, as well as older adult focused services through our Nutrition Services program. • Care Partners: The Care Partners program provides culturally competent care coordination services to In-Home Supportive Services (IHSS) Recipients, Care Providers, and members in their Circle of Care, as well as low-income disabled and older adults, to improve their quality of life at home. Using a “light touch” approach, the Care Partners program addresses all of the top ten concerns of older adults as represented in a Countywide survey, including linkages to social services, wellness promotion, and illness prevention education; system navigation for public benefits, durable medical equipment, housing, and other needs; and Advance Care Planning support. Services are available in Spanish, Cantonese, Mandarin, and Vietnamese. More information at https://gettingthemostoutoflife.org/ 1 1. Hill TE, Farrell DJ. COVID-19 Across the Landscape of Long-Term Care in Alameda County: Heterogeneity and Disparities. Gerontology and Geriatric Medicine. 2022;8. doi:10.1177/23337214211073419 Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 16 of 20 • Older Adults Healthy Results: The Older Adults Healthy Results (OAHR) program provides intensive home-visiting nurse case management to older adults 60+ who are having trouble managing complex health conditions due to psychosocial challenges. Clients include very low-income, medically frail, and socially isolated older adults. By developing care plans that prioritize client values, facilitate healthcare access, and link isolated clients to available resources, OAHR combats intersecting systems of ageism and racism that negatively impact our older adult communities and lead to premature functional decline. Visit https://acphd.org/older- adults-healthy-results for more information. • Nutrition Services: The Nutrition Services program offers older adults Bingocize, an evidence-based program combining Bingo with nutrition education and physical activity. The program encourages increased time spent exercising, strengthening workouts, and intentional movement. Bilingual English/Chinese classes reach low- income older adults, residents at senior centers, and those living in six affordable senior housing sites. In addition, the new Oakland Making Moves project aims to increase residents’ use of walking routes from affordable housing sites to other healthy neighborhood assets, such as libraries, clinics, and parks, using an intergenerational approach to conducting walk audits, mapping safe routes in the neighborhood, and supporting resident-led group walks. • Resource Guides and Web Sites: All of these programs are linked to the ACPHD or HCSA websites, though they may be somewhat difficult to locate. The Agency and Department are currently completing a rebranding initiative, which will include a complete overhaul of our public-facing website, including a more dynamic layout, with attention to translating key information and access for those with disabilities. The website is expected to launch in early summer 2024. The Healthy Brain Initiative staff will work to develop a new Alameda County HBI web site, ensuring that healthy aging and ADRD resources are linked, up-to-date, and more easily accessible and up to date on this website. In the interim, the Alameda County Age-Friendly Council is a go-to site for many healthy aging resources, including this guide which includes links to ADRD resources for patients and their caregivers: Age-Friendly Council Printable Resource Guides: https://agefriendly.acgov.org/get-help/printable.page Some listings are available in multiple languages, and additional translation is also available through Google Translate. VI. ALAMEDA COUNTY HEALTHY BRAIN INITIATIVE PRIORITIES Key informants emphasized the role of ACPHD and the County in building systems capacity and collecting/analyzing data that can inform decision-making and resource allocation. There was broad agreement that the two areas of work identified through the 2018-2019 Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 17 of 20 community-driven Healthy Brain Road Map prioritization process remain relevant and feasible. These identified areas build on existing priority efforts within the County, they have strong community buy-in, infrastructure, and the potential for substantial return-on- investment: • ADRD trainings for providers, from health care providers to homeless services providers to IHSS and home health providers. UCSF’s Geriatric Workforce Enhancement Project (GWEP), which has provided provider trainings focused on the “4 M’s” of geriatric care, is sunsetting in June 2024. Considerable infrastructure for the project has been developed over the last 4 years, both the Embracing Aging Work Group, and staffing within the Alameda County Social Services Agency for the Embracing Aging Initiative. These staff are seeking ways to offer Training-for- Trainers (T4T) sessions, recordings, or other means to institutionalize and continue these trainings. The Healthy Brain Initiative will coordinate with and build on these existing resources. The key informant interviews have revealed training needs for IHSS care providers and other home-based caregivers, as well as for primary care providers and service providers who participate in the Age-Friendly Council and the Senior Services Coalition. • Emergency Planning and Preparedness. We intend to work with the Alameda County Emergency Managers Association, HCSA’s Emergency Medical Services, and the ACPHD Emergency Operations Plan leads to broader Access and Functional Needs planning and to include the voice of older adults and those with ADRD and other disabilities. Lisa Haefele is representing Community Health Services and the Healthy Brain Initiative on the ACPHD Emergency Operations Plan revision committee. In addition, new areas of systems development, capacity building, and quality improvement emerged as themes and suggestions for additional work that ACPHD and the Alameda County Healthy Brain Initiative could play a role in: • Health Care Systems’ Role in Training and Cognitive Screenings: Work with healthcare systems to identify systems improvements to encourage and support timely cognitive screenings among primary care providers and appropriate referrals to specialists. We plan to explore various systems levers available, including modifications in Electronic Health Record prompts or protocols, writing data collection/data sharing into County contracts, leveraging HEDIS or other quality measures, legislative and policy changes, and so on. • Case Management/Patient Navigation: Conduct a survey of case management or patient navigation services and options for low-income and socially isolated individuals and families who need support in navigating medical, legal, housing, and financial systems. Many older adults lack family or friends with the capacity to assist them. If they have younger family members, they may have their own psychosocial needs, health concerns, or caregiving responsibilities that make it difficult for them to Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 18 of 20 assist their elders with their needs. • Housing and Legal Services: Evictions and housing insecurity were noted as top concerns by many key informants. The Healthy Brain Initiative has a role in conducting workflow and service mapping to explore barriers around housing evictions, legal services, and case management. Where is the system experiencing capacity or staffing challenges? Where are there gaps in navigation or case management services? How can we increase awareness among housing navigators, property owners, housing authorities, and homelessness providers understanding and best practices in working with those with ADRD? VII. ADDITIONAL PROGRAM AND POLICY RECOMMENDATIONS In addition to the specific objectives and activities identified in our Healthy Brain Initiative Work Plan, the following program and policy recommendations have emerged from our initial HBI Community Needs Assessment. We anticipate that additional priorities will come to light as we conduct additional system mapping and data collection, moving forward toward our Alameda County Healthy Brain Initiative Strategic Plan in June 2024. • Caregiving supports and respite slots are acutely needed, especially given the loss of Adult Day Health Care and Adult Day Care slots. Find ways to stabilize remaining providers and expand the existing services. Support caregivers in identifying and navigating resources and systems. • Ensure supports are neighborhood- and community-based: Explore ways to support and foster emerging and even informal networks of interdependence, including providing training and supports to neighborhood- and community-based peer navigators to provide supports for aging “in community.” Considering leveraging ACPHD’s neighborhood-based Community Resilience Coalitions in this effort. • Increase system capacity for services, care coordination, and navigation for patients and caregivers and service awareness/referral pathways for geriatricians, primary care providers, and case managers working with individuals with ADRD and their caregivers and families. Service needs mentioned include assistance in: utilizing resources such as the Alzheimer’s Association toolkit; in enrolling in Medi-Cal or other health insurance; in establishing a medical home or finding an ADRD specialist; in navigating housing insecurity and eviction proceedings; in establishing durable powers of attorney and other financial arrangements to preserve financial stability; and in identifying appropriate home health or IHSS providers when there is not a family member available. • Across all areas, there is an acute need for culturally and linguistically appropriate services, especially for Black, Latino/a/x, and LGBTQ+ communities. While several informants mentioned a number of community-based providers serving Asian populations, there remain significant needs among Cantonese, Mandarin, and Vietnamese speakers, as well as other culturally and linguistically isolated immigrant Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 19 of 20 populations. • Age-friendly shelters: The 2021 AFC Housing Work Plan included making shelters more age-friendly as a mid-level goal. Several members of the AFC elevated this at a recent discussion of the AFC’s Action Plan Refresh process, and we are advocating for this to be elevated in the refreshed 2024 plan. The most recent suggestion to is to work with shelters to plan for specific Use Cases, such as those in wheelchairs, those with cognitive impairment/dementia, and so forth. VIII. PLANNED ADDITIONAL COMMUNITY STAKEHOLDER ENGAGEMENT In addition to the members of the Embracing Aging/Healthy Brain Initiative Work Group and those already interviewed, some of the key partners and stakeholders that we plan to engage with further in the short- and mid-term include: • The Good Life • Alzheimer’s Services of the East Bay • Family Bridges • DayBreak Adult Care • Homelessness Prevention and Community Supports providers • Health Care for the Homeless • Senior Services Coalition members—40+ CBOs • Center for Elders’ Independence • Alameda County Emergency Medical Services | Fall Prevention Program • Clinical and hospital partners: Alameda Health Consortium, Kaiser, Sutter/Alta Bates • Emergency planning offices, including the Alameda County Sheriff's Office Communications Strategy • Focus Groups and Community Voice: Because the voices of older adults and those affected by ADRD are critical to planning a high-quality and responsive system that can meet community needs, we are developing plans to conduct focus groups with individuals living with or at risk of ADRD, their caregivers, and other community stakeholders to inform our Alameda County Healthy Brain Initiative Strategic Plan. • Caregivers: Convene Community Listening Sessions with caregivers, promotoras, IHSS providers, and others. • CBOs: With support from Wendy Peterson at the Senior Services Coalition of Alameda County, which has 40+ CBO members, convene Community Forums with groups of CBOs with similar services or populations served. Specifically Asian-serving organizations, • Housing and Legal issues: convene direct service case managers in multiple programs who are encountering challenges regarding eviction for those with diagnosed or suspected cognitive impairment who may need conservatorship. Share with legal assistance organizations and with SSA Public Guardian/Public Conservator office. • Clinical and Health Care Systems partners: We are coordinating and strategizing about the best approaches to clinical and systems partners, including the Alameda Alameda County Public Health Department Healthy Brain Initiative Community Needs Assessment | Feb. 2024 Page 20 of 20 Health Consortium, a coalition of the federally qualified health centers in the county, the Alameda Alliance for Health, our main Medi-Cal Managed Care Plan, and Alameda Health Systems, which runs our major public hospital, Highland Health Center. We are starting with internal conversations with the Alameda County Health Officer, the HCSA Medical Director, the HCSA Assistant Agency Director over Systems Initiatives, and the ACPHD Quality Improvement and Accreditation team, which oversees the Department’s Community Health Needs Assessment and the Community Health Improvement Plan. We will start with local clinical champions identified by key informants, including physicians at LifeLong/Over 60, Alta Bates, and Asian Health Services. IX. DATA SOURCES To assess the senior services provided in our county, we consulted these sources, as well as local analyses by the Alameda County Health Care Services Agency, the Alameda County Age-Friendly Council, the Alameda County Area Agency on Aging, and the Senior Services Coalition. o Department of Aging Services by County o National Council on Aging Map o Program of All Inclusive Care for the Elderly (PACE) Rates o City and County Older Californians Community Based Services Utilization To assess Alzheimer’s disease and related dementia (ADRD) prevalence, morbidity, and mortality rates in the county, we consulted these sources: o Prevalence Data: Alzheimer's Disease Prevalence Map by County (https://www.axios.com/local/san-francisco/2023/07/31/alzheimers-disease-prevalence- california) and Centers for Medicare and Medicaid Services (https://data.cms.gov/tools/mapping-medicare-disparities-by-population) o Mortality data: CAPE unit, Alameda County Public Health Department, with data from Alameda County Vital Statistics o Emergency Department and Hospitalization data: CAPE unit, Alameda County Public Health Department, with data from Department of Healthcare Access and Information (HCAI) o Alzheimer's Disease Prevalence Map by County Finally, to assess the demographics of the aging population in the county, we consulted these sources: o Population Demographics by County o Increase in 65+ Age Group by County o U.S. Census Bureau o Senior Services Coalition of Alameda County, “It’s 2023, Where are we on addressing the needs of Alameda County seniors?” (Fact sheet). https://seniorservicescoalition.org