Fit for Life

by Nancy Johnson

November 22, 2013
in Monthly

Local seniors benefit from a variety of wellness programs.

When North Bay health care providers talk about senior wellness programs, they often start with statistics. For example, they’ll cite the percentage of patients in the North Bay insured under Medicare, the federal program that provides health insurance for people over the age of 65. Nationally, the average is 13.2 percent, but in the North Bay, it’s much higher—anywhere from 16 percent to 33.8 percent.

They’ll frame today’s health care challenges in terms of the numbers “three, four and 50”: Three behaviors (physical inactivity, poor diet and smoking) cause the four diseases (Type II diabetes, lung disease, heart disease and cancer) that lead to 50 percent of deaths in the North Bay. Similar numbers bear out nationally as well.

They’ll mention that beginning January 1, 2011, more than 10,000 baby boomers per day have reached the age of 65—a trend that will continue until 2030.

Finally, they’ll cite research showing how a small strategic investment in disease prevention could result in significant savings in U.S. health care costs. For example, the nonprofit Trust For America’s Health concluded in a 2008 report that a return of $5.60 could be expected for every $1 in proven, community-based prevention programs. Medicare alone could save $5 billion annually.

North Bay health providers have understood the economic value of investing in prevention-oriented senior wellness programs for decades. Now, many are revamping or expanding these programs to address the new economic and care delivery models and to help 21st century seniors not only live longer, but also live better.

“Senior wellness is much more than fall prevention classes,” says Todd Finnemore, a geropsychologist at Petaluma Health Center. “It’s also about building rich relationships among seniors and their families, friends and care providers to support a healthy, engaged lifestyle.”

Exercising safely

The onsite senior fitness center at Sonoma Valley Hospital (SVH) isn’t big, and it doesn’t boast flashy equipment. You’re more likely to see orthopedic shoes and polo shirts than six-pack abs and bare midriffs, and you’re more likely to hear chit-chat and a Glenn Miller tune than weightlifter grunts or the screech of an electric guitar.

But for Janice Crow and her workout buddies, the slow pace and relaxed ambiance of Sonoma Valley Hospital’s onsite fitness center is just what the doctor ordered. “It’s much more congenial than other gyms,” says Crow, who started working out at SVH 15 years ago. “We can access the same types of machines without the blaring music and crowds of other gyms.”

Not long ago, a doctor’s referral was required to work out at this gym and another at SVH’s physical therapy center off Highway 12. Now, gym hours are offered as part of membership in an expanded senior wellness program that SVH launched in 2012. For a monthly fee of $50 per person, anyone in the community who’s 55 or older can join, no doctor’s note needed. Membership includes access to both gyms, a screening by a physical therapist t determine limitations and a personalized exercise program designed by a recreational therapist, a wide range of fitness classes and a monthly newsletter with tips and member profiles.

Dawn Kuwahara, RN, SVH’s director of personal services, helped design the program in conjunction with a three-year strategic plan spearheaded by SVH CEO Kelly Mather. In an effort to better serve the high number of seniors in the hospital’s district, Kuwahara and her team transformed an existing cardiac rehabilitation program into the membership-based wellness program, started a monthly healthy aging workshop series that’s open to the public and free of charge, and are partnering with ParkPoint fitness club to offer biometric screening to all members of the district regardless of age. In January 2014, SVH will introduce an “aches and pains” clinic designed to help seniors prevent injury.

“Many of our wellness program members are more frail than the seniors you’d see at the local gym,” explains Kuwahara. “People come in with walkers or on oxygen, and we show them how to exercise safely. Our trained physical therapists look at each member’s balance, strength and cardiovascular fitness, and then create an individualized program that’s medically appropriate.”

The experience of Katie and Ted Malecki, who retired to Sonoma from the Midwest, exemplifies the value of SVH’s approach with seniors. When Katie started at the gym in April 2013, she could exercise for only two minutes on the treadmill and two minutes on the step machine; five months later, she had advanced to 20 minutes on the treadmill (at a faster pace) and 30 minutes on the step machine. Ted says he’s noticed that consistent exercise helps stabilize his diabetes. “My blood sugar numbers are off if I miss a day or two at the gym,” he says. Based on his initial evaluation by the center’s physical therapist, he started with a 30-minute workout on the stationary bike. “The physical therapist told me to give it six months and then move up. I don’t know if I’m looking forward to it, but I’ll do it.”

Most of the program’s members gain as much from the social interaction with others as their workouts steps on the treadmill. “Our members share their life stories and often times bring their families,” says Kuwahara, whose passion for the program is apparent. “It’s all about improving health. We want to get people back to where they can do the things they love.”

Nurturing the spirit

Recognizing that seniors need to exercise their bodies and nurture their spirits, North Bay health providers offer a wide array of classes that help older patients stay mentally balanced. These include health education workshops on how to manage stress and support groups on addiction awareness. For some seniors, however, these activities aren’t enough to boost their mood. That’s where St. Joseph Health Sonoma County outpatient behavioral health services program comes in.

“Depression affects elderly people more than any other age group,” explains Program Manager Peggy Ledner-Spaulding, LCSW. “Up to 15 percent of independent older adults and more than 25 percent of nursing home residents suffer from this illness.”

A number of factors can cause depression, anxiety and mood instability in elders. These include hormonal changes, disrupted sleep or major illnesses like diabetes or strokes; certain medications, such as those used to treat high blood pressure and arthritis; and emotional trauma caused when lifetime partners and friends become ill, debilitated or pass away. Fears over financial security, frustration over losing one’s driver’s license or longtime home, and the sadness that comes with increased isolation can also lead to depression.

Mental health disorders in seniors are often misdiagnosed because some common symptoms—confusion, apathy or memory loss—mimic those of dementia and Alzheimer’s disease. Often, depression and anxiety manifest themselves in unexplainable chronic pain or accidents and injuries that send seniors to the doctor’s office or the emergency room.

Says Ledner-Spaulding, “Our department helps seniors get appropriate care without being admitted to the hospital, because, especially for seniors, a hospital stay weakens the immune system and puts a person at risk of developing other illnesses.”

The St. Joseph program offers the structure and services at-risk seniors need to recover. Some patients enter the program after hospitalization or on the advice of a physician. Others recognize the need for help and “self-refer” or join on the recommendation of loved ones or caregivers. No matter how they’ve been introduced to the program, all participants find trained staff and an environment that’s safe and supportive.

Patients receive an initial evaluation by a licensed clinician and a psychiatrist, and then attend three-hour sessions, three mornings per week until they’ve recovered. Ledner-Spaulding and her colleagues take a two-pronged approach in their work with patients. The first involves prescribing medication to address chemical imbalances in the brain, including loss of serotonin, that lead to mental health disorders. The second revolves around education and patient empowerment.

“We teach coping skills and behavioral techniques to help patients manage their stress and anxiety,” says Ledner-Spaulding. “We help them design a plan for avoiding isolation and for introducing more pleasurable activities into their lives. We coach patients on how to do healthy grief work, as well as on how sleep, diet and exercise can contribute to recovery.”

Growing national awareness and acceptance of mental health challenges has translated into more males joining the program and less stigma among male and female seniors overall. The program supports two groups—one for adults 18 to 64 and one for seniors ages 55 and older—which gives Ledner-Spaulding flexibility in placing older adults where they feel most comfortable.

“Our program balances education and the medical aspects with fun activities that are also therapeutic,” explains Ledner-Spaulding. “Most of our patients feel they can’t be honest with their emotions and don’t want to start crying while at their local senior center. But they find out quickly that it’s not only OK to cry here, it’s healing. We offer safety and support as well as a lot of tissue.”

Wellness and primary care

Step into Petaluma Health Center’s (PHC) two year-old facility on North McDowell Boulevard, and you immediately feel a sense of well-being. On the walls, photographs taken by PHC staff depict smiling children and dramatic nature scenes. Rays of sun filter in from skylights, and floor-to-ceiling windows allow visitors a peek at the staff-tended garden, whose bounty is shared willingly with anyone who comes through PHC’s doors.

The positive energy in PHC’s physical space mirrors the organization’s mission to provide quality health care with access for all in southern Sonoma County. Many of PHC’s 20,000 patients are impoverished and at risk of serious illness. PHC is a federally qualified health center (FQHC) and therefore eligible to receive special reimbursement rates under private and public insurance plans. That means PHC can offer its services on a sliding scale to patients who are uninsured or underinsured, including seniors whose health care costs exceed their benefits from Medicare and/or private insurance.

As a primary care provider, not a hospital, PHC is particularly motivated to prevent disease, rather than let it take hold and treat the consequences. PHC Wellness Manager Luke Entrup echoes the sentiments of other North Bay leaders when he states, “prevention is where health care is today and where it will continue to be.” PHC invests in preventive measures like biometric screenings and also offers a comprehensive wellness program that incorporates fitness and health education classes, support groups and alternative healing therapies like acupuncture.

“Many of the challenges our seniors face are related to chronic diseases,” says Entrup. “Our wellness program empowers them to make informed decisions and lead healthier lives.”

PHC has implemented shared medical visits to deliver primary care and health education in a convenient format for patients. It currently has 15 types of shared medical visits, many of which are appropriate for seniors. These shared medical visits combine one-on-one medical attention with group processing and health education focused on empowering patients to make positive changes in their lives. During or after these sessions, clients have the opportunity to discuss health-related concerns, request prescription refills or lab services and receive preventive care like flu shots or simple screenings. At the same time, PHC staff has the opportunity to check in with at-risk patients and make follow-up appointments and referrals to ancillary services. After the medical visit and group processing, patients experience education on topics ranging from chronic disease to obesity prevention to stress reduction. The combination of one-on-one attention from a clinician and peer education in a group deepens the wellness experience and helps empower change.

Another important aspect of PHC’s wellness department is its nutrition department. Many patients interact with a nutritionist during a shared medical visit, and every patient can schedule a private, 30-minute consultation with a member of the nutrition team. PHC recently launched a capital campaign to build a demonstration kitchen on its main site and has already partnered with local farms as part of its pediatric obesity prevention program. Entrup sees a similar partnership aimed at PHC’s senior patients. The demonstration kitchen will let PHC’s nutrition department show seniors how to make healthy, affordable meals with farm-to-table produce as well as items from grocery stores.

“Our wellness program and primary care visits provide integrated care delivery for seniors,” says Entrup. “It’s not just seeing a primary care physician or internist, but also having coordination of care across all disciplines, including mental health and social work, to ensure our seniors’ health and well-being.”

Tech + people = wellness

Kaiser Permanente sets a national standard for wellness programs, and for good reason.

“Kaiser Permanente has been a prepaid health plan from its inception in 1945,” explains Janet Franklin, health promotion service director at Kaiser Permanente San Rafael Medical Center. “A focus on prevention and wellness is in our DNA. We are always looking for ways to keep our members healthy.”

KP’s strategy around senior wellness combines tried and true methods, like healthy living classes and age-related disease screenings, with modern twists that reflect changing attitudes and new research. KP senior members can choose from health education courses on senior-friendly topics like bladder control, insomnia and fall prevention; programs for depression, chronic pain and grief; and fitness activities such as tai chi, yoga and Pilates, which boost mental and physical health.

“We’re sensitive to the needs of our seniors,” says Franklin. “Our movement classes are healing and restorative to ensure our senior members can participate safely. Many of our health education programs are offered during the day because we know a lot of seniors don’t like to drive in the dark.”

KP has also mastered the art of prevention and early intervention in illnesses that hit seniors particularly hard. For example, in recent years, KP has undertaken aggressive campaigns to encourage all its members—especially seniors—to get a flu shot. In September, patients receive a post card alerting them of the need for flu shots; those who haven’t come in by November receive follow-up mailings and phone calls.

Another disease prevention success story involves KP’s colorectal cancer screening program. Starting at age 50, members receive a home test kit in the mail on their birthday each year. KP includes simple instructions and pre-paid postage to make the screenings easy to complete and return, which helps members avoid undergoing more invasive procedures that might not be necessary.

A robust technology infrastructure enables KP to deliver wellness services to its 9.1 million members in eight states and Washington, D.C., in ways that are effective and extremely personalized. The most outward-facing example of this is KP.org , where members can communicate via email with their personal physician, check lab results, refill prescriptions and even access online health education classes and coaching. In October 2013, Kaiser Permanente rolled out its video appointments program, which lets members interact with care providers through video conferencing technology. Both KP.org and the video conferencing options are particularly valuable for seniors who have trouble traveling to in-person appointments, as well as for caregivers and/or adult children who’ve been authorized to participate in KP.org and video conferencing on behalf of the member. “More than 70 percent of members in Marin and Petaluma actively use KP.org ,” explains Franklin. “Seniors tend to use our online services more than our younger members.”

Less visible are KP’s data analysis capabilities, which let the organization conduct its powerful outreach campaigns and respond quickly to health improvement opportunities. For example, Kaiser regularly monitors Beer’s Criteria list (maintained by the American Geriatrics Society identifying medications that may be inappropriate for use by the elderly). Technology is used to identify at-risk members and send an alert and a spreadsheet of alternative medications to those members’ individual physicians.

Physicians and their staff play a central role in KP’s senior wellness strategy. They’ll review the day’s schedule to better accommodate the needs of senior members. During appointments, they can easily tap into the computer system and recommend health education classes and other wellness programs that address issues their senior patients might be facing.

Because much of their practice involves caring for seniors, KP North Bay facilities are set up with special equipment (including extra-long shoe horns) to better serve a population with visual, hearing and mobility challenges. KP staff members are experts in spotting signs of mental or physical decline during appointments.

“Changes in hygiene and stories of forgetting important items sound alarm bells that my senior patients might be more fragile than they’re willing to admit,” says David Conant, M.D., chief of adult and family medicine at Kaiser Permanente San Rafael Medical Center. “I can quickly send out a care management team to the member’s home to assess the situation and arrange help. We want our senior members to get the right care so they don’t end up in the hospital.”

End-of-life wellness

The health care providers in this article all offer workshops on creating an advance care directive, a legal document that names a power of attorney for health care decisions and specifies a person’s wishes in the event of a medical emergency and after death. How does planning for one’s potential decline fit into local wellness programs?

“It’s important to complete an advance directive when there’s no medical crisis, when the conversation isn’t emotionally charged,” explains Margaret Marquez, M.D., the director of palliative care at Kaiser Permanente’s Santa Rosa Medical Group. “It puts our seniors’ minds at ease to know they have their affairs in order and, if at any time they’re unable to speak for themselves, they have a document and an agent who knows their wishes.”

Dr. Marquez co-teaches an advance health care directive class with Santa Rosa attorney Janice Sternfeld, who volunteers her time. The course is free, open to the public and held once per month. Classes such as this one—as well as support groups and workshops focused on the challenges of disease and debility—can offer seniors and their loved ones a new perspective on declining function, as well as a renewed dedication for living.

“As we age, we may slow down a bit, but that doesn’t mean we can’t live well and thrive,” says Dr. Marquez. “Discussing our goals of care strengthens our bonds and opens communications with our loved ones. What a wonderful gift to give our family and ourselves.”