In the rural upstate town of Canajoharie, New York (population 3,800), hard on the Eerie Canal, an elderly couple in their nineties lives deep in farm country, dozens of miles from the nearest healthcare facility. Mrs. Cormac*, 93, requires regular dialysis for kidney failure, and she and her husband need ongoing help with the basic activities of daily living. Because of the distance to their home, it's difficult for an agency to send a home health aide to the Cormacs. Their granddaughter, who lives upstairs in the two-family house, has been caring for them, but she has a full-time job and can't afford to take any more time away than she already does.
Their story is all too common in rural America, a part of the country that is aging rapidly and now has a higher concentration of residents age 65+ than the nation's urban and suburban communities. At the same time, social, human and healthcare resources to support aging in place are few and far between in these communities. Many rural elders own their own homes, but those homes can be isolated, in disrepair and difficult to reach, far from the shops, pharmacies, doctor's offices and hospitals they need to stay healthy and functioning.
Yet this is a way of living that many rural seniors are deeply attached to--which is why Managed Long Term Care (MLTC) health plans are developing ways to provide this portion of the aging population with the same type of care coordination services that are being employed to support elderly Americans in other parts of the country.
"We always have in our minds that this is the life they've chosen," says my colleague Jim Riesel, regional director of market development for VNSNY CHOICE Health Plans, which serves the elderly population in rural communities in upstate New York as well as in the New York City metropolitan area. "For folks who live in remote, rural areas, the appeal is that they have their own space. They love their land: It's tangible, something they can touch and feel."
I wrote recently about Managed Long Term Care (MLTC) health plans and how, through comprehensive team-based care management, they're helping to keep even the sickest elderly patients stable and comfortable at home, resulting in lower healthcare costs and greater quality of and access to care. Almost all members of MLTC plans are eligible for nursing home care, but surveys show that the vast majority would rather live at home--so we bring the care to them, no matter the level of need or the medical complexity.
As I noted earlier, rural regions offer special challenges in this regard. Metropolitan areas, whatever their size--from New York City to smaller cities like Troy or Buffalo--offer a critical mass of people and concentrated resources that lend themselves to supporting aging in place. Shops, senior centers, doctor's offices and hospitals tend to be close by. Skilled nurses and home heath aides can get around on public transportation and serve multiple clients in a day--sometimes in the same building. There is public housing for seniors, offering health and support services on the premises, and other government and community services are near at hand as well.
In a place like Canajoharie, however--which has just 80 residents per square mile, compared with nearly 4,500 in Albany and some 28,000 in New York City--there are unique challenges to meeting the complex needs of fragile elders. Many, like the Cormacs, need daily care but live too far from a town center for a home health aide to come out regularly. For care managers, the logistical challenges layer one upon the next: Mrs. E, for example, suffers from congestive heart failure and is on oxygen. When she has to make the nearly hour-long drive to see her local dentist, the transportation, waiting and appointment can take up the better part of the day, which means her care manager has to be sure she has enough oxygen to leave the house for that long. There are similar issues with Mr. T, a diabetic whose food intake must be managed when he spends several hours out of the house getting to a podiatry appointment. Factor the area's not-infrequent blizzards into the mix, and you begin to grasp the extent of the challenges.
Solving Challenges, Big and Small
It takes creative problem-solving, a comprehensive look at healthcare, and wide-ranging collaborations to come up with solutions for these rural-dwelling elders who hold fast to their independence, yet also suffer from multiple chronic health problems, live far from resources, and need consistent care to age safely in their own homes.
Sometimes, the solution can ingeniously simple. Take this situation: A fragile elder living thirty miles from anywhere needs a hot meal every day, but Meals on Wheels has a difficult time making the daily drive. The solution: The agency delivers seven frozen meals once a week--and ensures that members have the capabilities to prepare the food.
Sometimes, the solutions are more complex and still evolving. One of MLTC's most-used benefits, home health aide services, continues to pose a challenge in rural counties, where the small pool of aides must own cars and drive considerable distances to their clients. The Eddy, a health care organization that offers a continuum of services for upstate New York seniors, will work with the members, families and community resources to find other means of assistance for a seventy-year-old resident of rural Saratoga County who has multiple health concerns, including an amputated arm, and lives with his 96-year-old mother. "We call every day and check in on them," says Ann Marie Moran, The Eddy's RN Manager. "But they live more than thirty miles from the nearest agency, and it's extremely challenging to get aides out there to him and his mother."
For the time being, The Cormacs are hiring their granddaughter and compensating her for her caregiving services, which means she can limit her outside work to part time and continue helping her grandmother with twice-daily dialysis and assistance with medications, shopping and other daily tasks.
The Power of Partnership
Collaboration is the key to building better systems of care for the fragile MLTC population. Health and social care organizations must work closely together, combining their resources, infrastructure and expertise, and sharing best practices and innovative approaches. VNSNY CHOICE work with The Eddy, among other upstate agencies, because no one knows better than they do what's required to help residents grow old safely in the rural Saratoga, Montgomery and Fulton Counties. They bring a trove of local knowledge, from the resources that are available in these counties to the literal lay of the land.
Our agency collaborates with them to provide the infrastructure, technology and expertise needed to deliver managed long term care at scale. For instance, we use quality data from the Uniform Assessment System (UAS) to drive our care management, producing evidence-based information that helps secure the reimbursements needed to care for people with complex physical and psychosocial issues. We share this expertise with upstate agencies, for example, to help them better identify elders they serve who are suffering from depression--a diagnosis that can then enable effective treatment.
"They may have thought someone was depressed before," notes Jim, "but they didn't know it. People only got service if they cried loud enough. Now, agencies are getting answers through the UAS, including high quality data that clearly shows when people they serve are feeling lonely or depressed. As a result, they can now do something to creatively combat it."
Jim, who himself comes from a family of upstate farmers, deeply understands the appeal of living independently in a place you've called home for decades, and sometimes even generations. "For someone who lives 25 miles away on top of a giant hill and needs a home health aide--or who lives in a 40-year-old mobile home that leaks--would it be safer and easier for them if they moved into different housing? Absolutely," he says. "Are we the ones to dictate where they live? Absolutely not. It's up to us to meet them where they are."
*The family's name has been changed to protect privacy