Dr. Sarita Mohanty, President & CEO of The SCAN Foundation: Collaborative Solutions to Support Aging Well

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development, and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Addressing disparities in access to healthcare and social services based on race, income, zip code, and other factors is a big enough challenge, but it is an even bigger, tougher climb to make progress on that front for older Americans because those inequities tend to compound as we age.

On today’s podcast, we’re going to learn much more about the barriers to older adults getting the support they need to age well — and what is being done to provide that support — from Dr. Sarita Mohanty, president and CEO of The Scan Foundation, a nonprofit working to connect public policy and private sector innovation to accelerate social change.

Dr. Mohanty has had many years of experience in leadership positions in care coordination, health management, and public health insurance. She is currently an associate professor at the Kaiser Permanente Bernard J. Tyson School of Medicine and a practicing internal medicine physician. Earlier this year, she was named to the Forbes 50 over 50 list.

Thanks so much for joining us today, Sarita.

Dr. Sarita Mohanty: I am so thrilled to be here today. Thank you so much. Thank you so much for inviting me.

Van: Well, we’re glad to have you, and I would love for you to get started by sharing an overview of The Scan Foundation. How are you working to achieve the mission of people aging well at home and in their communities?

Dr. Mohanty: Absolutely. So, I am fortunate to be part of The Scan Foundation, serving as the president and CEO. I have been with the organization almost three years now. We are an independent public charity focused on all of us aging well with purpose. That is really our vision statement because our current aging infrastructure does not serve all Americans equitably. We need policies, we need private sector investments and community support that will really help enable an equitable system.

Our work at The SCAN Foundation is really focused on what we call our priority populations, which are persons of color, individuals from lower incomes — particularly those at or below the 400% federal population — and then those living in what we call underrepresented geographies such as rural settings, health deserts.

Our mission is really to ignite bold and equitable solutions that advance the way people can age well in home and community…innovation, scalable solutions that address those critical barriers and risks that these particular priority populations are facing — from healthcare to financial security and housing — and even by-products such as biases in data collection and application and more. So, that’s really what The Scan Foundation is all about.

Van: Ooh, I love that phrase: ignite bold and equitable solutions. Before we deep dive into the topics that you mentioned, help us, Sarita, understand the magnitude of the issue. We hear all kinds of numbers about the aging of America and its current and future impacts in all areas of society. What are some facts about this demographic that stand out to you and that you think everyone should care about?

Dr. Mohanty:  So, really, when we think about California — which is where a lot of our work resides, but we also work nationally — what’s striking is that this population as a whole is not only aging, but becoming more racially and ethnically diverse. We know that by 2030, one in four Californians will be older adults and by 2034, the United States will comprise more older adults than children. Also, people of color will make up nearly half of the nation’s older adult population in 2060. The most significant growth there is really in the older Hispanic adult populations.

We are thinking about planning for the future. You know, as a philanthropic organization, we want to ensure that services are culturally sensitive, equitable, and again, responsive to the needs of this older adult population. So, that’s really something to understand and be aware of as a society.

The other thing, not a big surprise, but the number of older adults experiencing chronic conditions and disability will also increase.  According to the Centers for Disease Control, six in ten US adults experience a chronic condition. More than 70% of Americans sixty-five and older will need some sort of long-term services and support. That could be helping with their activities of daily living, getting them to appointments, helping with eating and bathing…those type of things. Half turning sixty-five today will need that kind of high level of help. So, we have to be thinking about that. In addition, one in seven of all older adults will need help with everyday activities for five or more years. Those are some of the statistics that we think we just need to be aware of.

The last thing I’ll just say is about affording aging. This has become more challenging with the rising cost of housing and increased cost of living, and that’s going to lead to barriers in being able to age well in your home and community. Of the unhoused adults age fifty and older in California, 44% are experiencing homelessness for the first time. So, there’s a lot of over-representation in the homelessness rates.  Older Black Californians — this is a staggering statistic — are five times more likely to become homeless than their white counterparts.

Van: Well, those are striking statistics and clearly indicate we’re not aging well, as you’ve laid out. So, you mentioned planning services. California has a master plan for aging that touches on housing, health, equity, inclusion, and caregiving, as well as financial security, all relating back to the topics that you’ve mentioned. What’s your assessment on how well that is being implemented and what state policy changes are still needed?

Dr. Mohanty: We call it the Multi-Sector Plan for Aging Across the United States. In California, it is called the Master Plan for Aging.  I will use the acronym MPA for short. This is a blueprint. This is a way for a state like California to say, what are the key priorities to help people age well with purpose, so they don’t have to deal with a fragmented system? How can we have a more coordinated system that really reflects the needs and wants of older adults? So that’s really the emphasis of an MPA. We’re still in the early stages of the implementation — we’re in year three of this ten-year plan — but I think there’s several kind of positive outcomes we should note.

One is that one of the biggest things that came out of the planning for the MPA was this sustained cross-sector effort. What do I mean by that? Thankfully, the MPA has initiated a lot of cross-sector relationships and trust building as a result of a collaborative effort. So, you have advocacy organizations; you have a lot of trust-building organizations, including disability; you’ve got private sector; you’ve got public sector; you have philanthropy; you have other community stakeholders, academia, health plans, all coming together to say, okay, how do we think about this plan? That includes coming together, data collection, aggregation,  to inform and plan and monitor progress. So, that’s really one positive outcome, I would say, is that sustained cross-sector relationship network that the MPA has afforded.

Second, we’ve expanded access to Medi-Cal coverage in California through this work and this involvement of the MPA constituents. We’ve had historic investments in older adult behavioral health services. We have an increase in the supplementary payment grant, SSP, for people on SSI, which is the Supplemental Security Income. That provides additional income to nearly 560,000 low-income older adults. That’s a really important step in support of older adults.

What is still needed? Some of the key priorities of the MPA as we move forward is that we have to embed equity and diversity in every step of the MPA. We have to sharpen our focus — that has been a key driver and emphasis — but how do we do that? We have to think about every initiative, every investment, every policy change in terms of is it making inequities worse? And how are we going to make sure that we are addressing lower income communities of color? CDA, the California Department of Aging, is creating an equity index for MPA implementation to help with that policy decision making. So that’s one.

The second one is that the state has to take action to build a home care system that works for all Californians. When we think about older adults, one area that is a big gap is this group called the forgotten middle. This is the population that is unlikely to qualify for Medi-Cal, but still does not have the sufficient resources to pay for housing and care options that they need and want. So that is an area of focus. We’ve got to make sure that they have resources and the supports availed to them, otherwise, they’re going to have to spend down their assets to qualify for Medicaid and then get those services. So that’s another piece.

Then the third thing is just about improving financial security and addressing homelessness. People don’t have enough savings to take care of themselves in home and community, and then they often have to go to institutions and most people do not want that.

Van: That’s a complex laundry list, and we really appreciate that The SCAN Foundation is there to provide advocacy and keep all the stakeholders on task. I was wondering from a workforce lens…accompanying the trend of the growing sixty-five plus population, isn’t there also a proportionally shrinking population of the adults who can provide care to them? How do you think about the workforce issues associated with aging well?

Dr. Mohanty: Yeah, this is a real challenge for us as a society. When we reflect back on the statistics I mentioned about a growing aging population, there’s a growing demand for long-term services and supports, and there is a clear shortage of direct care workers to meet that demand. That is the challenge. Paid caregivers contribute to the society in really important ways. Their work is some of the most physically demanding and mentally taxing, as you know, Van, and they perform at minimum wage at all hours of the day.

I think one of the things that’s needed with these jobs is what we call professionalization. We need to be able to recognize the criticality of these roles, and there has to be payment and supports attached to those paid caregivers to be able to do this really important work. We also can’t forget that many of these workers are unpaid family caregivers, caregiving in their time off. They’re unable to save for their own retirement and their long-term needs. So, what are they going to do as they’re aging when oftentimes they’re having to support their loved ones? This gets into the realm of things like financial security that I mentioned…that we have to work not only on the financial security of those that are in their later years of life, but start early and really start to think about ways and supports on savings for younger generations so they can plan as they get older.

Van: Speaking about payments to caregivers, including the family members who provide free care, are you seeing any path forward or any promising practices here or in any other state or country, for that matter?

Dr. Mohanty:  So, some of the things that we’re seeing and we’re evaluating with the state and monitoring in California, but also across the country, is going back to this group called the forgotten middle, which is that bucket of older adults that don’t have long-term care or long term services and supports available to them. Are there ways for an opt-in or a buy-in or even a payroll tax? You know, the state of Washington has a payroll tax where you can have some of that savings available to help you when you need services in your home and community.  There’s obviously a huge financial risk as a state to do that, and what we’re recognizing, is that even something like a payroll tax is not going to cover all the costs when a long-term care facility is going to cost you over $100,000 a year.

That is some of the analysis that is going on right now. On the caregiving side, I know there’s been a lot of emphasis on a caregiver tax, or tax credit. But I think actuarially, a lot of people are looking at how sustainable are these credits, these buy-ins, and payroll taxes. So, more to come. I should say the state of California is in that process. They have a long-term care committee that is doing some analyses right now. We should be seeing the results of that, hopefully, by mid-2024.

Van: Now, share for us what’s being done and needs to be done to help older residents in geographically underserved areas, Sarita.

Dr. Mohanty: That’s one of the priority populations for the SCAN Foundation. We firmly believe that if we improve the aging experience for older adults with lower incomes, older people of color, and older residents of underserved communities, we will improve it for everyone. Rural communities are a critical part of that because I think most can recognize that when you live in rural settings, there’s data that suggests that they have less access to primary care and certainly specialty care. Oftentimes they drive miles on end and if they don’t have transportation, how do they get to their services for specialty care in a timely way? These are kind of some of the things that we’re working on.

One example I want to mention about rural supports is that we, the SCAN Foundation, have partnered with what we’re calling the California Advocacy Network — which includes the California Collaborative of Long-Term Services and Supports, and nearly twenty regional coalitions — to advance important dialogue around the development of we’re calling local MPAs.

When it comes to why this is important for rural regions to be engaged in their local MPAs, all communities — urban, suburban, rural — have to be supported by an MPA. And what we’re finding is that there are some important areas of need that these rural MPA stakeholders are identifying. Things like, I cannot get to an appointment in a timely way; I can’t get in to see a primary care provider in my rural community for a month; healthy food is not readily available to me. There’s a lot of things like that.

These coalitions are identifying these issues and then they’re actually even advocating at a policy level, saying, okay, who do I talk to in my local jurisdiction? Who do I need to talk to, to say these need to be addressed? We’re working on those right now. I think we have funded three county-level regional coalitions in California representing Butte, Glen, Kings, Riverside, San Bernardino, Shasta, and Tulare counties to co-create a rural MPA. So, those are some of the things that I think it’s important for rural regions to be engaged in this process.

Van: With respect to the learnings from structuring these local MPAs, are there playbooks that you would recommend to other states? Or has this strategy incorporated some learnings from other states? What are some of the best practices you’d like to point to?

Dr. Mohanty: We actually readily share playbooks. We are one philanthropic organization supporting this but there’s many others who are involved. If you reach out to us, we could direct you to our website. We have access to those playbooks, the local playbooks. There’s many that have done some really remarkable work on the creation of these playbooks. It’s addressing how do we think about access to services and transportation and things that are really crucial for their communities.

The other thing is that we have supported the Center for Healthcare Strategies, with other philanthropic organizations, to actually convene and provide technical assistance to other states who are interested in creating their own MPA, whether it’s at the state level and then ultimately even at the local level. We’re definitely giving back. This is not just a California effort. This is something that we want to see scaled. We would love to see every state in the United States have an MPA multi-sector plan for aging. Happy to share that. Any information we can provide to this audience, we’d be happy to do so.

Van: So, as MPAs get together and these stakeholders deliberate on access to services and equitable services, what is the assumption in terms of who should be paying to support older Americans in aging well?

Dr. Mohanty: This is a very complex question to answer, as you probably know. I think a lot of people recognize, or at least most can see, that the financing, the whole administration of programs is fragmented, and it’s quite siloed, actually. Services range from federal supports, state supports, supports offered by local communities, there’s philanthropy, there’s private sector. I firmly believe society has a vested interest, quite honestly, in supporting older adults, given that they significantly contribute to the communities throughout their lives. Therefore, I think it’s important for various stakeholders — including governments, community, families, everyone —  to work together to ensure these adequate supports for older Americans.

So, I guess the answer to your question is complex. We have Social Security, we have Medicare, we have Medicaid, we have pensions, we have private health insurance, we can go into those funding sources. But there’s a confusion. There’s a vast confusion among beneficiaries, among older adults and families, and there’s a lot of frustration. There’s a lot of blame shifting, even, regarding who is ultimately responsible.

One of the things we are hoping to do as a foundation is to better demonstrate how complex this web of supports is. To say, like, okay, let’s lay it out on the table. It is complex. Can we identify the potential touch points and better understand who is and who should be responsible? We’re not there yet. I don’t think we have the answer to your question. But our role is to engage cross-sector leaders in research, convenings, policy solutions that start to address some of this complexity and better center aging adults in this work. We need to say to them, okay, what do you understand, what don’t you understand, and how do we help you navigate this complex array of funding sources better?

I welcome ideas and thoughts on this because this is a journey that, like I said, it’s not one entity at this point.

Van: Well, my takeaway in hearing you explain the situation is that there’s probably not enough resources to go around, so how do you make the resources that exist to be additive and braided so that they’re not siloed, right?

Dr. Mohanty: Yeah. We have to have braided solutions.

Van: Absolutely, absolutely. You previously spoke about the in-home direct care workforce and the need to professionalize that. I know the California Department Aging has grants in order to provide trainings and incentives for workers to stay in their job after doing the training — I know that because Futuro Health is one of the partners there — but I’d love to give you another opportunity to talk about any further workforce needs that are out there to accomplish your mission in terms of home care or related services.

Dr. Mohanty: We touched on the unpaid caregivers, the family caregivers, recognizing that the supports they’re going to need is critical — financially, physically, mentally, emotionally.  As we even think about Medicare, Medicare Advantage plans, working with older adults…they’re recognizing that this is not just about the older adult, it’s about the caregiver. So, let’s talk about the family caregivers, I think that’s critical.

I think on the unpaid caregiving side, the gaps are wages, and making sure that they’re getting the same recognition and reward for the hard work that they’re doing, and then the supports. They need to have all their access to healthcare. Especially in a state like California, where affordability is a challenge, a lot of people are leaving this workforce because it’s not financially feasible.

I’m a physician, and I actually still do some clinical practice and what I’m also seeing is the challenge around people leaving the licensed workforce. For example, most people are not going into primary care after medical school and a lot of people are leaving primary care or shortening their percentage of time in it, because they are burnt out or they’re doing more tasks than they are actually doing the clinical work that they sometimes want to do…charting and things like that.

One thing I’d like to call out, which I think is interesting, promising, and a little scary is the role of artificial intelligence to help support workers — whether it’s nurses, physician assistants, nurse practitioners, or physicians — to help them lessen the burden of the tasks so that they can do the work or the scope of practice. It’s already a huge topic of conversation.

The last thing I would just say is the community health worker model. I’m a big proponent, as are many others, of those with lived experience, those that reside in the community, helping to support, in this case, older adults where they are and where they want to be. You’ll see that there’s a lot of new incentives. Medicaid is starting to support or cover community health workers, or health plans are hiring community health workers, but that also has to be recognized as a professional service. So, those are some of the areas I think we’re seeing emerging. A lot of good data already suggests that models like community health workers are really critical, but we have to address the burnout and the pipeline. I know you’re working on that. A lot of pipeline development has to continue in our efforts, collectively.

Van: Well, speaking about data, part of The Scan Foundation’s focus is on data collection and analysis. Frankly, that could be sort of the grounding for conversations between disparate stakeholders. So, tell us more about what you’re doing on the data front to make an impact.

Dr. Mohanty: Data is incredibly powerful. We know that. Yet what we’re seeing, unfortunately, is that aging and health policies and systems at both the national and state level remain fragmented and do not reflect the needs and preferences of older adults. It’s still happening, in particular, in our priority populations. Both qualitative and quantitative data are critical to develop effective solutions. Data has to be disaggregated by population: we’ve got to look at dual eligibles, we’ve got to look at that forgotten middle, we’ve got to look at it by race and ethnicity, and we have to center the person’s perspective in all of this. That’s sometimes hard to do in quantitative work.

Now, I will say there’s a few things The SCAN Foundation has done on the quantitative side. We have supported the AARP Public Policy Institute’s Long-term Services and Supports Scorecard, which measures state performance on providing what we call high-quality care for older adults, people with disabilities, and family caregivers. That’s been a great advocacy tool for moving the needle on supporting more family caregivers, rebalancing state Medicaid funding from institutional services to more community-based services, et cetera. So, that’s one piece.

Another example is we’re working with the Medicare Office of Innovation and Integration Department in California, and they’ve actually used data to survey older adults to improve the state’s understanding of its Medicare population and those that are near income eligibility for Medi-Cal. How do we start to work with those folks? How do we think about that forgotten middle? Now, I will say that individual experiences, attitudes, and behaviors is just difficult to capture quantitatively, and so we are actually bringing on a whole array of work at the SCAN Foundation to highlight the lived experiences.

We actually have just recently partnered with an organization called the Public Policy Lab. They are establishing a research pool of older adults from diverse geographies across the United States, focusing on persons of color, lower income, and those in the rural areas. Those researchers are embedding themselves in the community, and they’re conducting in-person interviews with each older adult participant on topics ranging from models of care and financing, technology and financial security. We’re going to get some critical insights, some personas, and some real lived experience that should help us understand the needs and wants of older adults.

We are doing a lot of work on health equity. We’re going to actually fund three California-based organizations in 2024 that are ECO Groups — Equity, Community Organizing Groups of older adults and local stakeholders, really demonstrating diverse perspectives, and they’re going to basically drive the planning and solutions for those inequities in their communities.

So, lived experience, that is my take-home. We can’t drive change with just quantitative data, I would say.

Van: The stories that they tell will be really powerful.

Dr. Mohanty: Very powerful, yes.

Van: Bring life to the data.

Dr. Mohanty: Exactly.

Van: So let’s end with a future of care conversation. If we were to invite Sarita to have a clean slate, how would you craft a future of care for the aging that you would like?

Dr. Mohanty: (laughs) I think first and foremost, you know, I go back to that we are a fragmented system of care. We lack the care coordination that we need in our systems and we don’t have enough of a seamless focus on the individual. If I had that clean slate, I would say we’ve got to have a system where we have visibility and navigation to all the supports out there.

One of the things that the state of California is doing as part of the MPA work is trying to create what they’re calling a ‘no-wrong-door approach.’ By way of explanation, let’s say my mother needs a service. I can go somewhere on a platform and somebody will tell me, here are the five resources you could go to, or if you need more help, go to this location. That’s what’s missing right now. Or even things like, I don’t know what Medicare Advantage plan I should go to or I don’t know what Medicare even covers. A lot of people think Medicare covers long-term care. It only covers 100 days of institutional care. That’s it. So, there’s a lot of misconception. How do we start to break down that misconception?

For me, we need a seamless navigation portal and approach that makes it simple and easy for everyone to go to. Right now, there’s a lot of different platforms and portals, and I think people are still struggling with that. So, that’s one.

The other thing is making sure that we address the housing and the financial security crisis. I think for us, that’s about we as a society starting earlier in our planning about what we need to age well. It’s not even just for the older adult, but even for the younger generations. What do I need to save to have what I need when I get older?

If I had a clean slate, I would say we would have a seamless approach, path and supports to avert people having to lose their home and be on the streets because we’re seeing more of it in this population.

Finally, I will just say that technology, as scary as it is for some, is going fast and furious and we have to be on top of how AI and machine learning is going to make care more seamless. I’m excited about the possibilities as long as we do it in an equitable way.

Van: Well, we learned a huge amount from having you spend time with us today. Thank you very much, Dr. Mohanty, for joining us and deciphering all the complexities of aging and healthcare in America.

Dr. Mohanty: Thank you for the opportunity. It’s been a real pleasure and it’s great to connect with you. Thank you.

Van: I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.