Jarmin Yeh, Institute for Health and Aging at University of California, San Francisco: Making the Future A Better Place to Grow Old

Van Ton-Quinlivan

Hello, I’m Van Ton-Quinlivan, CEO of Futuro Health, welcoming you to WorkforceRx, where I interview leaders and innovators for insights into creating a future-ready workforce.

Eleven thousand people turn sixty-five every day in the US, a pace which is continuing to intensify the challenges of providing adequate care for seniors. We’re going to learn about what this means for the quality of life of the elderly population — especially for those with dementia and their caregivers — from Jarmin Yeh, associate professor in the Institute for Health and Aging in the School of Nursing at University of California, San Francisco.

Jarmin is a sociologist, gerontologist, and researcher in the field of age-friendly cities and leads the Community Action Research in Gerontology labs which encompasses a portfolio of community-engaged and interdisciplinary projects that aim to advance health equity in aging.

Thanks very much for joining us today, Jarmin.

Jarmin Yeh

Thanks for having me.

Van

Well, what are the biggest needs in terms of providing quality of life for seniors who live at home or in community settings, and what do you think is missing?

Jarmin

That’s such a great question. When we talk with older adults, most older adults desire to age in place, which means to age in their home or community regardless of their age, income or ability level. And what some of my research has been interested in looking at is what are the things that are needed to support this desire to age in place?

One of the big things that I look toward is the built environment and the neighborhood. You know, what is accessible in the environment where older adults and their families are living? Can they access their basic needs like food, grocery stores, health care? Is there accessible transportation if they’re unable to drive? Can they get around? Can they run errands? Can they go to the places that they desire?

And related to what I think of as the built environment are there third places…libraries and parks for socializing to meet with others, are the sidewalks smooth or are they missing altogether or are there curb cuts to allow for all sorts of different kinds of mobility for people using walkers, or people who might be in wheelchairs. So that’s one element and I think that the physical environment and the neighborhood environment is just sort of one layer of what it takes to support older adults well in the community.

We know that those who are unable to be mobile are more likely to feel isolated from the things that they want to be involved in and social isolation and loneliness is a growing phenomenon that is certainly very concerning from a public health standpoint. So I think those are just some of the more sort of physical aspects that are needed.

And then certainly I think there are unmet care needs as well. Older adults that need assistance with things like everyday tasks are often unable to find the help that they might need to do those things within their own home — such as chores, cooking, cleaning — and so there’s layers to it.

Van

So with regards to the physical environment, who do you work with to make the changes? Is it city planners, community planners…who’s coming to you to get these insights?

Jarmin

I think all of the above need to be involved or at least have a lens toward thinking about what does it take to create an environment that is quote-unquote age-friendly? The World Health Organization has a big global movement on age-friendly cities and communities.  San Francisco, where I live, is part of this global movement of age-friendly cities and nationally in the United States, AARP backs up this effort through their livability index.  So at these policy levels, people are thinking about what does it take to create environments that are age friendly.

Then locally, city planners, city governments, and then even the citizens themselves all have a role to play in creating neighborhoods that are age friendly for all.  I’ll give you good example. I’m part of a nonprofit organization here in San Francisco called the Community Living Campaign. They often go and do essentially sidewalk audits, street audits of what  needs to be fixed in the built environment. So, they look for cracks in the sidewalk, or uneven pavement because maybe a tree root has breached through, and they’ll photograph it and send it over to city officials so that they’re aware of areas that need to be fixed.

So, I think it really comes from all of us in a lot of ways, but certainly I think it’s important to activate older adults that are living in these environments to be advocates for the kinds of changes that they want to see in their neighborhoods.

Van

And Jarmin, are you seeing that there more communities now asking for this type of advice?

Jarmin

Yeah, I think it shows up in a lot of different ways. One model is called the village model, and that’s where folks come together and create essentially a volunteer membership to support each other to age in place and to age in local environments. This is a very sort of grassroots type model that has now grown nationally, which is pretty exciting. This is an example where people are coming together and saying, “These are our needs. This is how we can mutually support each other.” Then with a collective voice, they can also advocate for policy changes or programmatic changes at a higher level.  So I think that kind of work is really exciting.

In my own work I also try to work directly with older adults through what we call participatory research methods and one of the ways that I do that as a qualitative researcher is that I give them cameras to take images of their life world, of their social and built environments, and those images become really powerful launching points for storytelling and narration about some of their lived experiences, but also what they would like to see changed in their physical and social environments.

Van

So, as you talk about things that people would like to see change, you mentioned this concern about isolation and loneliness, and I know that the US Surgeon General had pointed out the severity of this situation amongst Americans. Tell us more about what is the current state and what are some strategies that can be deployed, especially with the elderly?

Jarmin

I think that there is a big gap between what people desire and what’s in place. And I think that one of the elements of it is what services and programs are not only available but accessible in two ways: physically accessible, meaning is it geographically close enough where one can get to it, especially if they might have mobility limitations; but also accessible from the standpoint of language, being culturally inclusive, and sort of accommodating to the different needs that an older adult may have.

As you mentioned earlier, people with cognitive impairment or who may have trouble with memory, you know, the services will need to be tailored in some way and sometimes that means even transportation and mobility services that pick up older adults from where they live to take them to adult day programs or to doctor’s offices and things like that. So I think that’s one component of it.

The other component that I mentioned earlier is thinking about this idea of built environments and even third places where people sort of naturally might interact with other people. So that diverse mix is I think part of what is really important for thinking about how do we combat social isolation and loneliness. We know that’s not just a phenomenon among older adults. Young people experience a lot of social isolation and loneliness too and miss those moments of organic interaction, mixing and mingling — again, parks are a classic example, libraries are classic example, and some folks even point to public transportation hubs as classic examples — where people from different backgrounds might serendipitously meet each other and that’s where a lot of interaction can happen to help enliven community living.

Van

I read about a great low-cost, or practically no-cost idea, which was a talk bench. Basically, you write ‘Talk Bench’ onto the bench in the park and anybody sitting on it is inviting conversation with any stranger walking by.

Jarmin

Yeah, I think that’s such a lovely idea because you know, we’re all certainly increasingly more tech enabled these days and so people are just focused on their phone instead of maybe chatting with someone. We see that all the time when we look around communities, so I love that idea.

Van

So, given your expertise in the built environment…let’s say if one of the listeners have parents that are aging and they’re thinking about transitioning them into a facility, do you have any practical tips in terms of things to think about with regard to the built environment?

Jarmin

Yeah, I think it just really depends on the person. There’s no kind of one size fits all single solution for everybody. I work with a nonprofit organization here in the Bay Area called At Home with Growing Older, and they’re really about supporting comfort and security within one’s proximate environment. So I would certainly start there with what are the small adaptations that one can make to their living environment that they’re already in because I think that familiarity is not only comforting, but I think provides a sense of security for someone whereas when you relocate them or move them into a different facility then they have to acclimate to a whole new environment…maybe new people, maybe a routine that’s really unfamiliar to them which could be potentially more disruptive until they start to get used to that.

I think providing that level of care though is quite complicated for many people that are growing older as well as their families, which you know is directly related to this topic of caregiving. A lot of family members may or may not have the capacity to provide direct care to their loved one to help them with any sort of activity in the home so that they can maintain their dignity and independence. So then, they’ll have to rely on other caregivers, maybe paid caregivers, direct care workers, other folks to come assist in that way. And so it’s really quite a combination. It’s a bit of the built environment — what are the physical adaptations that we can make to facilitate the living experience — but then the social support too. It could be a caregiver providing some of that assistance that’s needed so that someone doesn’t have to fully relocate until they either want to, they’re ready to, or that’s really the best environment for the level of care that they need.

Van

I’m definitely going to follow up on the discussion around the caregiving workforce, but before we go there, you talked about small adaptations in the home that might be helpful to the individual, but also might be helpful to the family members that provide the care. Could you give us some example what those small adaptations would be or could be?

Jarmin

I often see in my research that people get quite creative with the things that they have in their homes and how they decide that they want to use it. Simple things usually have multiple functions and sometimes for functions that they weren’t even really designed for. I think one example that we often see is people who use walkers put tennis balls on the bottom of them to help them move around. That would be an example of an adaptation that people have made that wasn’t part of the original design, but they’ve sort of jerry-rigged the instruments or the things in their environment that they’re using to make it work for them.

In gerontology, we tend to have a theoretical framework that we think about called person- environment fit. So you either adjust the person in some way or you adjust the environment, but essentially you’re trying to get optimal functioning. That’s how we think about it from a more conceptual standpoint. But in the home, people will do all sorts of creative things, like they’ll hang little hooks on mirrors or on refrigerator doors where they hang extra pairs of reading glasses or something like that. That would be an example of an adaptation where it functionally works for the individual that makes it easier for them to find their glasses when they need to in the kitchen, in the bathroom, wherever, and they just have a pair that’s right there for them.

Van

That makes a lot of sense. Now, you’ve observed in recent years that there have been state-level initiatives to bolster the direct care workforce. Are any of them bearing fruit or can you point to progress happening for any reason?

Jarmin

Here in California, there have been several state level initiatives to train the direct care workforce. These are really caregivers, but they’re sort of paid to provide a certain type of care. And we, as a state, have had a couple of years of really high level training programs for what we call In-Home Supportive Service Caregivers, IHSS, which is a Medicaid funded program.

There was a huge initiative called Career Pathways to train these IHSS caregivers in all sorts of topics — dementia, diabetes, basic care — and I think what was really unique and special about it was these caregivers also received a stipend for their training to honor the time that they were spending to learn these skills, to upskill their abilities to perform better care in the home.

The other big program was CalGrows, which focused on other direct care workers. It’s a similar concept in terms of all sorts of topics that are related to healthcare and social care, but the direct care workforce is so broad in the sense that it could be drivers of transportation programs, could be home care workers, it could be certified nurse assistants. I think that, again, these sort of opportunities for training are pathways to potential career development.

I think that we’re still watching and observing the longer term impacts and benefits of these investments in training, but in my research anyways, which looks more specifically at home care workers, we absolutely know that there is high satisfaction in these trainings, a desire to learn and keep learning through these programs and definitely increase in knowledge and self-confidence in their self-efficacy to provide care to their care recipients.  I think those outcomes in all the data we’ve looked at have been significant post their training experience. Following longitudinally the impact on their care recipients is what we’re working on looking at.

Van

Internally, I’m saying ‘yay’ because actually, Futuro Health has been involved in both of those programs. You might not even know that. We’re delighted to have been of support to the state in both of those programs. Now, Jarmin, what types of organizations do you partner with to improve supportive programming for older adults? I think you highlighted a few, and I’d like to invite you to elaborate.

Jarmin

I definitely work with many community-based organizations. Most of my research is community-engaged, meaning I try to partner with community organizations that directly provide services or supports to older adults in the community in their work. Most of them are also advocacy organizations, and so along with service provision, they are trying to influence policy and advocate for better resources.

I also work with educational type organizations, training organizations. A specific example is one of my projects is with the Center for Caregiver Advancement and they’ve done many of the trainings that we’ve evaluated to look at the impacts that I was just telling you about — the satisfaction with the trainings, and the increases in knowledge and self-efficacy in their ability to provide good care in the community.

Van

And you have a new project going on with Northern California communities aimed at amplifying caregiver voices in rural and underserved areas. Tell us more about that.

Jarmin

I’m really excited. This is a project that is being funded by the California Department of Public Health, and I’m partnering with the Alzheimer’s Association Northern California-  Northern Nevada chapter as well as Plumas District Hospital and several other stakeholder task force members here in Northern California. This project is called C-CARERS, which stands for Centering Caregivers in Alzheimer’s Research on Equity, Services and Supports. The premise is really trying to elevate and amplify the voices of caregivers and hear their experiences to better inform some of the policy decisions or practices that could be implemented to better support their needs to provide good care to their loved ones or the recipients that receive their care.

Van

I would imagine one of the themes that would come from their voices has to do with compensation, which is why it’s so difficult to build the in-home care workforce. I was wondering if you had any thoughts on that.

Jarmin

Yeah, in our work with home care workers, compensation and wages certainly comes up all the time. Many of the IHSS caregivers we work with are also affiliated with their union, which has done an incredible job advocating for wage increases and to protect their labor, which I think is critically important. Certainly in these times of austerity and inflation, it’s very hard for caregivers to make ends meet. Many of them that we have talked with in my research are doing overtime in some ways because they’re a family member who’s providing the care and if the person you’re caring for has soiled their sheets at 3 a.m., you’ve got to change the sheets whether you’re on the clock or off the clock.

So, many of them are doing a lot of extended work beyond probably the hours that they’re officially getting paid to do just by the nature of how caregiving operates. It’s not a job that stops at a certain time of day if you live with the care recipient or you are a family member of that care recipient. So, I think that that’s definitely one piece.

The other piece that we also see, particularly looking at some of the communities in Northern California, is the scarcity in rural areas to have enough of a workforce to meet some of the needs. We hear stories about services not being available in the geographic area, so then people have to move out of a county or move out of their town to get the services that they need, or there’s a shortage of caregivers that are able to help support the local population.

Trying to think really creatively about how to bolster the workforce in some of the rural regions of the state is a huge challenge, but I think it speaks to a couple of different things happening at the societal level.

Van

If I were to give you a magic wand where you can put in some solutions based on the themes that you heard through this project, what would be some solutions that you would advocate to be put in place?

Jarmin

That’s such a good question. I mean, I feel like more resources altogether is absolutely needed. As you know, there are major threats right now at the federal and the state level to the funding that supports home and community based services such as funding to Medicaid that directly will impact older adults that need long term services and supports that will impact them and their families.

And so a magic wand would, for one, be more money. But I think, too, restructuring our social contract with each other as a society.  You know, all of us are always strapped for time, but just having the luxury of time to spend with each other, to dwell, to talk, to hang out – as you were saying, the Talk Bench —  the challenge is oftentimes we’re running from one thing to the next, but to have that sort of time built in as part of our cultural norm seems like a great way for us to reconnect with each other as a society and for multiple generations and people with different backgrounds to maybe be able to spend a little bit more time with each other to build that solidarity.

Van

Let me ask you one question around Alzheimer’s. As the rate of Alzheimer’s disease keeps climbing, I’m curious to learn about a project that you have that offers training for in-home dementia caregivers and studies the impact of that on health system. Tell us more about that.

Jarmin

That’s a project that I’m really excited about. It’s with the Center for Caregiver Advancement and it is a training program for in-home supportive services caregivers. We know about one in nine older adults will have dementia and that prevalence is going to grow as our population ages, so preparing the home care workforce to recognize the signs and symptoms of dementia in their care recipients is a big part of it.  We launched this training  just before the COVID-19 pandemic. It was intended to be an in-person training, and then very quickly we had to turn it into a virtual and remote training.  I think in some ways, very luckily so, because it allowed us to sort of scale our reach in a way that we couldn’t do when it was an in-person training.

The caregivers go through ten weeks of training and from our evaluation, their dimension knowledge has increased significantly,  their self-efficacy to recognize the signs and symptoms of dementia in their care recipient and their confidence in finding services in the community for their care recipient have also significantly increased. So, that’s an exciting program where we can certainly see that being spread to other places. California is so diverse and so we did this training in English, Spanish, Cantonese and Mandarin as well. There are so many other languages and communities that would benefit from a training like this, so it would be incredible to see it go further beyond the counties that we’ve been able to reach so far.

Van

Would you know an example of a sign or symptom for dementia that most people don’t realize is associated with Alzheimer, for example?

Jarmin

I think forgetting certain words or people’s names, confusion, and sometimes agitation can be a sign or a symptom of dementia. I think one of the biggest misconceptions is that dementia is a normal part of aging, so to separate the normal trajectory of aging from dementia becomes a really important piece of recognizing the signs and symptoms of it and understanding how to appropriately respond.

I think we still live in a world where there’s a lot of fear and stigma around dementia, so there could be denial or as I mentioned, just sort of assumptions that that’s just the part of the normal part of aging. It’s not. So, just more recognition of that at a broad level is a beginning point.

And going back to what we were talking about in terms of training care workers — or anyone really in the community in the service area that might interact with older adults — having them recognize the general signs and symptoms of Alzheimer’s or dementia could also really better support older adults in the community, too. It could be a bus driver, it could be a shopkeeper that might be interacting with an older adult and they might manifest some early signs and instead of sort of getting frustrated or irritable with the person if they have certain signs and symptoms, recognizing that and understanding how to patiently work with them…I think would be such a beautiful world. We would have a very age-friendly, dementia-friendly community if we had that recognition.

Van

So, let’s wrap up by giving you an opportunity to let us know what makes you most optimistic about the future of care, especially for our aging population.

Jarmin

I think a lot of things.  When I think about aging, like, we’re all aging and to me, it’s really a very future-oriented thing. It’s about how to improve the world for our own future. One of the things that excites me is just more recognition of aging issues across all sectors. We have some excellent examples of narrative change that I see in movies, in television shows, in the public realm. People are starting to recognize the intergenerational aspects of aging so that there’s more solidarity around aging issues. So, I think that’s one piece of it.

The other piece that excites me is the bipartisan recognition that we will need to support an aging society because there isn’t a political side to it. What works well for older adults should theoretically work well for all of us because, if we can be so lucky, we will all be old and we all live in families where there are multi-generations all involved. And so it’s really sort of collective intelligence to think creatively about what does it look like to live in a world that embraces aging as part of the life course instead of a part of our life to avoid or to stave off in some way, but to really sort of see it more holistically.

Van
Thank you very much, Jarmin, for being with us today and sharing a lot of the projects that you’re working on. It’s super interesting.

Jarmin

Thank you for having me.

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.