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Cheverton & Associates Phone 619.562.4916 Fax 619.562.8450 www.Cheverton.net |
Chicano Federation of San Diego County, Inc.
Senior Services Program
Needs Assessment
Report to the
The
[Abridged For Internet Publication*]
July 2004
* For full unabridged version and attachments, please direct your
request to Chicano Federation of San
Diego County, Inc.
II. Assumptions and
Limitations of the Research
IV. Presentation of the Research
Indicators
of Low-Income Latino Seniors’ Needs
Research-based
Indicators of Need
Profile
of San Diego County Region and Targeted Population
Analysis
of Online Survey Results
Description
of Respondent Agencies
Analysis
of Key Informant Interviews
Existing
Services to Low-Income Latino Seniors.
Needs
and Gaps in Services for Latino Seniors
In July 2001 the Federation applied for a grant from The California Wellness Foundation (TCWF) to support, build capacity of, and evaluate the Federation’s existing senior services, and to conduct a needs and resource assessment of local services for Latino seniors. TCWF awarded the Federation a two-year grant in the amount of $87,500. This report provides information about how the grant was used to meet these stated goals, including an assessment of services currently available to low-income Latino seniors who have cultural and linguistic barriers to accessing services.
The Federation’s proposal to TCWF indicated that a consultant would be hired to conduct the needs assessment and contribute to Federation capacity building by acting as a liaison to the seniors services community. Cheverton & Associates (C&A), a San Diego-based consulting firm with expertise in research, evaluation, needs assessment, program design, grantsmanship, training, and networking, was contracted to perform these tasks, beginning work in February 2004. More information about C&A is available at www.cheverton.net.
In conducting the needs assessment and evaluation, C&A sought answers to questions about:
·
Needs and gaps in services for Latino seniors
considered important by service providers in
· Standards of practice for providing social services support to Latino seniors.
· Promising practices for services to Latino seniors.
· Issues and options related to planning and coordinating more effective services to Latino seniors.
Qualitative and quantitative methods consisted of:
· Face-to-face and telephone interviews.
· Archival review, document analysis, and online research.
· Participant observation of the Federation’s Senior Services Program
· An online survey of service providers.
For the Needs Assessment, Researchers used a combination of
quantitative and qualitative methodologies to obtain information about senior
services for low-income Latino seniors in
To assess service assets for Latino
seniors in San Diego County, to learn more about how others provide services
and their perceptions of gaps in the system of care, and to offer suggestions
for how the Federation can help improve service delivery to its seniors target
population, C&A created and conducted an on-line survey and conducted
interviews with key stakeholders. Tables detailing
responses to each question in the online survey are in Attachment 5.
A total of 61 individuals completed the survey. Due to the small geographic area where most of the population targeted by the Program resides, we decided to open the survey to providers of senior services throughout the county. We learned that problems we identified are similar across all areas of our large and diverse region because substantial populations of poor Latinos are scattered throughout the region. Along with other research presented in this report, the survey results paint a picture of a substantial gap in services for a silent population of low-income elderly Latinos who do not speak English or who may have limited or no social or family support.
Survey responses revealed a clear pattern, as respondents raised the same issues repeatedly in various contexts. Whether discussing needs and gaps in the service delivery system, obstacles to filling gaps, barriers to service access for the target population, or the best ways to improve services and address or eliminate access barriers, respondents sent a consistent and familiar message. Issues associated with meeting the needs of low-income Latino seniors are predictable and unsurprising, and the issues associated with meeting their needs effectively are reasonably consistent with issues identified in research among other age groups that hold traditional Latino cultural values. In compiling, analyzing, and synthesizing survey responses, researchers drew the conclusions below based on themes that emerged from the data:
·
More funding is
needed.
·
Outreach
practices are inadequate to reach the target population in culturally and
linguistically relevant and appropriate ways.
·
Bilingual does
not necessarily equate with bicultural, even among Latinos. We have not adequately prepared Latino youth
to obtain advanced education nor motivated them to develop professional careers
in “helping professions.”
·
Lack of adequate
transportation remains one of the foundational barriers for members of the
low-income Latino community.
·
Individuals see the benefits of interagency and
interdisciplinary collaboration, but organizations have not fully
committed to or adequately invested in collaborative projects and processes.
Researchers conducted 22 face-to-face and phone interviews
with key informants on the subject of services to low-income Latino
seniors. Individuals we interviewed
included experts and leaders in government, private, and nonprofit
organizations. Interview subjects told
us about senior service programs their organizations either operate or support,
how services could be integrated better, how to reach Latino seniors and how to
enhance senior services to low-income Latinos in the
In compiling, analyzing, and synthesizing interviews, online surveys, archival materials, and a research of standards of care and literature, researchers drew the conclusions below about the themes that emerged.
1. The
Federation should increase efforts to aggressively network and collaborate with
other organizations serving seniors in San Diego County, with the aim of
developing, initiating, and spearheading an effective partnership and regional
planning coalition to advocate for Latino seniors and to improve and expand
outreach and direct services to a larger population of culturally and/or
linguistically isolated low-income Latinos in the project target area[*] and
throughout San Diego County. Potential
issues for the coalition to explore arise from the Needs Assessment and include
(but are not limited to):
a) Availability
of funding and collaborative fund-seeking approaches.
b) Lack of Spanish literacy
among non-English-speaking low-income Latinos.
c) Developing
ways to promote careers in the helping professions among young people and
others with bilingual and bicultural skills.
d) Using
existing delivery systems (e.g., social services, I&R services,
healthcare, schools, and other sectors to disseminate needed information about
available services to low-income Latino seniors, their families, caregivers,
and other stakeholders.
2. The
Federation should promote self-sufficiency among the broader population of
culturally and linguistically isolated low-income Latino seniors by building
their capacity, and the capacity of their family members and/or caregivers, to
access and receive benefits for which they are eligible, by developing,
facilitating, and/or sponsoring training classes on available benefits and
application procedures for Social Security, Medicare and Medi-Cal, tax credits,
ways immigration laws may affect eligibility for benefits, etc., as well as
Spanish literacy classes for illiterate Spanish-speakers. Such classes should be conducted in
neighborhood settings easily accessible to seniors and their families, by
culturally competent bilingual trainers selected by the Federation or another
appropriate entity.
3. The
Federation should consider developing an internal information and referral
(I&R) database of services specifically relevant and useful to low-income
Latinos of all age groups, categorized by age group and cross-referenced by
service category. This reference guide
would allow Federation personnel, regardless of program or expertise, to
quickly and efficiently direct any client to culturally competent,
linguistically appropriate services, creating a “no-wrong-door” service
environment that would better serve the Federation’s constituency.
The database would then serve
as the basis for a printed brochure containing referral information for
services typically needed by low-income Latinos. The Federation should seek separate funding
for this project.
4. The
Federation should consider developing written agency-wide standards and
evaluation procedures for both linguistic and cultural competency that are attentive
to the wide variety of traditions and multi-cultural and multi-ethnic origins
of those who constitute the Latino population in
[Deleted from this abridged version.]
[Deleted from this abridged version.]
In this study, C&A used a combination of quantitative and qualitative methodologies. Quantitative research allowed C&A to study local senior service issues raised by providers and other stakeholders using standardized, objective measures. Quantitative methods included the online survey of providers serving seniors, which was distributed as described earlier. C&A also used qualitative methods to compare documents and narratives, including transcripts of face-to-face and phone interviews with key informants;[†] analysis of responses to qualitative survey questions; and analysis of archival materials.
Researchers reviewed websites and archival and additional resource materials, observed the Federation’s Senior Service Program operation, and conducted key informant interviews with 22 local senior service providers, subject matter experts, and other key stakeholders. Copies of the interview questions and the survey instrument used in this study are in Attachments 2 and 3 respectively. We were careful to seek and include input from members of a range of disciplines and sectors that individually and collectively have a significant stake in the outcomes of our region’s senior service programs.
C&A pursued three main branches of inquiry:
· What senior service issues are of paramount interest to those who provide services to Latino seniors?
· How can the Federation help bridge gaps in services for Latino seniors?
· How can the Federation’s Senior Services Program improve in providing services to Latino seniors?
To gain context for our research and to better understand
the Federation’s goals and objectives, C&A thoroughly reviewed and
summarized documents provided by the Federation at the initial project meeting
as well as those provided by the Federation’s Senior Services Program.[‡] Later, additional documents were reviewed
on-site at the Senior Services Program to gain further insights into the
Program and its practices. We also
reviewed and analyzed documents located online and provided by other
organizations, including the Survey of Senior Americans conducted by
Researchers conducted 22 face-to-face and phone interviews with local key informants during April through July 2004. Key informant interviews allowed C&A to gather both information about programs and services, and opinions about senior service issues. Criteria used to identify interview subjects included their:
· Personal knowledge of or involvement in local senior service delivery.
· Personal knowledge of or involvement in local services to Latino seniors in other disciplines.
· Positions as stakeholders in senior services delivery outcomes or services to seniors.
· Identification by C&A research, the Federation, or an interested stakeholder as an important subject matter expert.
We developed general categories of disciplines and sectors from which we believed it would be important to include a sampling of opinion and insight. These included:
· Seniors home assistance programs
· Adult/senior day care programs
· Generalized seniors service providers
· Senior centers
· Hospital programs
· Hospice facilities
· Health services (including mental health) community
· Housing programs
· Nutrition programs
· Information and referral services
· Support groups
· Seniors advocates
· Elected officials
· Latino community
· HHSA Regional Managers for targeted areas
Using each category and research question as stimuli, we developed a preliminary list that expanded over time of potential interview subjects. It quickly became clear that our categories were somewhat arbitrary since many possible key informants had expertise and/or experience that crossed multiple categories … an attribute we viewed as a strength.
To help identify the most appropriate interview candidates, we asked subject matter experts recognized by colleagues as leaders in their fields to suggest names of others knowledgeable in their disciplines. The list of key informants grew as research progressed. Not all potential key informants we contacted were available for an interview.
We developed generic protocols and interview questions for
each category of potential key informants above, and tailored questions
individually for the relevant discipline, category, or key informant. For instance, we developed a set of interview
questions specific to social work experts, then conducted interviews to obtain
their opinions and knowledge about the most pressing senior service issues in
To request and schedule interviews, we contacted potential subjects by phone, fax, and/or e-mail. Some persons we contacted did not respond to our messages, and a few did not consent to be interviewed. A list of persons interviewed, their organizations and contact information is in Attachment 4.
To prepare for interviews, C&A conducted Internet research about interview subjects’ agencies and reviewed information gathered from other key informants. We used this information to modify questions as appropriate or to develop additional specific questions.
Most interviews were conducted by phone and took between 30 and 60 minutes to complete. Some were conducted face-to-face at the key informant’s workplace. A few interviews involved groups. Interview subjects participated voluntarily; in a few cases a supervisor requested that we interview a subordinate more qualified to speak on the topic.
All interviews were conducted in private and audiotape-recorded. Before each interview began, researchers used a prepared script to explain the purpose of the study, answered any general questions, and requested permission to audiotape the interview. Subjects could elect to have the tape recorder turned off at any time during the interview.
We also requested permission to quote the key informants’ comments in our written report. Some interview subjects gave C&A “blanket” permission to quote any comment they made during the interview; others requested the opportunity to review direct quotations before we used them. The latter authorized use of their comments by phone or e-mail, and researchers noted the date and time permission was provided.
C&A had the audiotapes transcribed; then researchers studied transcriptions searching for patterns and themes. We grouped themes that relied on participants’ observations and opinions, and correlated them to archival records.
Researchers attended various meetings and events to further the Federation’s goal of networking with public and private organizations serving seniors, to learn about potential partnership opportunities available to the Federation, and to obtain additional background information for the report. We also used these opportunities to inform meeting participants about the Federation’s Senior Services Program needs assessment project, answer questions, and learn about stakeholder interests, goals, activities, and plans. Meetings included:
· San Diego Council on Aging
·
· San Diego/Imperial County Regional Home Care Council
·
· Long Term Care Integration Project Planning Committee
· Mental Health and Substance Abuse Coalition
·
Older Adult Mental Health Conference, sponsored
by Mental Health Services, Inc. (held at Bahia Hotel,
Cheverton & Associates developed an online survey that we made available to all interested parties. Participants filled out the survey online. Survey questions were designed to capture information identified in the state of work, such as: updated information on issues most important to providers of senior services, efforts and suggestions for collaboration, existing needs and gaps, and more. A copy of the online survey questions is in Attachment 3.
Information about the online survey and a clickable link
from which to access the survey directly was posted on a variety of websites
frequented by those who provide services to seniors such as HHSA AIS and San
Diego ElderCare. We called,
e-mailed, and faxed invitations
to take the survey to approximately 90
Written and online surveys have inherent limitations, such
as respondents’ inability or hesitancy to ask questions of the researchers if
anything is unclear. It is also possible
that respondents may guess at answers they don’t know, rather than taking the
time to look up accurate information.
This issue is discussed further in Limitations. C&A conducted pilot testing to mitigate
respondent confusion, distributing surveys to 5 subjects, including other
researchers, prior to posting it online.
Based on pilot test results and respondent comments, C&A made
revisions for clarity and survey length. The online survey closed
[Deleted from this abridged version.]
[Deleted from this abridged version.]
Statistical indicators of the burgeoning seniors population
through the next half-century due to the aging “Baby-Boom” cohort have been
discussed for several years.[§] Although the over-65 population in all states
will swell,
Diversity amongst
Older Adults with Developmental Disabilities [†††††]
Adults over age 42 with developmental disabilities increased
from 14% to 17% in nearly a decade. The
California Department of Developmental Services (
Recently, the California Commission on Aging examined
concerns confronting seniors and the need for a coordinated cooperative plan
integrating medical, housing, transportation, and other issues in the context
of creating a long term strategic plan for integrated senior care in
Proximity to Mexico, combined the largely unguarded border
running 80 miles through rugged backcountry, makes San Diego County a favored
entry point for smugglers of both illegal drugs and humans, and highly
vulnerable to unceasing waves of worker migration from all parts of Central and
South America and Mexico. Official
population statistics and demographics quoted earlier fail to account for this
“invisible” population of undocumented workers, many of whom arrived in
In the City of
Detailed demographic data on Latino seniors are unavailable
beyond simple population estimates and projections. Breakdowns by income, housing status, and
other indicators such as rates of crime victimization, domestic violence
prevalence, substance abuse, etc. are difficult to extrapolate, partly because
culturally and linguistically isolated low-income Latinos generally access
services at lower rates than other ethnic groups. Nor do they participate in
population-comparable numbers in self-report surveys, such as the Survey of
Older Americans, published by
Many members of our target population do not receive benefits to which they are entitled and care they need to remain healthy and independent for as long as possible. Often they become a financial burden to their families, and sometimes are abandoned by them. This further perpetuates inequities in our system of public benefits, as Anglo seniors with better access to services receive a disproportionate share of available resources. In addition, our target population can become a greater drain on public resources because they fail to receive preventive care or early interventions, resulting in the need for more expensive emergency, intensive, and long-term care when they become ill sooner than those with better access to services.
To assess service assets for Latino
seniors in San Diego County, to learn more about how others provide services
and their perceptions of gaps in the system of care, and to offer suggestions
for how the Federation can help improve service delivery to its seniors target
population, C&A created and conducted an on-line survey and conducted
interviews with key stakeholders. In
this section, we present a summary analysis of online survey results.[‡‡‡‡‡‡‡] Tables detailing responses to each question in the
online survey are in Attachment 5.
C&A directly contacted
approximately 90 organizations and 500 individuals with information about the
survey. We used a “snowball” sampling
technique, in which the individuals and organizations we contacted, drawn from
a variety of sources,[§§§§§§§]
were asked to pass the survey on to colleagues.
A total of 61 individuals completed the survey. Originally, we planned to focus specifically
on providers of services to Latino seniors in the
One survey respondent stated: “
Along with other research presented in this report, survey results paint a picture of a substantial gap in services for a silent population of low-income elderly Latinos who do not speak English or who may have limited or no social or family support. This presents the Federation with a call to action in support of those whose voices are unheard. In the Recommendations section of this report, we make suggestions about ways the Federation might help to address these issues.
Types of services offered: Respondents represented a cross-section of disciplines and programs serving seniors, including information and referral, transportation, nutrition, County Aging and Independence Services (the mandated local Area Agency on Aging), Social Security Administration, Medicare, Medi-Cal, hospitals, family service programs, faith-based programs, and private non-profit programs specifically targeting the general senior population. Fifty-one percent (51%) of respondents said their programs were public (government agencies), 46% private non-profit, and 9% faith-based. Their programs provided a variety of services to seniors including:
Services (in descending order of percent of respondent agencies providing them)
|
Case management (59%) |
Paraprofessional counseling (14%) |
|
Social services (45%) |
Emergency food/clothes/transportation (12%) |
|
Home visiting (36%) |
Home repairs/handyman services (12%) |
|
Transportation (31%) |
Housekeeping (12%) |
|
In-home personal care assistance (29%) |
Primary medical health care (10%) |
|
“Other” health services (24%) |
Housing assistance (9%) |
|
Medi-Cal/Medicare (21%) |
Center-based senior day care (7%) |
|
Congregate meals (19%) |
General Relief (5%) |
|
Licensed mental health services (19%) |
Law enforcement/crime prevention (3%) |
|
Legal services (16%) |
Pet services (adoptions, in-home care, veterinary, etc.) (3%) |
|
Home delivered meals (16%) |
Food Stamps (2%) |
Forty-one percent (41%) of respondents provided services not specifically listed such as information and referral, exercise programs, general senior support services, and help preparing government forms required to obtain benefits. No respondent indicated that his/her agency’s program provided home-based senior day care.
Clients served: Eighty-six percent (86%) of respondents said their programs served seniors in the target communities (City of San Diego south of I-8, east of I-5 and west of 70th Street), with 91% of those programs serving low-income, limited- or non-English speaking Latino seniors. Most respondents said their programs served a mix of ethnicities. Thirty percent (30%) said that more than half of their senior clients identified themselves as Hispanic/Latino; 52% said half or fewer of their clients were Hispanic/Latino (34% said one-quarter or less were Latino); and 17% said their agency did not track ethnic information.
Respondents were fairly evenly split between programs serving more than 1,000 senior clients annually (43%) and programs serving fewer than 1,000 senior clients annually (41%). Fourteen percent (14%) of respondents said their programs served 1,000-2,999 senior clients annually; an equal percentage did not know how many senior clients they served, suggesting a lack of information and data necessary to adequately assess needs of their target populations.
Waiting time for services: Twenty-eight percent (28%) of respondents said a waiting list was not applicable to their program, and 14% had a waiting list. Of those with a waiting list, 40% had more than 100 people on the list, another 40% had 6 to 20 people on their waiting list, and 20% had waiting lists with 50 to 75 people. For two-thirds of the programs, average wait time was 1-60 days, with the remaining one-third split evenly between 3 to 6 months and 6 to 9 months.
Funding: Fifty percent (50%) of respondents were not sure how much funding supported their seniors program. Seventeen percent (17%) said their seniors programs had more than $1 million in funding (all of these were government agencies). All other programs stated their seniors programs had less than $500,000 in annual funding, with 16% having less than $200,000 annually. Programs obtained funding from a variety of sources including State contracts and grants (67%), County contracts and grants (65%), federal contracts and grants (56%), private foundation contracts and grants (44%), private donations (39%), and client fees (26%).
Seventy-seven percent (77%) said they thought funding for low-income Latino seniors programs should be increased now in anticipation of projected population growth.
Overall assets specific to the Central Region mentioned by respondents included:
·
Strong desire
to provide services to seniors.
·
Existence of
multi-service organizations (such as Chicano Federation).
·
Proximity of a
full array of services, many of which are bilingual.
·
Community and
provider willingness to address and meet challenges of demographic change.
·
Many services
for seniors are centered or headquartered in the area.
To obtain a clear picture of low-income Latino seniors’ needs, barriers and obstacles they face in accessing services, and gaps in the system of service delivery available to this population, we posed similar or slightly different questions in various ways, providing opportunities for both multiple-choice and narrative answers. Regardless of question format, responses focused on similar themes.
For example, in Question 11, we asked respondents to describe the challenges their programs experienced in providing services to low-income Latino seniors with limited or no English language skills. Many respondents mentioned that language was a challenge in the sense that they had difficulty finding qualified (educated and experienced) bilingual staff, including professional social workers, physicians, and more. Informing and educating Latino seniors about the need for services was listed as a challenge by several respondents, which suggested a lack of adequate outreach to the target community, and illiteracy among its members. Some discussed culture (including religious beliefs), as a challenge. One respondent stated that agency policies and service delivery practices tended to reflect majority urban culture and to exclude or ignore values more prevalent among minority and rural subgroups, such as poor Latinos with limited or no English language skills.
In Question 21, we presented a list of 43 specific issues common to the general population of seniors and asked respondents to rate each issue for their low-income Latino clients as “No Problem/Doesn’t Apply,” “Minor Problem,” or “Major Problem”. Respondents selected 26 issues as “Major Problems,” shown in the table below, along with the percent of respondents who selected each issue as a major problem.
|
Issues rated as “Major
Problems” |
% of
Respondents |
|
·
Having
enough money to live on |
68% |
|
·
Cultural
barriers to accessing services (distrust, fear of deportation, unwillingness to share
private concerns outside the family, role or gender stereotypes in
traditional culture, etc.) |
67% |
|
·
Understanding
available information about services/benefits |
67% |
|
·
Communicating
with/understanding health care provider |
66% |
|
64% |
|
64% |
|
62% |
|
61% |
|
60% |
|
60% |
|
58% |
|
53% |
|
53% |
|
53% |
|
52% |
|
52% |
|
48% |
|
49% |
|
47% |
|
47% |
|
45% |
|
44% |
|
40% |
|
40% |
|
39% |
|
38% |
In Question 25, we asked respondents to give their professional opinions as service providers about the frequency with which low-income, limited English-speaking or monolingual Spanish-speaking Latino seniors have adequate access to existing senior services. Responses were:
· Always: 4%
· Frequently: 19%
· Sometimes: 35%
· Infrequently: 29%
· Never 0%
· Don’t Know 13%
Barriers to service access: In narrative answers to Question 12, we asked respondents to describe obstacles faced by low-income Latino seniors in obtaining services. Themes that emerged included the following:
Language
Lack of
appropriate language skills is the primary barrier to acquiring information
about available services. Translating
materials into Spanish does not compensate adequately for lack of literacy
among the target population and lack of linguistic competence by service
providers, particularly among professional staff who cannot communicate with
seniors in their own language about diagnoses, treatment plans and outcomes,
how to access resources, self-care, pharmaceuticals and other therapies, legal
issues, and much more.
Culture
Many low-income
Latino seniors lack trust in
To be
accessible, services must be offered in local neighborhoods, the senior’s home,
and other local settings in which the senior feels comfortable. Furthermore, services must be provided by
people the senior respects and trusts, and who understand the senior’s cultural
framework. Regardless of income level or
station in life, Latino seniors who hold traditional cultural values resist
seeking help from anyone outside the family.
They may also feel ashamed if family members, even when absent or
unavailable, do not care for them and see that their needs are met. Consequently, many poor, culturally isolated
Latino seniors may live quietly amid squalid or desperate conditions that would
be unacceptable to others, rather than ask for help. Stigma associated with needing or receiving
physical or mental health care is particularly challenging to overcome.
Outreach
Many culturally
and linguistically isolated, low-come Latino seniors do not receive clear,
accurate, culturally relevant information in their own language about the
complexities and realities of housing, health care, transportation, nutrition,
legal rights and duties, and more. Nor
are they informed about services and benefits available, how to access them,
and potential consequences of receiving services versus not receiving
them. This creates a downward-spiraling
continuum in which seniors do not understand their own needs, fail to make
appropriate decisions, do not receive help they need when they need it, and
eventually enter the system of care when it is too late, a victim of their own
ignorance and a burden on tax dollars.
Illiteracy
Even when
low-income Latinos have access to information about services, lack of education
results in inability to read or write, even in their own language. This makes it difficult or impossible to read
and understand print materials, know what services are available, learn how to
access services, and understand or apply for benefits.
Researcher
note: Although many adult literacy resources exist in
Poverty
Low
socio-economic status; illiteracy; lack of education; and inadequate family,
neighborhood, or other social support systems are risk factors linked to higher
rates of physical and mental health problems, substance abuse, homelessness,
crime, violence, and other problems.
Medicare and Medi-Cal do not pay for all services needed, and low-income
Latino seniors may not have access to adequate health insurance coverage to pay
for services needed. Lack of access to
adequate transportation is typical in poor neighborhoods, and is compounded by
frailty and infirmity linked to aging may make it difficult for seniors to use
existing transportation services.
Coordination/Collaboration,
Funding
As mentioned
under the Culture heading above, alternative systems of service delivery have
not yet been developed. Effective models
exist and organizations may be willing, but leaders may believe they do not
have adequate resources for anything new or different beyond current levels of
service. Developing more bilingual/
bicultural volunteers could help overcome language and cultural barriers. This also would require resources, but could
be a more cost-effective way to move forward until more staffing resources are
available. Policy-makers may lack
commitment to allocating dollars needed to meet the needs of diverse
populations because such groups do not or cannot speak for themselves. Unless or until a strong leadership voice
speaks to decision makers in behalf of Latino seniors, little is likely to
change.
In Question 17, we asked providers to choose factors, which based on their professional experience, they believed limited low-income Latino seniors' ability to access services. Sixty-five percent (65%) of respondents said access is limited by language; 57% said access is limited by transportation; 51% said culture limited access; 41% said existing outreach practices limited access; 39% thought lack of adequate funding limited access; and 35% said that all of the above factors limited service access for low-income non- and limited-English speaking Latino seniors. Eight percent (8%) said additional factors including lack of education also are a limitation, alluding to illiteracy among poor Latinos.
Survey respondents thought the biggest overall service
needs specific to the Central Region target area consisted of:
§
More funding for adequate services.
§
More bilingual and bicultural professional staff.
§
Improved transportation availability.
§
Improved service coordination and integration.
§
More culturally appropriate care management.
§
More support to help seniors maintain their independence,
such as free or low cost in-home respite.
§
Literacy appropriate training programs.
§
Bilingual programmatic information and training.
Language Barriers: Ninety-one percent (91%) of respondents said their programs served low-income Latino seniors with limited or no English language skills. Many offered services in both English and Spanish (98%). Thirty-two percent (32%) cited language barriers as an obstacle to providing services. Some respondents described how their services supported low-income Latino seniors in a culturally sensitive manner because they had bilingual staff. However, others had few or no Spanish speaking staff, and some respondents’ comments suggested that they thought having materials available in Spanish demonstrated that their services met the needs of limited English- and monolingual Spanish-speaking, low-income Latino seniors.
Client illiteracy in both Spanish and English was mentioned often as an access barrier. Inability of clients to write or read, in any language, interfered with their ability to receive information, apply for services or benefits, and care for themselves independently. Forty-one percent (41%) of seniors programs employed fewer than 10 staff, most of whom were not bilingual. Fifty-six percent (56%) of respondents said that their programs needed more bicultural staff. Sixty-six percent (66%) of those who said they had bilingual staff also said they still needed more; they were too few or not always available when needed. Many respondents said bilingual staff might be available at the client intake level, but not at professional or supervisory levels where clients need help to communicate. Respondents also repeatedly mentioned the great need for bilingual professional staff such as RNs, physicians, occupational/physical therapists, psychologists, and social workers with advanced degrees. Inability of many professionals to speak Spanish prevents them from communicating directly and effectively with clients.
Cultural Barriers: Respondents said that some clients had a faith-based reluctance to utilize some services (e.g., hospice and other end-of-life care). They expected their families to take care of all their needs, despite the highly unrealistic nature of this expectation, especially among working poor families struggling to make ends meet. One respondent stated that her agency’s policies and service delivery practices tended to reflect majority urban culture and to exclude or ignore values more prevalent among minority and rural subgroups, such as poor Latinos with limited or no English language skills. Respondents thought educational outreach to the Latino community about certain medical conditions affecting seniors (e.g., Alzheimer’s and other dementias, other mental health issues) was also difficult because of lack of family interest or support and certain cultural stigmas. Respondents reported that some Latino seniors may fear accessing government agency services because they believe they might be reported to immigration services and arrested or deported, or resist because they are too proud to accept “charity.” Others do not or will not access services outside their neighborhoods because of issues such as distrust or lack of transportation. Latino seniors [especially those who do not speak English] often do not seek services at senior centers that do not serve Latinos exclusively.
Outreach and providing information: In various narrative answers, most respondents indicated either directly or indirectly that their programs needed better outreach to elderly Latinos. Of the 44% of respondents who said their programs conduct outreach specifically aimed at non-English speaking and monolingual-Spanish speaking Latino seniors, many stated that staff members regularly attended health fairs and other community events targeting the Latino community. Some distributed written materials translated into Spanish. They said that the best method of outreach was through churches, utilizing native speakers known to the community, holding clinics where numerous Latino seniors live, and by word-of-mouth, one client to another. They agreed that bicultural staff was needed to reach low-income Latino seniors. Some said that more collaboration and coordination among seniors programs is required to adequately reach all in need, particularly those in culturally isolated groups. Others recognized that some seniors may not have the emotional, financial, or cognitive wherewithal to follow-up with referrals, or that they may lack literacy skills necessary for such follow-up.
Although almost one-third (31%) of respondents stated that
50-100% of their senior clients identified themselves as Hispanic/Latino, none
mentioned current program efforts to seek out Latino seniors who had not
requested services to determine their needs and/or intervene in culturally
relevant ways. Although illiteracy was
identified repeatedly as a problem in the target population, no respondent
described special programs to reach Latino seniors who may be illiterate in
Spanish as well as English.
Sixty percent (60%) of respondents said they obtained
information needed to provide referrals to Latino seniors through collaboration
and networking, and 50% said they obtained information from contacts they
developed on their own. It is unclear
whether this was because their agencies did not provide information to help
them learn about resources or because respondents simply preferred to develop
personal contacts they knew they could trust.
Thirty-five percent (35%) said they obtained information from an
internally prepared directory of services, with 27% utilizing
Survey respondents thought the biggest overall barriers or obstacles to filling existing gaps in Central Region services included:
§
Lack of adequate funding
§
Difficulty
with inter-agency cooperation
§
Lack of adequate outreach (getting the word out about services)
§
Inappropriate hiring practices
§
Lack of appropriately qualified staff
§
Lack of volunteers
Respondents replied in narrative form to Question 13 regarding how obstacles to service delivery could be overcome. Most stated that improved outreach was crucial, and many also thought improved cultural competence was needed. Respondents said that providing transportation would help make services more accessible or that making services available at one-stop centers would be effective and certainly more realistic for some frail seniors. Many said that additional funding for their senior programs was necessary to improve services, conduct outreach, and prepare for the increasing size of the aging population.
Respondents declared that programs must go well beyond simply providing translation services and must build rapport within the community they serve. They also suggested that a way to fill the need for more bilingual/bicultural staff would be to utilize the promotora model to serve low-income Latino seniors in their homes, churches, or other settings where seniors are most comfortable. Some suggested providing orientations through community agencies, or providing a centralized phone number to disseminate information.[††††††††]
Many respondents indicated that their agencies were very interested in partnering with Latino-focused organizations to reach the Latino community effectively and deliver relevant messages. One respondent stated that partnering with Latino-focused organizations was often challenging, leading to situations in which agencies with established programs had difficulty reaching Latino seniors with their services. This suggests that cultural barriers may also play a part in ways Latino organizations work together with “majority culture” organizations.
Overall, respondents thought the most effective ways to overcome obstacles and fill gaps in services included:
·
Collaborations
and interagency projects.
·
Developing a
positive presence in the Latino community.
·
Developing
strong relationships between key members of the Latino and majority culture
communities.
·
Identifying and
obtaining more funds.
·
Utilizing
planned outreach programs, including the promotora model.
·
Utilizing
volunteers, including professionals.
Suggestions respondents gave reiterated the need to go where low-income Latino seniors live or congregate to provide culturally sensitive outreach and services at an educational level geared to each individual client. They mentioned that many mental and physical health conditions are preventable or treatable with appropriate information, interventions, and early care, thus avoiding hospitalization, premature nursing home placements, and early death.
In compiling, analyzing, and synthesizing survey responses, researchers drew the conclusions below about the themes that emerged from the data:
· More funding is needed.
· Outreach practices are inadequate to reach the target population in culturally and linguistically relevant and appropriate ways.
· Bilingual does not necessarily equate with bicultural, even among Spanish-speaking Latinos.
· Cultural sensitivity in service delivery remains a goal to be achieved, despite 50 years of legislative mandates, court decisions, and “equal opportunity.”
· We have not adequately prepared Latino youth to obtain advanced education nor motivated them to develop professional careers in “helping professions.”
· Lack of adequate transportation remains one of the foundational barriers for members of the low-income Latino community.
· Individuals see the benefits of interagency and interdisciplinary collaboration, but organizations have not fully committed to or adequately invested in collaborative projects and processes.
We respect the opinions of survey respondents who generously gave their limited time to provide input for this study. We also recognize that personal and institutional filters may focus opinions according to specific agendas. We suggest, therefore, that local findings presented herein may require review in cross-disciplinary, multi-agency settings and in conjunction with research presented in other sections of this report.
Although the survey sample size
was relatively small, we believe respondent agencies represented a good
cross-section of agencies that provide social and health-related services to
low-income
Researchers conducted 22 face-to-face and phone interviews
with key informants on the subject of services to low-income Latino
seniors. Individuals we interviewed
included experts and leaders in government, private, and nonprofit
organizations. Researchers asked
questions designed to elicit their knowledge and opinions about how local
services to low-income Latino seniors could be enhanced or improved, especially
for those with little or no English-language skills. We also asked if low-income Latino seniors
had adequate access to services and for descriptions of obstacles to accessing
services. Interview subjects told us
about senior service programs their organizations either operate or support,
how services could be integrated better, how to reach Latino seniors and how to
enhance senior services to low-income Latinos in the
· Access to Services
· Bilingual/Bicultural staff
· Collaboration and Integrating Services
· Fear of Government and Other Institutions
· Funding
· Low-income Housing
· Low Literacy
· Culture
· Outreach
· Policy
· Residency/Immigration
· Transportation
Most key informants thought their programs made an effort to outreach to low-income Latino seniors, but they also acknowledged that more was needed to reach this growing population. Overall, most key informants thought their agencies were doing a good job with the services they provided to Latino seniors, but acknowledged that more was needed. Several spoke of how collaboratives were working to serve seniors, including Latinos.
Pamela Smith, Director,
Smith said AIS operates a comprehensive call center,
providing resource information and other forms of assistance to seniors and
their families. More than 65 nutrition sites
around
·
Our Lady of Angels Senior Nutrition,
·
·
·
Centro Hispanico,
·
Golden Age Apartments,
· St. Jude’s Nutrition, 3751 Boston Av., 92113 (site of Federation Seniors program)
Other nutrition programs located in the target area appear to serve primarily other ethnic groups. Many nutrition sites also offer socialization, activities, and exercise. Many sites also partner with adult education programs to offer language classes, basic literacy classes,[§§§§§§§§] and computer skills.
Steven Escoboza, President and CEO, Health Care
Association of San Diego and
Escoboza said CHIP is comprised of 30 organizations,
including entities that staff community clinics, nonprofits such as the Lung
and Heart Associations, hospitals, universities, mental health services, and
health plan operators. CHIP provides a
forum for open communication and dialog among service providers regarding the
multiple needs of the senior population.
The collaborative supports lead agencies in their efforts related to
health care and works to bring funding into
Some key informants whose services are located in
Anabel Kuykendall, Aging Programs Specialist II for AIS Outreach and
Education Unit, discussed the countywide Action Networks for seniors. The Action Networks constitute collaborations
where professionals and consumers help develop and support specific projects
that help the older adult and disabled adult population. The South County Action Network, for example,
focused this year on volunteerism and last year on transportation. One
of the goals of the Action Networks steering committee is to ensure that the Latino community is included
through partnership representation from CBOs, non-profits, and consumers.
Viviana Criado, Older Adult Coordinator, County of
San Diego HHSA Mental Health Services Administration (MHSA), related that
translation services help facilitate service delivery to older Latinos
throughout
Rene Santiago, Deputy Director,
Christina Estrada, Patient and Family Services
supervisor, Centro de Salud de San Ysidro (San Ysidro Health Center
[SYHC]), Inc., Social Work Department, described the four clinics her
organization operates. SYHC serve the
very poor, including mostly Latino seniors in the south
Juan Garcia, Information and Referral Specialist
Senior Supervisor,
Janya Bowman, Medi-Cal Program Manager,
Key informants, including social work supervisors, whom we
interviewed at
Key informants acknowledged that barriers exist making it hard for Latino seniors to access services. Rene Santiago believed access to health care is a priority issue for elderly Latinos in terms of both eligibility for benefits and identifying primary care providers and hospitals that are senior-friendly and culturally competent. Santiago also noted that another critical population in need is comprised of uninsured Latinos ages 50-64 [eligibility for most senior services begins at 60] with limited access to health care who experience early onset of chronic health problems resulting from a lifetime of hard labor. Reaching this population with accessible information, and reinforcing education about and monitoring their chronic conditions must be a priority to reduce health care costs and early mortality.
Viviana Criado said increasing access to care is critical because the Latino senior population is already large and constitutes the fastest growing segment of the elderly population in San Diego County. She thought language and lack of education are barriers to accessing services for Latino seniors, and explained how County mental health clinics will soon begin using peer education and counseling to help provide Latino seniors with information and referral services. She saw this model as a way to increase access to mental health care for low-income, uninsured Latino seniors, as well as an opportunity for early intervention before problems become crises.
Sara Barnett is the Project Consultant for County HHSA/AIS Long-Term Care Integration Project (LTCIP). Now in its fifth year of planning and development, LTCIP is a special initiative project to improve the local system of long term care for low-income seniors by integrating medical, health, social, and support services across the continuum of care and across providers to integrate Medicare and Medi-Cal funding. Barnett said she is well aware that Latino seniors have barriers in learning about available services and how to access them, and she made suggestions about ways to overcome these barriers:
Barnett emphasized the importance of staff with bilingual and bicultural skills. She commented that the AIS call center uses bilingual workers to guide callers to services and providers appropriate for Latino seniors, but acknowledged that seniors may not be familiar with the call center phone number. She thought that San Diego is very service rich, but fragmentation and lack of service coordination increases access problems.
Other key informants agreed that Latino seniors are not aware of services available to them. Those we interviewed at County AIS/IHSS saw access as a key issue and thought it was mainly because seniors do not know about the services.
Juan Garcia said that seniors and their families need
to learn how to access services either by calling
Mary Mazyek commented that some of the obstacles to receiving medical services include lack of insurance to cover surgery for cataracts and appropriate medication. For some seniors, she said this may be complicated by immigration issues. Pam Smith said that the cost of prescription drugs is heard over and over as a problem for low-income seniors, regardless of ethnicity. Christina Estrada did not think the new Medicare discount card would impact low-income Latino seniors at all. For one thing, the information is very confusing and it is unclear how the new system will help the population. She would like to see the process simplified. In her experience, enrolling patients using the new system was not easy and she thought patients would have difficulty enrolling on their own.
County AIS/IHSS Social Workers expressed concern for low-income Latino seniors who receive no-cost medications, which subsequently are classified as over-the-counter drugs and consequently not covered by insurance. Seniors then have to pay out of pocket for the same medication. IHSS workers felt there should be more competition in drug sales to force the prices down and that seniors should be reimbursed for their [prescribed] over-the-counter medications.
Christina Estrada said that being next to the border creates a unique dilemma for some low-income Latino seniors. When they become ill, their only family support structure is in Mexico, they may leave the U.S. and fail to receive benefits to which they may be entitled. She thought low-income Latino seniors do not take advantage of available adult day health care services that would allow them to stay in their own homes, because they lack knowledge of the services or prefer family care for cultural reasons. She reiterated that services should be located within local neighborhoods and communities. If seniors have to go very far to access services, they will not utilize them.
Janya Bowman is involved in the Outreach and
Eligibility Subcommittee of the Increasing Access to Health Care
Initiative. The initiative was designed
several years ago to bring the community together with County agencies to consider
Medi-Cal issues and develop ways to increase Medi-Cal enrollment for the
general population. She described a
State program that paid community agencies a $50 incentive for each Medi-Cal
application submitted in an eligible applicant’s behalf. The incentive permitted agencies to use
Certified Applicant Assistors (
Mary Mazyek observed that having more
Spanish-speaking staff on-site resulted in a dramatic increase in
Rene Santiago (General Manager, Central and South HHSA regions) stated that both regions have limited bilingual capacity and absolutely need more highly competent and culturally sensitive translation and interpretation services. Anabel Kuykendall of AIS maintained that the South Region HHSA office has an adequate number of bilingual staff to address Latino seniors’ needs, but acknowledged that there will always be a need for more bilingual staff.
Christina Estrada explained that San Ysidro Health Center has three or four bilingual physicians out of 15 total; they have lost several good bilingual doctors. Currently, RNs, LVNs, and medical assistants provide most translation support for doctors who cannot communicate with their patients. Anabel Kuykendall stated that translation by adult children and grandchildren for monolingual seniors may not always be accurate and some information may not be shared.
Viviana Criado sees language, lack of education, and the lack of services tailored to specific age groups as barriers to accessing services. Criado thought agencies should not rely on interpreters, and should train staff in cultural competence skills to match clinical skills in delivering services to Latinos seniors. She said all County Mental Health Services programs need additional bilingual/bicultural staff. Due to lack of resources, County salaries cannot compete with better paying jobs elsewhere, making it hard for the County to retain qualified staff.
Juan Garcia said
Steven Escoboza believed social workers and health care workers at all levels need more cultural competency training. He pointed out that the California Endowment has provided some agencies with funding for this purpose. He said many health care providers try to provide culturally sensitive services; however, staff needs a higher level of cultural competency training to recognize the many cultural and linguistic needs that exist, so consumers receive the complete array of services they need. He was confident that the 30 CHIP members agree that more cultural competency is needed.
Escoboza also discussed the nurse shortage, and said hospitals are recruiting in Mexico and other countries because insufficient numbers of bilingual/bicultural nurses are being trained here. He said one reason is that U.S. nursing programs do not have enough spaces for everyone interested, and because community colleges and universities generate more revenue by training students in disciplines other than nursing.
Key informants described collaborative efforts, but agreed that barriers to collaboration exist. In general, they thought that more coordination is needed to integrate fragmented services and to encourage agencies to seek funding in partnerships with others that can help provide comprehensive services, needs assessment, technical assistance, support and credibility.
Sara Barnett explained that LTCIP started in 1999 with 50 participants, but is now comprised of over 600 stakeholders from community-based organizations, health plans, physicians, caregivers, consumers, and consumer advocates. They meet monthly to inform each other about available services and to make decisions and recommendations regarding increased collaboration and integration of services. LTCIP is a system-wide effort touching and affecting different constituent groups in different ways. Stakeholders volunteer their time and meet in workgroups to develop broad recommendations to be forwarded to the San Diego County Planning Committee and Advisory Group and, ultimately, to the San Diego County Board of Supervisors.
LTCIP’s vision is to create an improved system of long term care for low-income seniors by integrating medical, health, and social and support services across the continuum of care, and across providers, to integrate Medicare and Medi-Cal funding. Because various seniors programs have different eligibility requirements, assessments, and funding, it is difficult to navigate the system or know where to access services. LTCIP’s mission is to streamline care and offer a continuum of care to seniors, caregivers, and providers, and to enhance communication and linkages between health services and social services. She said an integrated strategy planned for piloting in 2006 involves complementary strategies working side-by-side, including Network of Care, Physician Strategy, and Healthy San Diego Plus.
Mary Mazyek spoke of the Senior Homelessness
Prevention Coalition, which was started as a way to combat the homeless problem
downtown. She suggested development of a
similar coalition of service providers focused specifically on low-income
Latino senior needs. In addition, she
said
Anabel Kuykendall believed joining forces through partnerships and collaborative efforts with agencies and organizations is key to providing information about services to communities. Steven Escoboza suggested that coordination with consumer groups representing seniors’ interests could be strengthened for more consistent collaboration and advocacy for all seniors. He said he believes collaboration reduces redundancy and is more focused on outcomes for services provided. Pam Smith stated that AIS has many staff stationed in the communities they serve to provide integrated services at convenient locations. She agreed that organizations must continually work at improving service integration to increase clients’ access to services.
Steven Escoboza suggested Senior Care Action Network Health Plan as a model of a culturally competent integrated system that provides an array of services that are medically and socially appropriate; he said Kaiser is also moving in that direction. He also acknowledged that these services are for those who can afford insurance. He mentioned one challenge to developing an integrated system for the uninsured: they often obtain their primary medical care at emergency departments.
Juan Garcia explained that one of
Janya Bowman stated that she is involved with collaborative groups that include health plans, hospitals, and community clinics, and which have increased enrollment in Medi-Cal and improved community relations in support of shared goals and initiatives.
Viviana Criado described a County Mental Health
Services partnership with UCSD to provide education to primary care physicians
on early assessment and referral for integrated primary care and mental health
care services. She believed senior
centers lack capability to assist seniors with mental health issues and should
seek funding to add this component. Families
and caregivers also need education about seniors’ mental health issues to help
them assess and seek help for their family members. She pointed out that
Rene Santiago mentioned that collaborative efforts have resulted in better integration of services and coordination across multiple agencies. He saw agencies developing partnerships that share service competencies and strengths. Santiago also acknowledged that barriers exist to collaborative efforts, including turf issues. He observed that some agencies were created during periods of limited access or to fill a specific neglected need, building a political base and community support. Such agencies may find it difficult now to collaborate in ways that could be perceived as departures from the original mission. Also, differences of opinion arise among agencies when prioritizing needs and effective methods to meet those needs.
Christina Estrada stated that San Ysidro Health Center is one of the strongest clinics in the county and growing. High patient volume allows SYHC to maintain a position of community leadership. Recognized by other agencies and clinics, SYHC has been successful as an effective partner in collaborative projects. She also thought, however, that a certain stigma was attached to being part of the San Ysidro border community, making it difficult in some cases to obtain funding. She also believed that services to low-income Latino seniors are fragmented and not well coordinated throughout the county. She believed agencies should make seniors a higher priority and that funding should be available that provides support specifically for seniors. Estrada suggested a directory in English and Spanish based solely on services to low-income Latino seniors as one way to improve service coordination. She thought another approach would be a planning group targeting low-income Latino seniors’ issues, with seniors participating in advocating for their needs.
Key informants noted that for many low-income Latino seniors, distrust and fear of government and government agencies, and of government representatives seen as authority figures, is a major issue that limits access to services. Pam Smith said non-English speakers’ mistrust of government has been a barrier historically. Fear keeps seniors from accessing services and, when troubles arise, they often disappear from the radar screen, magnifying their problems. To address this issue, AIS works through community partners such as CBOs and other service providers.
Anabel Kuykendall noted that AIS, as a government agency, is required to ask for eligibility information. Seniors who fear deportation or other sanctions fail to cooperate and then are unable to receive needed services. She thought many seniors never seek services to begin with, because they anticipate requirements for information, which if provided, they believe may allow the government to persecute them.
Mary Mazyek discussed how
Continued funding for established programs and obtaining new funds to expand services or create new services are constant challenges in serving seniors. Pam Smith said she sees community agencies struggling with budget-cutting issues, especially in the current milieu. Sara Barnett stated that funding for LTCIP planning was received from State, federal, and private entities, but as the fiscal year ends, the status of continued State funding is an open question; LTCIP is waiting to see if the project will be supported in the future. Barnett advocated seeking additional funding opportunities to address Latino seniors’ needs in light of projections that the Hispanic seniors population will almost double in the near future.
Anabel Kuykendall asserted that changes in the funding climate, especially within State agency budgets, require local organizations to work together to find creative ways to continue to provide needed services. Funding cuts impede creation of programs needed for this growing population, so AIS keeps other agencies informed about funding opportunities, to foster collaborative grant-seeking that may help offset other losses.
Viviana Criado saw lack of funding as an obstacle in providing services to low-income Latino seniors because it impacts community outreach efforts. She asserted that County Mental Health Services does not have funding to perform educational outreach. She said everyone in the mental health community is hoping the Mental Health Initiative (Proposition 63[†††††††††]), now on the November ballot in California, will pass making funding available for prevention services, which could include new outreach efforts to underserved communities.
Rene Santiago believed that more funding would help improve outreach through community-based organizations that know and are trusted by community members.
Steven Escoboza said the current budget deficit has negatively affected agencies’ ability to provide health and social services to the community, and that the level of services has declined. He said that CHIP tries to identify funding opportunities and provide support in applying for funds to agencies that may have lost funding because of County cutbacks. In response to a particular RFP, CHIP members conduct discussions and agree upon which member agency is best positioned to lead a collaborative application, reducing or eliminating competition for funds. He thought funders respond more positively when proposals demonstrate a comprehensive multi-disciplinary approach to health care and social issues, rather than trying to weave together disparate approaches from the multitude of existing services in San Diego County.
Christina Estrada talked about the impact of funding cuts on San Ysidro Health Center’s programs, making it almost impossible to provide services other than primary care at no cost. She said funding cuts have prevented some community organizations from supporting SYHC financially as they have in the past, limiting available services even more. Limited funds led to cessation of SYHC’s specialty disciplines. She mentioned the Alzheimer Association’s Dementia Care Network effort to pay for a part-time on-site case manger dedicated to SYHC dementia cases; it will not move forward due to lost funding. In her opinion and experience, the poor are always the ones who suffer from cutbacks. Estrada believed public representatives are not connected to the communities they serve as well as they should be. She thought the public is unprepared for the projected increase in the low-income Latino senior population and, in fact, SYHC is already seeing a need for more services for people age 55 and older.
Juan Garcia stated that
County AIS/IHSS Social Workers would like to see more funding for low-income Latino seniors issues that include adequate low-income housing, transportation services, medical services at no cost, adult day care and recreational services. Of particular concern was the availability of Section 8 housing (funded by U.S. Department of Housing and Urban Development [HUD]) for seniors so they can continue to live independently. They said that they often see abuse of seniors who move in with family. They would like to see programs that offer one-to-one contact by volunteers who would make visits to seniors at home.
Pam Smith was very concerned about cutbacks in HUD funding and support for Section 8 low-income housing for seniors, noting that the waiting list already takes years. But the older adult population is growing, the needs are growing, and it is hard to keep up with the growth rate. She suggested lobbying both at the federal and State levels to create better and more affordable housing. She said that next to transportation, housing is the biggest challenge expressed by seniors. Acknowledging that housing in San Diego is very expensive, she said redevelopment in the Center City area also is pushing out a lot of low-income people.
Rene Santiago stated that his staff needs training on available housing opportunities so that when seniors have to move, they are fully informed about their options. Having seen a number of seniors displaced, he recognized affordable housing as a big issue for seniors, especially with rents increasing tremendously and causing increased financial pressure. He said the need to increase affordable housing for seniors is becoming urgent because San Diego is one of the most expensive places in the nation. He said more low-income affordable housing must be built, and pointed to the MAAC Project’s[‡‡‡‡‡‡‡‡‡] accomplishments in this area. Funding and land availability issues will continue to make this a barrier, requiring a combined effort at city, County, State, and federal levels to address the problem.
Christina Estrada characterized the need for more affordable housing for low-income Latino seniors as “desperate.” She maintained that no new senior affordable housing has been built in 10 to 15 years. This difficulty is compounded by the fact that seniors do not want to leave communities with which they are familiar. She emphasized that strong leadership is needed in this area.
Juan Garcia recognized a significant need for low-income housing, subsidized housing (such as Section 8), and senior housing. He suggested establishing a resource for agencies as opposed to individuals, which would assist agencies in understanding housing issues and guide them through the process of accessing low-income housing for their clients.
Informants saw low literacy skills as another barrier to
accessing services for low-income Latino seniors. Mary Mazyek noted that low-income Latinos
served by
Jim Siler, HHSA Medi-Cal program specialist, stated that his office provides some support to assist people with low literacy levels. They refer to agencies in the community that offer these services. Janya Bowman stated that low literacy impedes Medi-Cal applications since they contain a lot of mandatory reading. County AIS/IHSS Social Workers explained that the terminology used in forms and other materials are a barrier for low-income Latino seniors and suggested using less complicated verbiage for less confusion. They said low-literacy or not, most seniors need “hand-holding” through the social services process.
Many of our key informants told us that Latino seniors’ traditional culture often kept them from obtaining needed services. When coupled with language barriers, Latino seniors find themselves dependent on family and friends for help. But those interviewed also said that family members do not always have the time or knowledge to provide seniors with the help they need.
Sara Barnett said services to the Latino community should be offered in culturally meaningful ways, being sensitive to the culture’s different perspectives on seeking medical or social care. Cultural traditions and values may also determine whether seniors prefer caregiving services in their own home or staying with family members to receive care. Seniors may feel that they should be self-sufficient and are uncomfortable accessing public assistance. Barnett said physicians report that when a doctor uses a translator to impart medical information, some information is lost in translation. Consequently, questions remain unanswered, leaving the patient with feelings of uncertainty or anxiety, and s/he may not receive needed services, perpetuating the cycle. Barnett commented that the Network of Care website has inherent limitations. Although available in Spanish, it is not available to low-income Latino seniors without Internet access. Further, most low-income Latino seniors are unfamiliar with and may actively distrust technology.
County AIS/IHSS Social Workers explained that challenges for low-income Latino seniors include being taken advantage of and coached to make demands by their children, and caregivers who may overpower their wishes. Fraud can also be an issue. Clients do not understand the different programs available and become confused. For many, pride interferes with desire for services, and they are discouraged by all the red tape.
Mary Mazyek believed that some Latino seniors traditionally wait until they have an active medical problem before seeing a doctor. For example, they do not have annual check-ups, blood pressure screening, blood sugar testing, or other preventive tests. She thought this was primarily because they do not realize that not taking preventive measures is high-risk behavior. When living in neighborhoods steeped in Latino culture, they may not have a place to engage in simple dialog that can trigger conversations leading to obtaining information about preventive care.
Rene Santiago said it is common among culturally isolated Latino seniors to have a strong sense of self-sufficiency and, when they experience a tragedy, they resist obtaining help. Reaching out to the diversity of the Latino population is also a challenge because they may come from rural or poor urban settings, each requiring different ways of effectively communicating information. Interacting with and navigating through complicated systems driven by rules and regulations can be frustrating, and seniors may become discouraged when services are not immediately available.
Steven Escoboza noted research has documented that services should be provided in a culturally competent and linguistically appropriate manner to be effective. As a simple example of linguistically appropriate care, he said medication labels must be written in the patient’s primary language for clarity and effective patient compliance with prescribed treatment.
Christina Estrada stated that low-income Latino seniors become fearful when they cannot communicate with agencies not offering appropriate language translation. The struggle causes seniors to give up and get lost in the system. At the same time, Latino seniors typically are not assertive to obtain services because they do not want to “bother” anyone. At San Ysidro Health Center, they try to educate low-income Latino seniors about the system by walking them through the process so they can see it is possible to get help from some programs. They try to help seniors gain confidence and to dispel misinformation received from well-meaning but ignorant friends and other community members.
Estrada felt that seniors on medication need in-home monitoring and support. She cited as an example Project Dulce (Sweet), which assists patients with diabetes management. She believed Latino seniors need education to understand their various illnesses, and they often get help later rather than sooner. Estrada also expressed concern about what she called the dismantling of the traditional family network of support for Latino seniors. She told us that families are now more dispersed in different locations, and seniors say their sons and daughters are too busy and stressed from daily life to be there for them.
Those interviewed described outreach efforts already in place, but admitted that much more must be done to reach this target population. Some organizations have efforts underway.
Pam Smith said those who need services the most are often the hardest to reach. Outreach is a constant effort and multiple approaches are needed. When AIS rolled out its elder abuse campaign, they conducted outreach through newspapers, TV, radio, and direct mail. Smith noted that although Latino populations tend to have large extended families, they are often working poor, struggling to make ends meet. Every effort must be made to reach out and help them to be healthy and self-sufficient.
Sara Barnett explained that part of the LTCIP workplan will be to increase the community’s use and awareness of AIS and its call center, creating a one-stop shop for aging and disability resources. The plan is aimed at all seniors, but includes specific components will identify underserved/underutilizing groups that require targeted outreach, including Latino seniors.
One objective of the LTCIP project is to identify naturally occurring social gathering places where Latino seniors may congregate; these may be different from places where African-American or white seniors would congregate. Bilingual staff will go there to provide outreach and education orally and with culturally sensitive Spanish written materials.
Barnett suggested outreach at festive community events that offer food and health booths as a fun and interactive way to reach seniors, providing them with incentives to attend as well as engaging their interest. Isolated seniors must be reached through either a family member or someone in the community who knows about their problems and how to address them.
Anabel Kuykendall discussed the four AIS Outreach and Education units, one in each County region, to raise awareness of AIS services and linkages for low-income seniors through presentations and community events. Other methods include TV, radio, and mailings. She acknowledged that reaching isolated and homebound seniors requires a collaborative approach of committed individuals. She thought the promotora approach was useful, but felt seniors are not always comfortable with strangers knocking on their door asking them to provide confidential information.
Viviana Criado suggested that outreach using Latino media can be effective; she mentioned that in the past, there existed a monthly radio talk show promoting services.
Rene Santiago thought improvements are needed in informing the emerging and growing Latino senior population about available services. He explained that the County has changed its way of providing services and is now more linked to the community through partnerships. He believed the public should be better informed about these partnerships, and added that improvements are needed in informing and enrolling seniors when they become eligible for programs. He said the best way to do so is through community-based organizations that understand the Latino senior population. Reaching Latino seniors requires a diverse set of strategies and resources, depending on needs and priorities. Creative ideas must be implemented in a variety of settings, including natural congregation points, and utilizing the vast Latino family and social networks to disseminate simple but accurate information. Santiago suggested identifying block leaders and senior leaders, tapping into neighborhoods to disseminate information and promote health resources in the community. He also mentioned Project Dulce and its promotora model as an effective program.
Steven Escoboza related how hospitals conduct a substantial amount of community outreach to the senior population, each providing different types of education programs for seniors and the community at large. It is challenging to identify the support needed to inform seniors about treatment compliance and assist them with prescribed treatments or medication.
Christina Estrada stated that the best way to reach low-income Latino seniors is at community conferences, community events, and senior centers. She thought more isolated seniors could be reached through their community clinics and churches. She also suggested recruiting apartment managers as contacts. San Ysidro Health Center has two mobile units, obtained through funding from First 5 Commission of San Diego County. The vehicles visit apartments, senior housing, and shopping centers to perform health screening and inform community members about services. She believed their home visiting program was the most effective way to reach low-income Latino seniors, but the program was discontinued due to liability issues. Also, she thought one-on-one counseling is very effective, provided bilingual/bicultural staff conduct the sessions. She suggested other effective outreach methods include Spanish language radio, church organizations, and schools.
Juan Garcia felt that consumers do not know how to
use
Garcia felt more people are needed to conduct outreach and provide information to seniors, giving them the resources to get help. He said public service announcements through Spanish language radio and TV have been effective outreach methods. Face-to-face meetings are another effective method in reaching low-income Latino seniors because it personalizes service.
Janya Bowman explained that HHSA provides Medi-Cal training presentations for all seniors in the community who call with a request. If funding was available, she would use the promotora model to go where seniors congregate to give them information and assistance applying for Medi-Cal. County AIS IHSS Social Workers thought effective ways to outreach to low-income Latino seniors include churches, volunteer workers, word-of-mouth, movie theatre ads, and bus bench ads.
Informants thought policies should be changed to made access easier and to increase the resources available to seniors. Noting that the senior population is increasing at exponential rates, most thought policy makers should make changes now rather than waiting for a crisis to build.
Pam Smith stated that advocacy is needed to increase resources for Section 8 housing. She thought such advocacy would be much more powerful if AIS combined its advocacy efforts with other organizations, including Chicano Federation. She believed there should be an effort to work with State and federal legislators and local policymakers to make them aware of the growing need.
Sara Barnett said LTCIP is a project that was developed at the administrative policy-level as people came to realize that the system needed improvement in light of the increasing older population and before crisis was reached. She thought additional issues must be addressed by policies now before the system reaches crisis mode.
Anabel Kuykendall wished that seniors would be more proactive and learn to advocate for themselves in spite of any limitations they may have. She would like to see policy changes regarding residency criteria that results in denial or limitation of services to seniors. She told us that, as a result of the Aging Summit, committees have been established to work specifically on trying to improve the marketing image of aging, and advocate for awareness about the issue of negative media images of older people.
Viviana Criado believed that immigration laws and aspects of acculturation should be examined at the policy level to assist in the process of entry for those who are in the U.S. both legally and illegally. She thought low-income Latino seniors should advocate for their rights and voice what they need and want.
Rene Santiago argued that health services providers for people ages 50-64 should change policies to also include insurance coverage for the Latino elderly population.
Steven Escoboza has advocated in the State Legislature for insurance coverage for the very low-income population. He said some legislative measures are currently languishing in committees. In his opinion, federal Medicare reform does not accomplish enough. The priority should be to focus attention on the very low-income uninsured. He thinks this population needs a champion on the San Diego County Board of Supervisors, one who is willing to advocate on behalf of seniors issues in the face of other Board priorities.
Christina Estrada thought that when policies change, often the new policy information is slow to be disseminated at networking meetings. She would like to see an effort to make information on new policies available more quickly to case managers.
Residency and immigration status are issues that can
severely limit both Latino senior’s motivation to seek services and their
eligibility for those services. Mary
Mazyek told us
Anabel Kuykendall explained that Adult Protective Services residency requirements allow AIS to use only limited resources for non-resident Latino seniors. These resources may include repatriation services, helping a senior return to Mexico. The problem however, is that seniors are either afraid of the government or assume they are not eligible and, therefore, do not attempt to access these services. Christina Estrada related that she has seen some sad situations where health services were denied based on residency issues.
Janya Bowman stated another barrier for low-income Latino seniors is their concern that they may unintentionally acquire “public charge”[**********] status if they avail themselves of services. Bowman has heard repeatedly that people are afraid to apply for Medi-Cal because they feel it is going to impact their ability to become naturalized or gain other legal resident status. HHSA works with and supports advocacy groups such as Consumer Center for Health Education and Advocacy and Legal Aid whose staff attorneys help people understand the public charge issue. Bowman noted that, 99% of the time, public charge is not an issue. At the same time, advocates have to be very careful to present full, truthful information to applicants while simultaneously fostering trust.
Pamela Smith saw transportation as one of the largest gaps in services to low-income seniors. She believed that local officials must be educated about the impact lack of transportation on seniors’ access to services, and decision-makers must be encouraged to allocate funding to fill this need. Sara Barnett said that public transportation is not adequate to meet the needs of seniors. Also, she noted that non-English speaking seniors face even larger difficulties if transportation coordinators cannot communicate with them.
Mary Mazyek described how transportation is a big issue and a challenge. She explained how a senior with no income qualifies for a bus pass. Those with some income, however, must figure the cost of a bus pass into their monthly budgets. Although free transportation may be available through the County’s MTS service, seniors may have difficulty utilizing the service, which requires appointments for transportation and advance planning.
Viviana Criado believed that low-income Latino seniors face a major challenge in accessing care and meeting their needs when they do not have a reliable means of transportation. She argued that there should be more services that will pick up seniors at their doors and deliver them to appointments. Criado thought agencies should also consider the physical limitations of older adults when discussing transportation options (e.g., assessing seniors’ ability to walk distances necessary to access public transportation).
Rene Santiago stated that transportation is becoming more of a challenge as people are moving away from the core centers because of redevelopment and increasing housing prices. County AIS/IHSS Social Workers would like to see medical plans cover transportation when clinics cannot offer transportation services.
Some informants discussed transportation programs their
agencies developed to meet seniors’ needs.
Christina Estrada explained that San Ysidro Health Center
designed its own transportation programs to help seniors access services. The program involved purchasing two
wheelchair-accessible vans and contracting with a taxicab company to provide
transportation to the clinic, a specialist, or emergency department when
needed. Estrada said SYHC also utilizes
MTS, volunteers at senior centers, Project Concern,
Anabel Kuykendall discussed the Lutheran Social Service Caring Neighbor Program, a volunteer driver service with no wheelchair access. Low-income seniors can get rides to doctor appointments and grocery shopping. There is no cost for those meeting low-income eligibility requirements, or $6 round trip for those who do not meet the requirements. She said a recent drive in South Bay focused on increasing the number of volunteers providing alternative transportation services to seniors. MTS Access is limited to picking up a senior at the curb rather than at the door, which may create difficulties for some seniors. AIS obtained a van with wheelchair access on a limited basis. In her experience, Latinos are intimidated about calling for services because they have residency issues. Even when they do call, Latino seniors may not have access to a Spanish-speaking transportation coordinator. She found that Latino seniors may also assume they are not eligible for the service if they have any income at all.
We acknowledge and thank the key informants for their generosity in participating in these interviews. We respect their opinions but also recognize that personal and institutional filters may focus opinions according to specific agendas. Further, some key informants may be reluctant to voice opinions in conflict with organizational philosophies, especially those with legislated obligations and limitations. As with the online survey, we suggest that local findings presented herein may require review in cross-disciplinary, multi-agency settings and in conjunction with research presented in other sections of this report.
We believe the key informants represented a good cross-section of agencies that provide social and I&R services to low-income San Diego County seniors. Although they drew from their experiences in varying fields of expertise and from government, private, and non-profit venues, the topics of concern in serving low-income Latino seniors were the same across the board. This led us to the conclusion that issues associated with meeting the needs of low-income Latino seniors are predictable and unsurprising, and are reasonably consistent with issues identified in research among other traditional Latino age groups.
In compiling, analyzing, and synthesizing interviews, online surveys, archival materials, and a research of standards of care and literature, researchers drew the conclusions below about the themes that emerged. We address these issues in the Recommendations section.
· Low-income Latino seniors need greater access to services.
· Organizations need more bilingual/bicultural staff to effectively serve Latino seniors.
· Organizations serving seniors do not adequately collaborate and integrate services for low-income Latino seniors.
· Low-income Latino seniors may not seek necessary services because of their fear of government institutions and/or immigration issues.
· Inadequate funding to sustain or expand existing senior programs or to establish new senior programs negatively impacts low-income Latino seniors, who may be left out when resources are scarce.
· Lack of affordable housing is a desperate issue among low-income Latinos.
· Illiteracy and low-literacy in Spanish and English creates dependency in low-income Latino seniors since they need others to explain documents, applications etc. to them.
· Traditional cultural values may deter low-income Latino seniors from seeking preventive health care or help outside the family, leading them into lives of isolation until a crisis occurs.
· Coordinated outreach is required across disciplines to inform low-income Latino seniors of their rights and the benefits to which they may be entitled.
· Government policies as well as organizational policies must be changed to allow easier access to health care and other services for low-income Latino seniors, if we are to effect savings over the long term.
· Some low-income Latino seniors are denied benefits or health care based on residency or immigration issues. These issues may also prevent Latino seniors from requesting assistance based on fear that they will be deported.
· Transportation is one of the highest concerns for low-income Latino seniors. Without adequate efficient transportation, they cannot maintain their independence, and become dependent on others for daily existence, as well as in times of crisis.
[Deleted from this abridged version.]
[Deleted from this abridged version.]
[*] The City of San Diego east of I-5, west of 70th Street, south of Interstate 8, and north of the boundary with the City of National City.
[†] A list of key informants interviewed is included in Attachment 4.
[‡] See Materials Reviewed For This Study attached hereto for a complete list of archival documents.
[§] Torres-Gil F. The New Aging: Politics and Change in America. Westport, CT: Auburn House; 1992; Feder J, Komisar H, Niefeld M. Long Term Care in the United States: An Overview. Health Affairs. 2000;19(3):40-56.
[**]
Campbell PR. Population Projections for States - by Age, Sex, Race and
Hispanic Origin: 1995-2025: U.S. Census Bureau: Population Division; 1996.
[††] Lee R, Miller T, Edwards R. The Growth and Aging of California's Population: Demographic and Fiscal Projections, Characteristics and Service Needs. Berkeley, CA: California Policy Research Center; 2003.
[‡‡]O'Hara-Devereaux M, Falcon R, Li J, Kristensen H. Fault Lines in the Shifting Landscape: The Future of Growing Older in California - 2010. Menlo Park, CA: Institute for the Future; November 1999.
[§§] Pastor P, Makuc D, Reuben C, Xia H. Health: Chartbook on Trends in the Health of Americans. Hyattsville, MD: U.S. National Center for Health Statistics; 2002.
[***] Lee R, Miller T, Edwards R. The Growth and Aging of California's Population: Demographic and Fiscal Projections, Characteristics and Service Needs. Berkeley, CA: California Policy Research Center; 2003.
[†††] Ibid.
[‡‡‡] Ibid.
[§§§] Ibid.
[****] U.S. Census. California Population Aged 55 and over by Race and Hispanic Origin. Washington, DC August 2001.
[††††]Lee R, Miller T, Edwards R. The Growth and Aging of California's Population: Demographic and Fiscal Projections, Characteristics and Service Needs. Berkeley, CA: California Policy Research Center; 2003.
[‡‡‡‡] Lee R, Villa V. Cprc Brief #2: Population Aging in California. Berkeley, CA: California Policy Research Center; 2001.
[§§§§] Lee R, Miller T, Edwards R. The Growth and Aging of California's Population: Demographic and Fiscal Projections, Characteristics and Service Needs. Berkeley, CA: California Policy Research Center; 2003.
[*****] Cahill S, South K, Spade J. Outing Aging: Public Policy Issues Affecting Gay, Lesbian, Bisexual and Transgender Elders. Washington, DC: National Gay and Lesbian Task Force; 2000.
[†††††] Department of Developmental Services. Fact Book. 5th Ed. Sacramento, CA: California Health and Human Services; 2002.
[‡‡‡‡‡] Scharlach A. Cprc Brief # 11: Family Caregiving for Older Californians. Berkeley, CA: California Policy Research Institute; 2001.
[§§§§§] Ibid. Coleman B, Pandya S. Fact Sheet: Family Caregiving and Long Term Care. Washington, DC: AARP Public Policy Institute; November 2002.
[******] Coleman B, Pandya S. Fact Sheet: Family Caregiving and Long Term Care. Washington, DC: AARP Public Policy Institute; November 2002.
[††††††] California Commission on Aging. (2003, April 1-2). Statement of Findings Planning/System Design, Prepared for Planning For An Aging California An Invitational Forum. Available at:
www.calaging.org/works/works_system.html.
[‡‡‡‡‡‡] California Commission on Aging. (2003, April 1-2). Statement of Findings Planning/System Design, Prepared for Planning For An Aging California An Invitational Forum. Available at:
www.calaging.org/works/works_system.html.
[§§§§§§] County of San Diego HHSA, 2003.
[*******] San Diego Unified School District statistics, 2004.
[†††††††] The City of San Diego east of I-5, west of 70th Street, south of Interstate 8, and north of the boundary with the City of National City.
[‡‡‡‡‡‡‡] Please note that all totals may not equal 100% due to rounding.
[§§§§§§§] We invited individuals drawn from lists of representatives of seniors home assistance programs, adult/senior day care programs, generalized seniors services providers, seniors centers, hospital programs, hospice facilities, health services (including mental health) community, housing programs, nutrition programs, information and referral services, support groups, seniors advocates, elected officials, Latino community, HHSA Regional Managers for targeted areas, and others.
[********] San Diego Association of Governments, SANDAG, Online Data Warehouse, 2004.
[††††††††]
Although
[‡‡‡‡‡‡‡‡] HHSA is the widely understood abbreviation for County of San Diego Health and Human Services Agency, and is used throughout this document.
[§§§§§§§§] Classes are geared for English-speaking individuals or focus on English as a Second Language.
[*********] Researcher note: Based on demographic data, many low-income Latino “grandparents caring for young children,” although qualified for other benefits, may not be old enough to qualify for seniors services.
[†††††††††] Proposition 63, funded by a 1% tax on taxable personal income over $1 million annually, expands mental health care for children and adults, using programs proven to be effective. It requires strict financial accountability and is supported by nurses, mental health professionals, law enforcement, educators, and others.
[‡‡‡‡‡‡‡‡‡] MAAC Project is a multipurpose social service agency with an emphasis on serving Latinos, headquartered in National City.
[§§§§§§§§§] Researcher note: We
were unable to identify any programs that provide ongoing Spanish literacy
instruction for illiterate Spanish speakers.
Just before this report was completed, we learned that the Mexican
Consulate in San Diego has been working to develop a cadre of trainers for such
classes to be offered at various locations throughout the county.
[**********]
’Public charge’ is a term used in immigration law to describe persons who
cannot support themselves and who depend for income on benefits that provide
cash, such as CalWORKs or Supplemental Security Income (SSI). Depending on immigration status, the
Immigration and Naturalization Service (
