Community Needs Assessment to Inform a Geriatric Clinic in Washoe County, Nevada

Transcription

1 Community Needs Assessment to Inform a Geriatric Clinic in Washoe County, Nevada October 2014 Sanford Center for Aging University of Nevada, Reno

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3 Community Needs Assessment to Inform a Geriatric Clinic in Washoe County Zebbedia G. Gibb, MA Peter Reed, PhD, MPH Sanford Center for Aging University of Nevada, Reno Division of Health Sciences October 2014 dhs.unr.edu/aging

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5 Purpose The Sanford Center for Aging is actively engaged in planning and launching a new set of geriatric clinical services to support elders in Washoe County and across Northern Nevada, including a clinic to be housed at the Sanford Center. Critical to this development process is establishing a clear and complete understanding of the state of elder (i.e., individuals aged 65+) health and well-being needs, community needs, resources and assets. This comprehensive Community Needs Assessment will serve as a guiding document to inform decision making regarding the most relevant set of services to be offered by the Clinic. Through a collaborative process, the Operational Planning Committee for the Clinic established the following vision and mission for the Clinic, with a central goal of offering affordable services that enable all elders to have a voice in their own healthcare experience and enable them to remain in the positive, supportive environment of their choosing for the longest possible time, promoting independence, health, quality of life and overall well-being. Vision: All elders in Northern Nevada have access to comprehensive geriatric services. Mission: To offer geriatric clinical services that utilize a whole-person, interdisciplinary approach to care, promoting the psychosocial and physical well-being of each individual. Ultimately, all services and supports offered by the Clinic will be built on a set of foundational values and will reflect community needs, as detailed in this Community Needs Assessment. These values include: Whole Person Interdisciplinary Approach: Assessment, planning, referral and navigation services should embrace all available disciplinary perspectives to consider the entire person, including physical and psychological well-being, as well as the strength of their social support network and resources. Elder Driven Partnerships: Services provided should be driven by and centered around the client in a genuine partnership with the entire care and support team. Cultural Humility: Services provided by the clinic should be reflective of client cultural values, ensuring all services and supports are offered in a manner consistent with the client s cultural needs and preferences. Experiential Learning: The clinic will serve as an educational center for both the current and future providers, allowing for the development of skills necessary for working within an interdisciplinary clinic providing whole-person approaches to care. Knowledge Generation: Through various research activities, the clinic will support all disciplines represented across the University to further the knowledge base regarding the aging experience and appropriate supports and services. iii

6 Executive Summary This needs assessment attempts to explore the possible challenges that elders living in Washoe County will face, as well as what challenges the county will face in providing them services. Currently, elders make up approximately 14% (58,216) of the total population (431,143) and this number is expected to increase within the next 10 years by approximately 32%, making the elder population the fastest growing population segment in the county. The majority of elders in Washoe County are between the ages of 65 and 74 and report at least a minimal level of physical frailty, with the level of frailty increasing as age increases. As indicated by the data contained in this report, elders in Washoe County face increasing medical costs at the same time that their income drops by approximately 24%. Most elders report having had some form of medical insurance during their adult life, although this number has decreased by approximately 2.2% since 2010 and does not ensure utilization of preventative services. The rate of health care coverage increases once elders turn 65 with Medicare eligibility, a national health insurance program that covers in-patient hospital services and limited outpatient expenses. Only a small percent (30%) of Medicare enrollees in Washoe County have Medicare Part C or Medigap policies designed to help cover other health care costs (e.g., deductibles or co-insurance fees) not covered under the overall program. This may leave elders without access to affordable preventative services and screenings that may help to reduce overall frailty, decreasing the ability of the elder to maintain a high quality of life and remain in the positive, supportive environment of their choosing. Elders also face the development of multiple chronic conditions, sometimes requiring significant coordination between service providers. Treatment of multiple conditions is complicated due to the interaction of different treatment plans as well as the development of side effects that may limit physical and social activities. Early identification of chronic conditions can significantly increase the efficacy of milder treatment options, allowing the elder to remain outside of long-term care placement. Early identification also allows for the elder to make decisions regarding their plan of treatment before the condition worsens and requires more advanced forms of treatment that may reduce their cognitive abilities. Along with increasing physical and cognitive concerns, elders also face increased social isolation, making it important to increase the connectedness of the individual to the larger community. Many elders within Washoe County report feelings of social isolation, with only an extreme minority (no greater than 5%) reporting no feelings of social isolation. These feelings of social isolation increase with age, although there are several volunteer organizations within the community that strive to keep elders connected through volunteer opportunities and providing volunteers to help elders who are unable to leave their homes. The population of elders is expected to dramatically increase at both the national and local level and it is unlikely that the current systems (i.e., both medical and social systems) in place will be able to handle the increased pressure. Many elders rely on a fixed income in order to maintain their independence, making early treatment options more important (as compared to costly emergency care). It is possible to modify the current system so that it will better serve the needs of the elders and increase their overall life satisfaction, while at the same time reducing the pressure on the medical and social systems. It is the goal of the Clinic to provide needed services to the elders of Washoe County and Northern Nevada. To do this, a mix of health, social and psychological services will be offered at the same location, allowing primary care providers to gain a better understanding of the elders overall health and social status, as well as their service goals, and enabling the elder to more fully participate in service and support decisions. iv

7 Table of Contents Purpose... iii Executive Summary... iv Current Landscape... 1 Demographics... 3 Population... 3 Household Income... 8 Employment Health Insurance Medicare Enrollment Healthcare Infrastructure and Environment Elder Services Health Care Environment Health Care Occupations Health Care Providers Health Concerns Key Health Challenges County Health Rankings Health Risk Behaviors Leading Cause of Death per 100,000 Population Physical Functioning Disability and Frailty Falls Chronic Disease Management Arthritis Vascular Risk Factors Diabetes Mellitus Coronary Heart Disease Cerebrovascular Disease / Stroke Chronic Obstructive Pulmonary Disease (COPD) Non-Vascular Risk Factors Parkinson s Disease Cancer Psychosocial Needs Social Isolation Depression Suicide Dementia Alzheimer s Disease Appendix A: References Appendix B: Comparison of Geographic Areas by Chronic Condition, Selected Medicare Chronic Conditions v

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9 Current Landscape The elder population (i.e., individuals aged 65+) has been projected to dramatically increase both nationally and at the local level. Elders currently make up approximately 13% of the population within Washoe County; with approximately double that (26%) making up the next oldest population (i.e., individuals aged 45 64). By 2020, it is expected that the elder population will account for approximately 16% of the total population of Washoe County, an increase of approximately 32% (Nevada State Demographer, 2014). Of elders currently living in Washoe County, it is estimated that approximately 64% are between the ages of 65 and 74 (Washoe County Senior Survey, 2013). The current CDC estimates suggest that women will live an average of 20 years after their 65 th birthday whereas men will live an average of 17 years after (CDC FastFacts, 2014). The prevalence of chronic conditions within this population is high (e.g. 67% of women and 62% of men have been diagnosed with hypertension; CDC FastFacts, 2014), increasing the demand for medical services. The increasing need for services and supports will also be driven by other factors (e.g., income/available personal resources, availability of and access to services) currently present within the community. This need is clearly indicated by the data provided within this report. Elders in Nevada as well as Washoe County reported lower median incomes in 2012 than individuals aged 19 64, although only a small percentage (7%) of elders in Washoe County report incomes below the federal poverty level (FPL) for elders (FPL for elders is $11,011 for one person and $13,892 for two people). The majority of elders report incomes below $50,000/year posing a problem for elders income becomes increasingly limited at the same time that more expensive services are being utilized. In terms of employment, elders in Washoe County are more likely to report that they are active within the labor force (i.e., either actively employed or looking for work; approximately 34%) compared to the state and the U.S. as a whole (approximately 31% for both the U.S. and Nevada). Leading up to enrollment in Medicare (at age 65), elders in Washoe County are slightly more likely to have some form of private insurance (approximately 81% in 2012) than elders in Nevada (approximately 79%), although this number has decreased by approximately 1% every year since The majority of individuals who do not have health insurance were low-income workers (i.e., individuals who made less than 250% of FPL). Approximately 15% of Washoe County residents are enrolled in Medicare, with elders making up the vast majority of enrollees. However, only 30% of Medicare beneficiaries in the county are also enrolled in Medicare Part C or Medigap plans, which provide greater financial protection. For elders, the cost associated with primary care coverage may mean an increased rate of emergency care visits, leading to greater financial (emergency medicine tends to be significantly more expensive than comparable preventative primary care) and physical (e.g., higher rates of long term care institutionalization due to prolonged chronic illness) costs. Although changes to the health care system have been passed by Congress through the Patient Protection and Affordable Care Act (ACA), the long-term effect of these changes remain unclear. Also problematic for elders is a pronounced lack of geriatric services in the area. Currently, there are less than three geriatric service providers (either primary care physicians who specialize in geriatric medicine or an advanced practice nurse certified in geriatrics) per 100,000-population aged 65+. This lack of specialized care significantly increases the chances that individual elders are not receiving the type of skilled medical care that would allow them to remain out of the hospital and reduce both long term skilled nursing placement and hospital readmission. Washoe County does provide elder services (e.g., Daybreak, a senior day program, as well as support groups for caregivers) and there are also numerous private organizations that provide both volunteer opportunities as well as volunteer services to elders within Washoe County (e.g., the Retired Senior 1

10 Volunteer Program and the Senior Outreach Service program). However, there is no place for elders to receive a specialized comprehensive assessment that could identify areas of concern before the issue escalates and threatens their independence. There are no services in place that can help an elder navigate the primary care system and community supports available, ensure that their personal/medical information is easily accessible, or ensure their goals for treatment are respected. Although some elders are able to accurately and completely describe their current service plans to service providers (e.g., primary care physician), as the number of specialists seen increases the risk of omitting important information (e.g., leaving out a medication) also increases. 2

11 Demographics Population In Washoe County, it is projected that the elder (i.e., individuals aged 65+) population will increase by approximately 32% by 2020, making this demographic the fastest growing in the county. As this specific population increases, the county will be faced with challenges in coordinating not only medical care but also the cognitive, psychological and social care of elders living in Washoe County. Washoe County is also expected to maintain the current level of diversity for both gender and race/ethnicity, although minority ethnic populations are expected to increase at a higher rate than non-hispanic White populations. Population Estimates Nevada Washoe County 2013 Population Estimates Total Population Estimate 2,782, ,143 Adults (19 64) 1,698, ,488 Adults ,749 58,216 Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October Population Estimates 2013 Population Estimates by Age: Washoe County 12% 1% 27% 26% Age <19 Age Age Age Age % Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved June

12 2013 Elder Population Estimate by Age: Washoe County 12% 8% 37% Age Age % Age Age Age % Note. Percentages are estimates out of total sample of elders. Source: Washoe County Senior Services (2013) Population Estimates 2020 Population Estimate Nevada Washoe County Total Population Estimate 2,973,490 (+6.9%) 483,123 (+ 12.1%) Adults (19 64) 1,775,868 (+ 4.6%) 264,488 (+ 9.3%) Adults ,829 (+ 23.8%) 76,577(+ 31.5%) Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October Population Estimates by Age: Washoe County 15% 1% 26% 24% Age <19 Age Age Age Age 85+ Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October % 4

13 2013 / 2020 Population Estimate by Sex 2013 Nevada Washoe County Women 1,373,053 (49.4%) 1 216,981 (49.7%) 2 Men 1,402,163 (50.5%) 1 214,162 (50.3%) Women 1,472,493 (49.8%) 1 240,807 (49.9%) 2 Men 1,487,149 (50.2%) 1 242,316 (50.1%) 2 Source: Nevada State Demographer (2013). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved June Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October Population Estimates by Sex: Washoe County 50% 50% Women Men Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October

14 2013 Population Estimate by Race/Ethnicity Nevada Washoe County White (Non-Hispanic) 1,515,087 (58.3%) 284,260 (65.9%) African American (Non-Hispanic) 227,246 (7.2%) 10,435 (2.3%) American Indian and Alaskan Native 31,828 (1.3%) 7,086 (1.9%) Asian or Pacific Islander 242,133 (6.7%) 28,502 (6.3%) Hispanic (Any Race) 765,870 (26.5%) 100,861 (23.6%) Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October Population Estimates by Race: Washoe County 23% NonHispanic White 7% 2% 2% 66% Black American Indian and Alaska Native Asian or Pacific Islander Hispanic or Latino origin Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October

15 2020 Population Estimate by Race / Ethnicity 2020 Population Estimate by Race/Ethnicity Nevada Washoe County White (Non-Hispanic) 1,537,216 (51.7%; + 1.5%) 300,341 (62.2%; + 5.7%) African American (Non-Hispanic) 250,040 (8.4%; %) 12,398 (2.6%; +18.8%) American Indian and Alaskan Native 33,317 (1.1%; + 4.7%) 7,281 (1.5%; 2.8+%) Asian or Pacific Islander 270,485 (9.1%; %) 35,301 (7.3%; +23.9%) Hispanic (Any Race) 882,433 (29.7%; %) 127,801 (26.5%; +26.7%) Source: Nevada State Demographer (2014). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved October Population Estimates by Race: Washoe County 26% NonHispanic White Black 7% 2% 3% 62% American Indian and Alaska Native Asian or Pacific Islander Hispanic or Latino origin Source: Nevada State Demographer (2013). Age, Sex, Race, and Hispanic Origin Estimates and Projections: October Retrieved June

16 Household Income The US Census Bureau updates the federal poverty level (FPL) yearly, which allows for an estimate of the number of American s living in poverty. A percentage of this level is typically used as qualification criteria for assistance programs, such as SNAP and low-income energy assistance programs. For 2012, the FPL for elders (i.e., those individuals aged 65+) was $11,011 for one person and $13,892 for a twomember household. While the percentage of elders in Washoe County who fall below the FPL is roughly half of the rate throughout the rest of the state (7.3% vs. 15.3%), elders in Washoe County have a lower median household income ($38,638 per year) and receive less in Social Security benefits ($16,617) than the state average ($40,191 and $17,055 respectively). Approximately one third of elders surveyed in Washoe County (32.4%) report income less than 30k per year. Household Income in 2012 Nevada Washoe County Income Per Capita Household $66,044 $66,569 Median Household $49,760 $49,029 Median Household (65+) $40,191 $38,638 Mean Social Security $17,055 $16,617 Percent of Persons Receiving Social Security 27.3% 27.4% Percent of Persons 65+ Below Federal Poverty Level 15.3% 7.3% Source: U.S. Census Bureau American Community Survey (2012a). Report B Retrieved June Median Household Income $49,760 $49,029 $40,191 $38,638 Nevada Washoe County Median Income Individuals Median Income Individuals 65+ Source: U.S. Census Bureau American Community Survey (2012a). Report B Retrieved June

17 Elder Income Distribution in Washoe County Income for Individuals 65+: Washoe County 30.0% 27.5% 25.0% 20.0% 15.0% 13.8% 12.3% 17.8% 10.0% 7.7% 5.0% 0.0% < $10,000 $10k - $19k $20k - $29k $30 - $49k $50k + Source: Washoe County Senior Services (2013). 9

18 Employment Approximately 29% of individuals aged 65+ reported that they were still active in the labor force (either currently employed or currently unemployed but seeking work). Similar to traditional measures of unemployment, unemployment for individuals aged 65+ is defined as individuals who do not have a job, have actively looked for work within the past 4 weeks, and are currently available for work (i.e., it does not include individuals who report that they have retired). Washoe County (and Nevada as a whole) has more elders either working or actively searching for work than the national average. Elder Labor Force Statistics 2012 Estimates United States Nevada Washoe County Individuals Aged Who Are: In Labor Force 64.1% 63.4% 64.9% Not In Labor Force (Retired) 35.9% 36.6% 35.1% Individuals Aged Who Are: In Labor Force 25.5% 24.7% 28.2% Not In Labor Force (Retired) 74.5% 75.3% 71.8% Individuals Aged 75 + Who Are: In Labor Force 5.9% 6.4% 5.9% Not In Labor Force 94.1% 93.6% 94.1% Source: U.S. Census Bureau (2012b); Table B Retrieved June Elder Employment Statistics 2012 Estimates United States Nevada Washoe County Individuals Aged Who Are: Employed 59.8% 56.3% 57.8% Unemployed 6.6% 11.2% 11.0% Individuals Aged Who Are: Employed 23.8% 21.7% 24.9% Unemployed 6.5% 12.2% 11.8% Individuals Aged 75 + Who Are: Employed 5.6% 5.3% 4.9% Unemployed 5.6% 17.4% 17.4% Source: U.S. Census Bureau (2012c); Table S2301. Retrieved June

19 Employment Estimates 2013 Elder Employment Estimate: Washoe County 92.5% 92.0% 88.6% 76.8% 73.5% 27.3% 11.7% 10.7% 7.4% 2.8% 26.5% 19.2% 6.0% 11.4% 4.0% Employed Unemployed* Retired** Source: Washoe County Senior Survey (2013). *Does not have a job but would like to work. **Does not have a job and does not want to work. 5-Year Unemployment Estimates ( ) 48.6% 47.2% 23.0% 22.9% 18.4% 19.7% 9.9% 10.3% Nevada Washoe County Years Years Years 60+ Years Source: U.S. Census Bureau (2012d). American Community Survey (EEO-ALL14). Retrieved June

20 Health Insurance Individuals aged between 50 and 64 are more likely to have some form of private health insurance, with approximately 81% of Washoe County residents in this age range reporting having some form of health insurance. However, those individuals who do not have health insurance are more likely to be low income (e.g., approximately 42% of individuals who make less than 138% of the federal poverty level do not have any form of insurance). Approximately 25% of uninsured individuals in Washoe County make between 138% and 400% of the Federal Poverty Level (FPL). These individuals are less likely to seek preventative care, relative to those with insurance, and more likely to use more costly emergency services when they do need medical assistance, irrespective of the severity/urgency of need. Long-term impacts of the Patient Protection and Affordable Care Act (ACA) on the uninsured rates remain to be seen. Health Insurance Coverage Nevada Washoe County Adults (19 64) 1 Private Insurance 56% ~ Other Private 6% ~ Medicaid 6% ~ Other Public 4% ~ Uninsured 29% ~ Age (All Incomes) 2 Insured 79.4% 81.1% Uninsured 20.6% 18.9% Uninsured by Percent of Federal Poverty Level (FPL) 2 <= 138% FPL 44.8% 41.5% <= 200% FPL 42.2% 39.9% <= 250% FPL 39.5% 37.6% <= 400% FPL 31.7% 30.4% Total Uninsured Between 138% FPL and 400% FPL % 25.4% Source: 1 Henry J. Kaiser Family Foundation (2012a). 2 United States Census Bureau Small Area Health Insurance Estimates (2012f); SAHIE Interactive data tool. ~ = no data available. 29% 2012 Source of Insurance in Nevada 4% 6% 6% 55% Employer Other Private Medicaid Other Public Uninsured Source: Henry J. Kaiser Family Foundation (2012a). 12

21 3 Year Insured Rate 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 81.6% Percent Insured Age 50-64: Nevada 81.6% 79.4% 18.4% 18.4% 20.6% Insured Uninsured Source: United States Census (2012f); SAHIE Interactive data tool. 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 83.0% Percent Insured Age 50-64: Washoe Co. 82.1% Insured 81.1% 17.0% 17.9% 18.9% Uninsured Source: United States Census Bureau (2012f); SAHIE Interactive data tool. 13

22 Current Estimate of Insured Elders 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 2012 Percent of Nevada Uninsured Aged by FPL 41.5% 39.9% 37.6% 30.4% 25.4% <= 138% FPE <= 200% FPE <= 250% FPE <= 400% FPE 138% - 400% FPE Source: United States Census Bureau (2012f); SAHIE Interactive Tool. 14

23 Medicare Enrollment When an individual turns age 65, they become eligible for Medicare. The core of the program provides for in-patient hospital (Medicare Part A) and some outpatient (Medicare Part B) services for eligible members. There is typically no premium associated with Medicare Part A, however, there are premiums associated with Part B, Medicare Part D (prescription drug coverage) and Medicare Part C (Medicare Advantage Plans) plans. Individuals who receive Medicare coverage are also able to purchase Medigap policies (i.e., policies sold by private insurers that cover services not covered under Medicare Part A, B, or D) instead of Part C plans. In Washoe County, approximately 14% of the population currently receives some Medicare benefits. Approximately 30% of Medicare beneficiaries in Washoe County are enrolled in Medicare Part C type plans (either HMO, PPO, or Medicare Part C plans), similar to the state rate of 32%. This may leave some individuals without access to affordable preventive care, increasing the risk of needing more costly emergency services. Medicare Nevada Washoe County Beneficiaries as Percent of Total Population 1 14% 14.6% Beneficiaries % ~ Dual Qualifying Beneficiaries 3 13% ~ Medicare Enrollment by Federal Poverty Level (FPL) 4 <100% FPL 15% ~ % FPL 16% ~ % FPL 14% ~ 200%+ FPL 54% ~ Enrollment in Medicare Advantage (Percent of Total Medicare Enrollees) 5 Local HMO 29% 25% Local PPO 3% 4% Sources: 1 Kaiser Family Foundation (2012b). 2 Kaiser Family Foundation (2012c). 3 Kaiser Family Foundation (2012d). 4 Kaiser Family Foundation (2012e). 5 Kaiser Family Foundation (2014) Percent Nevada Medicare Beneficiaries by FPL 60.0% 50.0% 54.0% 40.0% 30.0% 20.0% 10.0% 15.0% 16.0% 14.0% 0.0% <= 100% FPL % FPL % FPL 200% + FPL Source: Kaiser Family Foundation (2012e). 15

24 Effects of Income on Elder Health 13.4% 10.5% 8.6% 7.8% 7.9% 5.6% 4.0% 4.0% 7.4% 5.6% Percent Reporting They Have Gone Without A Prescription Due to Cost Percent Reporting They Did Not Seek Medical Care Due to Cost Source: Washoe County Senior Services (2013). 16

25 Healthcare Infrastructure and Environment Elder Services Select Elder Support Services in Washoe County Service Provider Type of Service (as applicable) Washoe County Senior Services Daybreak Adult Daycare Grandparent s Raising Grandchildren Support Group Other Services General elder care concerns, including Social Service assistance, nutrition program, recreational activities, senior law project Alzheimer s Association Education, Information and Referral, Care Consultation, Support Groups and Safe Return Chronic Disease Self-Management CDSME, health education The Continuum Alzheimer s Adult Day, Home modification, PT/OT Foster Grandparent Program Senior Outreach to Children, K -12 Golden Opportunity (JOIN) Part time employment assistance Medication Therapy Management Polypharmacy medication reviews Nevada Rural Counties Retired and Senior Volunteer Program (RSVP) Senior volunteer opportunities / volunteer assistance program Retired and Senior Volunteer Program Senior volunteer opportunities / volunteer assistance program Senior Community Service Low Income Financial Assistance (55+) Employment Program (AARP) Senior Companions Program One-on-one companionship for low income elders Senior Korner Senior volunteer assistance Senior Outreach Services One-on-one companionship for low income elders Multiple Long-term Care Providers Assisted Living, Skilled Nursing, Memory Care Multiple Hospice Providers 17

26 Health Care Environment Hospital and Skilled Nursing Physical Resources Hospital Resources 1 Nevada Washoe County Critical Access Hospitals (CAH) 11 0 Critical Access Eligible Hospitals 4 0 Acute Care Hospitals 19 4 Total 34 4 Acute Care Investor Owned Hospitals 19 3 Acute Care Non-Profit Hospitals 13 1 Acute Care Public Hospitals 6 0 Beds Setup and Staffed - Acute Care CAH CAH Eligible Acute Care Hospitals 4,970 1,022 Beds Setup and Staffed Long-term Care CAH CAH Eligible 49 0 Acute Care Hospitals 5,559 1,069 Beds per 1,000 people (Acute Care Hospitals) Licensed Community Hospital Beds Licensed Long-term Hospital Beds Licensed Long-term Hospital Beds (65+ Population) Skilled Nursing Resources 2 Skilled Nursing Facilities (2011) 49 7 Skilled Nursing Facilities Total Beds 5,724 1,069 Skilled Nursing Facilities Certified Beds 5,560 1,025 Source: 1 Griswold, Packham, Etchegoyhen, Marchand, & Lee (2013). 2 U.S. Department of Health and Human Services (2012). 18

27 Health Care Occupations Health Care Occupations Provider Type Nevada Washoe County Primary Care Physicians (MDs & DOs) 1, Psychiatrist Psychologists Neurologists 2 79 ~ Geriatricians* Geriatrician Psychiatrists ~ ~ Licensed Clinical Social Workers Physician Assistants Registered Nurses 20,214 4,015 Advanced Practice Registered Nurse Certified Nursing Assistants 7,223 1,409 Dentists 1, Pharmacist 2, Chiropractors Physical Therapist 1, Speech Language Pathologists EMT Personnel 6,425 1,281 Source: 1 Griswold, Packham, Marchand, & Lee (2013). 2 Packham, Griswold, Etchegoyen, & Marchand (2014). *Data taken from physician referrals made by healthinaging.org and individuals listed as having a geriatrician endorsement from the American Board of Family Medicine ( Advanced Practice Registered Nurse by Specialty Specialty Nevada Washoe County Acute Care 19 8 Family Practice Psychiatric 25 6 Geriatric 6 0 Source: Only selected specialties shown. Nevada State Board of Nursing (2013) Ratio of Population Health Care Professionals Per 100,000 Population Health Occupations Nevada Washoe County Primary Care Physicians Psychiatrists Psychologists Licensed Clinical Social Workers Physician Assistants Registered Nurses Licensed Vocational Nurses Certified Nurses Assistants Dentists Pharmacists Chiropractors Licensed Speech Language Pathologists EMT Personnel Source: Griswold, Packham, Etchegoyhen, Marchand & Lee (2013). 19

28 Health Care Providers Washoe County System/Hospital Beds Type of Service Renown Medical Group Renown Regional Medical Center 808 Acute Care Renown South Meadows Medical Center 808 Acute Care Renown Rehabilitation Hospital 62 Non-Acute Care Saint Mary s Medical Group Saint Mary s Regional Medical Center 380 Acute Care LifeCare Hospital Group Tahoe Pacific Meadows 39 Acute Care Tahoe Pacific West 21 Acute Care Tahoe Forest Hospital Group Incline Village Hospital 4 Acute Care Individual Hospitals Northern Nevada Medical Center 108 Acute Care/Psychiatric Care Sierra Surgery Hospital 15 Acute Care Federally Qualified Health Clinic Community Health Alliance NA Primary, Behavioral Health, Dental Care Northern Nevada HOPES NA Primary Care Skilled Nursing Facilities Hearthstone of Northern Nevada, Sparks 125 Skilled Long Term Nursing Manor Care Health Services, Reno 189 Skilled Long Term Nursing Manor Care Health Services Wingfield 120 Skilled Long Term Nursing Hills, Sparks Regent Care Center of Reno, Reno 174 Skilled Long Term Nursing Renown Skilled Nursing, Sparks 160 Skilled Long Term Nursing Rosewood Rehabilitation Center, Reno 99 Skilled Long Term Nursing Geriatric Specialty Care Geriatric Specialty Care of Nevada Medwise Primary Care for Seniors Senior Companion Program Medical Group Practice Mobile health services, chronic disease education, primary care referral Mental Health/Local Mental Health Authority BHC West Hills 95 Psychiatric Dini-Townsend Hospital NNAMHS 40 Psychiatric Senior Bridges Inpatient / Outpatient Geriatric Psychiatric treatment services Willow Springs 116 Psychiatric Ambulance Provider REMSA NA Emergency Medical Transportation Source: Nevada Department of Health and Human Services (2014). 20

29 Health Concerns The current health care system typically limits the time available to elders to discuss their problems with their primary care physicians due to the high volume of patients. Elders also face accelerating health changes, many of which can go unnoticed by the elder or their primary care doctor until a significant health risk is posed. For example, increased difficulty rising to a standing position is often ignored by elders and is typically not brought to the attention of primary care providers (although this change can significantly increase the chances of falls and can signify the early stages of other health problems). These changes can be readily identified through simple, non-invasive monitoring techniques (e.g., recording the time required to stand from a seated position), and can be moderated through non-pharmacological means if caught early. However, many providers do not have the necessary time to provide these preventative screening services to elders within their practice due to increasing patient loads and decreasing number of general practitioners. In order to provide a better experience, the proposed Clinic would provide elders a health resource specifically designed to address these concerns and to help monitor their overall health. Working in cooperation with their primary care providers, the Clinic proposes to help elders identify health concerns while still manageable, as well as to help elders understand both their conditions and their service/support options. Elder health can be broken down into five interdependent areas: the overall level of physical disability currently experienced by the elder, the existence of multiple chronic conditions, the use polypharmacy to treat multiple chronic conditions, the overall level of cognitive disability currently experienced by the elder, and increased social isolation experienced due to decreased physical mobility or other chronic conditions (e.g., decreases in cognitive abilities). The level of physical disability, limitations to normal activities of daily living (ADL; e.g., bathing and dressing the self) as well as limitations to instrumental activities of daily living (IADL; e.g., preparing meals) often influence an individual s ability to maintain an active and independent life. These limitations can either be impairments to daily life, as is the case with ADLs, or may be markers for future disability and eventual long-term care placement, as in the cased of IADLs. Increases in limitations to IADLs may provide information about the development of more severe disabilities (e.g., decreases in hearing ability is associated with later balance problems) allowing for the implementation of prophylactic treatments (e.g., balance training) extending the amount of time that an elder can live in an environment of their choosing and delay long-term care placements. Chronic conditions stem from a range of causes but impact an individual s quality of life and experiences. Early detection of developing physical and cognitive frailty (e.g., balance issues, dementia) as well as better monitoring of chronic conditions (e.g., high blood pressure, Parkinson s Disease) allows for the implementation of service plans, with ongoing care coordination that: 1) fit the elders goals for supports and services, 2) increase the chances of delaying long-term care placement, 3) reduce hospital admittance as well as hospital re-admittance, and 4) reduce negative side effects associated with over medication. These plans also give the elder a voice in their treatment plan, increasing the likelihood that the elder will feel confident in implementing the care plan. The existence of multiple chronic conditions may decrease the effectiveness of social and behavioral approaches to care. For example, although exercise has been shown to decrease the risk of future cardiovascular and cerebrovascular problems, individuals with severe arthritis may not be able to engage in prolonged physical activity. Decreases in overall muscle strength as well as physiological capacity (e.g., lung capacity) may limit non-pharmacological interventions. However, early interventions may decrease the rate of disability associated with many chronic conditions (e.g., 21

30 balance training may decrease the occurrence of falls, leading to fewer broken bones and increased mobility) and increase the overall efficacy of these interventions, delaying long-term care placement. These individual factors play an important role in both maintaining and increasing the quality of life of elders and should be factored into the treatment plans for chronic conditions. The presence of multiple chronic conditions also increases the likelihood that they are taking multiple medications. Alone, medications can have negative side effects (e.g., an increase in lethargy experienced by some people who take beta blockers). The risk of experiencing negative side effects increases when multiple medications are taken. Different medications prescribed for different chronic health conditions may interact, increasing the odds that the individual experiences severe negative side effects. The American Geriatric Society recommends that every new prescription be accompanied by an extensive medication review, as well as an annual review of all prescriptions currently being taken by an elder. Cognitive decline poses a risk to an elder s ability to maintain an active and independent lifestyle. These declines can range from mild (e.g., difficulty remembering doctor s appointments) to more severe (e.g., inability to recognize familiar places/people). If identified early, cognitive decline can be significantly slowed down, and, in more severe cases, decisions regarding long term care options can be made while the elder can still express their wishes, increasing the control experienced by the elder in relation to their care options. Elder care must also take into account the individual s psychosocial well-being. Elders can experience depressed mood due to limitations to their independence, as an unintended side effect to pharmacological treatment, increased social isolation, or dementia. The three plagues of old age (loneliness, helplessness, and boredom) can reduce the quality of life experienced by an elder and can actually be risk factors for developing cognitive disabilities. By recognizing the causes of psychological distress and cognitive decline, it may be possible to increase individual life satisfaction without adding to the myriad of medications that the individual may already be taking. Primary care providers are being asked to provide care to an ever increasing amount of individuals, resulting in an overall decrease in time spent with each individual. In addition to this, elder care often requires an understanding of multiple chronic conditions as well as a clear picture of the entire person. By providing the necessary non-invasive testing (e.g., frailty monitoring), as well as providing elders with resources needed to make informed decisions regarding their conditions as well as their service and support options, the Clinic hopes to ensure that elders receive the care necessary to positively age in place, and reduce hospitalizations (both primary and re-admissions), both of which can to increase an elder s quality of life. Age-adjusted mortality rates and overall prevalence rates are reported in the tables below. These rates are used to give an estimate to the number of individuals who experience each condition within Nevada and Washoe County. Medicare utilization rates are also reported for those conditions that are tracked by the Centers for Medicare and Medicaid Services. This information is presented in text as well as in Appendix B. Although ethnic minorities experience chronic conditions differently than Whites, these rates are not reported due to the small number of ethnic minorities in Washoe County (as evidenced in the demographic section presented above). Gender differences are reported even though there are no significant differences in gender within the county. 22

31 Key Health Challenges County Health Rankings Health Outcomes Washoe County National Benchmark Nevada Mortality: Premature Death 1 7,100 (4) 5,317 7,252 Morbidity: Poor or Fair Health 15% (5) 10% 17% Poor Physical Health Days 3.6 (4) Poor Mental Health Days 3.5 (5) Source: County Health Rankings. Retrieved June Years of potential life lost before age 75 per 100,000 population age adjusted. All measures age-adjusted. Rank is out of counties that have the measure reported. Health Risk Behaviors Health Factors Washoe County National Benchmark Nevada Health Behaviors: County Rank (Overall Health Behaviors) 7 Adult Smoking 18% 14% 21% Adult Obesity 23% 25% 25% Physical Inactivity 16% 21% 22% Excessive Drinking 21% 10% 18% Motor Vehicle Mortality Rate 11% ~ 14% Sexually Transmitted Infections (Chlamydia rate per 100,000) HIV Prevalence Rate (per 100,000) Clinical Care: County Rank (Overall Clinical Care) 3 Access to Care couldn t see doctor due to costs 15% ~ 16% Emergency Department Visits (per 1,000 population) ~ Preventable Hospital Stays (per 1,000 Medicare Enrollees) Diabetic Screening 77% 90% 77% Mammography Screening 62.6% 71% 56% Social & Economic Factors: County Rank (Overall Social & Economic Factors) 10 Violent Crime Rate (per 100,000 population) Physical Environment County Rank (Overall Physical Environment) 6 Limited Access to Healthy Foods 5% ~ 4% Fast Food Restaurants 57% 25% 53% Source: County Health Rankings (2014). ~ = No data available. Retrieved June

32 2011 Leading Cause of Death per 100,000 Population Condition Washoe County Nevada United States Heart Disease (1) (1) All Cancers (2) (2) Chronic Lower Respiratory Disease (3) 42.5 (3) Unintentional Injury (4) 39.1 (5) Cerebrovascular Diseases (6) 37.9 (4) Alzheimer s Diseases (10) 24.7 (6) Female Breast Cancer (7) 12.1 (11) Suicide (9) 12.3 (10) Influenza & Pneumonia (8) 15.7 (9) Diabetes Mellitus (11) 21.6 (7) Atherosclerosis (5) 16.9 (8) Homicide ~ 4.8 (12) 5.2 (12) Source: Data ranked for Washoe County. Centers for Disease Control and Prevention (2014). ~ = Data suppressed due to low rates. Retrieved June

33 Physical Functioning Disability and Frailty Disability is defined as a physical or mental impairment that substantially limits one or more major life activities (U.S. Department of Justice, 2009, Section 1202). For individuals who are living alone, the development of a disability may be the reason that they move into a residential care setting. However, there are often simple home modifications (e.g., installing a raised toilet seat or handle bars in a shower) or other needed supports or services than can help an individual remain in their home and avoid long-term care placement. The American Community Survey (ACS) categorizes an individual as having a disability if they answer affirmatively for any one question across six domains: hearing, visual, cognitive, ambulatory, self-care, or independent living. For individuals over the age of 65, approximately 34.9% of Nevada residents reported being disabled compared to 32.7% in Washoe County (US Census Bureau, 2012g). Disability can also be measured as difficulty in completing activities of daily living (ADL). In a random digit survey completed by Washoe County Senior Services, the majority of the sample (90.5%) reported no difficulty in completing any of the ADLs listed. For those who did report some difficulty with ADLs, the individuals reported having problems with an average of two activities. Although included in disability definitions, limitations to ADLs typically develop over time and are the result of progressive declines that have already reached a high level of impairment (e.g., problems with balance may be predicated by problems hearing a conversation at a normal volume). The ability to complete instrumental activities of daily living (IADLs; e.g., reading without glasses or climbing a flight of stairs) may indicate future limitations. A higher number of respondents (n = 267, 57.4%) reported experiencing difficulty with instrumental activities of daily life (e.g., reading without glasses or climbing a flight of stairs). This may indicate that an increased number of the population is at risk for developing limitations associated with ADLs in the future. It is possible that interventions designed to limit the progression of these impairments may reduce the overall disability rate associated with the elder population. Percent of Washoe County Residents Who Reported That They Are Limited in Any Activity Due to Physical, Mental, or Emotional Problems 22.1% 77.8% Yes No Source: CDC Behavioral Risk Factor Surveillance System (2012). Retrieved June Numbers may not add to 100 due to rounding errors. 25

34 Disability Estimates Nevada (+ / - ) Washoe County (+ / - ) Estimated Population With 1 Any Disability 127,076 (4,521) 18,126 (1,698) Hearing Difficulty 49,684 (3,168) 6,926 (1,036) Vision Difficulty 25,245 (2,499) 2,860 (1,000) Cognitive Difficulty 27,950 (2,485) 3,615 (787) Ambulatory Difficulty 82,801 (3,730) 11,250 (1,686) Self-Care Difficulty 24,579 (2,226) 3,628 (899) Independent Living Difficulty 49,360 (3,328) 7,420 (1,219) Population Aged Men 31,901 (2,542) 4,646 (819) Women 28,224 (2,026) 3,607 (770) Population Aged Women 38,105 (1,897) 5,698 (675) Men 28,846 (1,596) 4,175 (754) Source: 1 U.S. Census Bureau, American Community Survey (2012g; Table B1801). 2 U.S. Census Bureau, American Community Survey (2009; Table S1810). 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 35.8% 32.2% Population Percent Ages 65+ Who Report Disability 14.0% 12.3% Hearing Difficulty 7.1% 7.9% 5.1% Vision Difficulty Nevada 6.4% Cognitive Difficulty 23.3% 20.0% Ambulatory Difficulty Washoe County 6.9% 6.5% Self-Care Difficulty 13.9% 13.2% Independent Living Difficulty Source: U.S. Census Bureau (2009). American Community Survey (Table S1810). Retrieved June

35 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 2012 Percent Ages 65+ Who Report Disability By Age & Gender 29.6% 27.0% 24.9% 20.4% 27.2% 23.7% 47.6% 43.8% 51.6% 49.8% 41.2% 46.2% Nevada Washoe County Source: U.S. Census Bureau (2012g). American Community Survey (Table B1801). Retrieved June

36 Instrumental Activity Limitations and Frailty Classification 20.0% 15.0% 10.0% 5.0% 2013 Percent of Individuals Ages 65+ Reporting at Least One Limitation to Instrumental Activity 18.9% 15.3% 12.7% 7.1% 3.4% 0.0% Number of Impaired Instrumental Activities of Living Source: Washoe County Senior Services (2013). Counts are exclusive (i.e., individuals who reported more than 1 IADL are not included in the previous count) Percent Ages 65+ By Frailty Index: Washoe County 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 36.0% 27.3% 16.0% 18.5% Not Frail 2.8% 46.9% 42.6% 47.2% 44.0% 40.1% Some / Minimal Frailty 30.7% 29.6% 25.0% 22.7% 18.6% 5.8% Moderate Frailty 13.9% 5.3% 2.3% 1.9% High Frailty Source: Washoe County Senior Services (2013).Frailty index included 18 items including self-perception of health, problems with ADLs and IADLs, number of prescription medications taken within the past month, nutrition information, and fall status. 28

37 Falls Next to existing disability, falls pose the greatest risk to an elder s independence. Decreases in muscle tone and stability, coupled with changes in both hearing and vision associated with age increase the risk of unintentional falls. As these physical changes increase (e.g., changes in hearing/vision and decreased bone density), it becomes more likely that an individual will suffer from injuries due to unintentional falls. In the U.S., unintentional falls were the number one cause of non-fatal injury, with approximately 2.4 million falls among older adults being treated in emergency departments, costing approximately $30 billion dollars (CDC, National Center for Injury Prevention and Control; 2013). The consequences of falls for elders include fractured bones, increased mobility limitations, increases in fall related anxiety (including increased fear of falling), reduced social interaction (due to fear of falling) and death. Unintentional falls remain one of the top ten causes of death for individuals aged 65+, accounting for 48.2% of unintentional fatal injuries nationally. In Nevada, approximately 7 per 100,000 deaths are due to falls, with approximately 8 deaths per 100,000 in Washoe County attributable to falls. Exercises that focus on leg strength and balance (e.g., Tai Chi) have been shown to decrease the risk of injuries resulting from falls. Regular eye exams, prescription drug monitoring, and environmental modifications (e.g., the installation of grip bars in the bathroom), can also decrease the risk of falls US Age-Adjusted Unintentional Non-Fatal Fall Injuries for Elders Females 6, Males 4, Both Sexes 5, , , , , , , , Per 100,00 Population Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2013). Retrieved October

38 31.0% 30.0% 29.0% 28.0% 27.0% 26.0% 25.0% Elders in Washoe County Reporting Having Fallen Within the Last Year 28.6% 26.7% 29.8% Both Sexes Males Females Source: Washoe County Senior Services (2013) Age Adjusted Unintentional Fall Deaths Ages Both Sexes Males Females* Per 100,000 Population Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012a). Retrieved October *Rate suppressed due to small number. 30

39 Chronic Disease Management The existence of comorbid conditions in elders can complicate support by reducing treatment options as well as increasing the possibility of elders receiving multiple medications. The incidence of comorbid chronic conditions (i.e., individuals who present with multiple chronic conditions) has significantly increased from 21.8 (2001) to 26.0% (2010; Ward & Schiller, 2010). Nationally, as well as in Nevada, individuals with arthritis are significantly more likely to have a comorbid condition, with arthritis, diabetes, and hypertension being the most common comorbid chronic conditions. In Nevada, the most common comorbid chronic conditions with diabetes are arthritis, coronary heart disease, and chronic obstructive pulmonary disease (COPD). 60% 50% Prevelance of Arthritis Among People with Other Chronic Conditions 57% 52% 44% 40% 30% 26% 20% 10% 0% Heart Disease Diabetes High Blood Pressure Obesity Source: CDC (2013). Retrieved June Prevelance of Arthritis Among People with Other Chronic Conditions in Nevada % 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 61.1% 54.7% 45.7% 50.0% 40.6% Coronary Heart Attack* Stroke* Diabetes High Blood Heart Disease Pressure 25.8% 26.8% Overweight** Obesity*** Source: CDC Behavioral Risk Factor Surveillance System, Retrieved June *Ever diagnosed. **BMI ***BMI

40 Arthritis Arthritis is one of the most common chronic ailments reported by elders in the state of Nevada as well as in Washoe County. Arthritis is characterized by pain, stiffness in joints, and/or swelling of the joints, and although the condition can occur in anyone, it is more prevalent in individuals ages 65+. Women are more likely to experience the symptoms of arthritis compared to men. Currently, the number of individuals estimated to be living with arthritis is 50 million (about 1 in 5 adults) although this number is expected to increase dramatically (to 67 million) by In 2012, approximately 22% of Medicare beneficiaries received services for arthritis in Washoe County, which ranked 7 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare & Medicaid Services, 2012). Risk factors for osteoarthritis include injury to the joint (e.g., it is estimated that approximately 57% of individuals who had a knee injury will develop arthritis in the joint) and obesity (approximately 60% of individuals who are overweight will develop some form of osteoarthritis). Although not directly related to mortality, arthritis increases the risk of developing other chronic health conditions or can increase complications from other chronic health conditions due to limitations on physical activity. Arthritis can also increase psychological distress, as greater restrictions are placed on the individual s independence and mobility Percent of Nevada Residents Told That They Have Arthritis 24.0% Yes No 76.0% Source: CDC Behavioral Risk Factor Surveillance System (2012a). Retrieved June Percent of Washoe County Residents Told That They Have Arthritis 24.2% Yes No 75.8% Source: CDC Behavioral Risk Factor Surveillance System (2012b). Retrieved June

41 Vascular Risk Factors Diabetes Mellitus Diabetes is a group of diseases marked by high levels of blood glucose, also called blood sugar, resulting from defects in insulin production, insulin action, or both. In 2007, diabetes was the seventh leading cause of death in the United States and an estimated 23.6 million people or 7.8% of the population had diabetes. The prevalence of diagnosed type 2 diabetes increased six-fold in the latter half of the last century, with rates expected to reach 33% by In 2012, approximately 19% of Medicare beneficiaries received treatment for some form of diabetes in Washoe County, which ranked 13 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare & Medicaid Services, 2012). Diabetes risk factors such as obesity and physical inactivity have played a major role in this dramatic increase. Age, race, and ethnicity are also important risk factors. Diabetes can have a harmful effect on most of the organ systems in the human body; it is a frequent cause of end-stage renal disease, non-traumatic lower-extremity amputation, and a leading cause of blindness among working age adults. Persons with diabetes are also at increased risk for ischemic heart disease, neuropathy, and stroke as well as blindness, kidney failure, and amputations. In economic terms, the direct medical expenditure attributable to diabetes in 2007 was estimated to be $116 billion with an additional $58 billion in indirect costs (disability, work loss, premature death). Health care expenses are approximately 2 times greater for individuals with diabetes than individuals without the disease Percent of Washoe County Residents Told That They Have Diabetes 6.6% Yes No 93.4% Source: Department of Health and Human Services (2014), Diabetes in Nevada:

42 2012 Percent of Nevada Residents 65+ Told That They Have Diabetes 19.8% Yes No 80.2% Source: Department of Health and Human Services (2014), Diabetes in Nevada: % 20.0% 15.0% Diabetes Prevalence in Nevada by Age Group 13.9% 16.0% 15.1% 22.2% 19.8% % 8.1% % 3.6% 3.0% 0.0% Source: Department of Health and Human Services (2014), Diabetes in Nevada: Age-Adjusted Death Rate for Diabetes Mellitus Individuals Ages Both Sexes Male Female Per 100,000 Population Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012b). Retrieved October

43 Coronary Heart Disease Heart disease is a term that encompasses a variety of different diseases affecting the heart and is the leading cause of death in the United States accounting for 25.4% of total deaths. The most common type in the United States is coronary artery disease, which can cause heart attack, angina, heart failure, and arrhythmias. Coronary artery disease occurs when plaque builds up in the arteries that supply blood to the heart and the arteries narrow (atherosclerosis). There are many modifiable risk factors for atherosclerosis including tobacco usage, obesity, sedentary lifestyle, and high levels of low-density lipoprotein in blood serum (high cholesterol). In 2012, approximately 18% of Medicare beneficiaries received services for coronary heart disease in Washoe County, which ranked 16 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012). Two risk factors for both coronary heart disease and stroke are hypertension (high blood pressure) and hyperlipidemia (high cholesterol). In 2012, approximately 43% of Medicare beneficiaries received services for hypertension in Washoe County, which ranked 11 th in the state. A similar percentage 38% of Medicare beneficiaries received services for hyperlipidemia in Washoe County, which ranked 5 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012). Percent of Washoe County Residents Who Reported They Experienced a Heart Attack 3.5% Yes No 96.5% Source: CDC Behavioral Risk Factor Surveillance System (2012c). Retrieved June Numbers may not add to 100 due to rounding errors. 35

44 Percent of Washoe County Residents Who Reported That They Had Angina or Coronary Heart Disease 2.9% Yes No 97.2% Source: CDC Behavioral Risk Factor Surveillance System (2012d). Retrieved June Numbers may not add to 100 due to rounding errors Age-Adjusted Death Rates for Atherosclerosis for Individuals Ages Nevada Washoe County Both Sexes Male Female Per 100,000 Population Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012). Retrieved October

45 Coronary Care Unit Admissions Coronary Care Unit Admissions 9,000 8,000 7,763 7,430 7,000 6,000 5,000 4,000 3,000 5,180 3,824 Nevada Washoe County 2,000 1,709 1,527 1,479 1,459 1, Source: Center for Health Information Analysis for Nevada (2014). Nevada Healthcare Quarterly Reports (NHQR) for Years Retrieved June

46 Cerebrovascular Disease / Stroke Cerebrovascular diseases (e.g., stroke) rank fourth among the leading causes of death in the U.S and are the leading cause of stroke. This group of brain diseases is most often the result of hypertension, especially in elders. Sustained hypertension (i.e., sustained high blood pressure) can cause changes in the architecture of the blood vessels that supply blood to the brain, causing narrowing and stiffening. This increases individual vulnerability to stroke, especially when blood pressure changes (e.g., drops in the early morning, or spikes due to stress during the day). A stroke occurs when blood vessels carrying oxygen to the brain become blocked (ischemic) or rupture (hemorrhagic), cutting off the brain's supply of oxygen. Lack of oxygen causes brain cells to die, which can lead to death or disability. Each year, approximately 795,000 people in the U.S. will suffer a new or recurrent stroke. Although people of all ages may suffer strokes, the risk of stroke more than doubles with each decade of life after age 55. The most important modifiable risk factors for stroke are high blood pressure, high cholesterol, tobacco use and diabetes mellitus. Stroke is the number one leading cause of disability in elders in the United States due to the damage done to the brain. Immediate medical attention can mitigate the severity of disability for many individuals, although the level of disability is highly dependent upon the severity of the incident. In 2012, approximately 3% of Medicare beneficiaries received services for stroke in Washoe County, which ranked 9 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services; 2012). Percentage of Washoe County Residents Who Reported They Had A Stroke 1.3% Yes No 98.7% Source: CDC Behavioral Risk Factor Surveillance System, Retrieved June Numbers may not add to 100 due to rounding errors. 38

47 Age-Adjusted Death Rate for Cerebrovascular Disease for Individuals Ages Both Sexes Male Female Per 100,000 Population Nevada Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012d). Retrieved October Washoe County 39

48 Chronic Obstructive Pulmonary Disease (COPD) Chronic obstructive pulmonary disease (COPD) is a chronic condition that includes emphysema and chronic bronchitis. Although tobacco use is the greatest risk factor of development of COPD, longterm exposure to dust and other pollutants also contribute to the development of COPD. COPD is a major cause of disability in the United States and is the number three cause of death nationally. Rates of COPD (measured as deaths from chronic lower respiratory diseases per 100,000) are higher in Washoe County (approximately 53.4) compared to Nevada as a state (approximately 49.4). In 2012, approximately 10% of Medicare beneficiaries received services related to COPD in Washoe County, which ranked 15 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012) Percentage of Washoe County Residents Who Reported They Have COPD 5.8% Yes No 94.2% Source: CDC Behavioral Risk Factor Surveillance System, Retrieved June Numbers may not add to 100 due to rounding errors Age-Adjusted Death Rate for Chronic Lower Respiratory Diseases for Individuals Ages 65+ Per 100,000 Population Both Sexes Male Female Per 100,000 Population 53.3 Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012e). Retrieved October

49 Non-Vascular Risk Factors Parkinson s Disease Parkinson s disease is a neuro-degenerative disorder that affects body movement. Early symptoms of the disease include slurred or softening of speech, reduced emotional expression in the face, as well as restriction of arm movement during walking. Later symptoms include an inability to control movement, including automatic movements (e.g, blinking). Parkinson s disease can lead to difficulty walking (increasing the risk of falling) as well as dementia. Current treatments for Parkinson s disease are largely pharmaceutical in nature, although Tai Chi has been found to decrease the risk of falling as well as increase muscle tone and flexibility. Per 100,000 Population NevadaAge-Adjusted Death Rate for Parkinson's Disease for Individuals Ages Both Sexes Male Female* Per 100,000 Population 4 Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012f). Retrieved October *Rates not reported due to low numbers. 41

50 Cancer According to the CDC, cancer is the second leading cause of death in the United States. The physical, emotional, and social challenges associated with cancer and treatment are important challenges faced by many Americans. According to the National Institutes of Health, cancer cost the United States an estimated $263.8 billion dollars in medical costs and lost productivity. There are several external factors that are known to increase the risk of developing cancer (e.g., lung cancer is associated with smoking). In 2012, approximately 7% of Medicare beneficiaries received services for cancer in Washoe County, which ranked 6 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012). Race/ethnicity also plays an important factor in the development of cancer, with African Americans more likely to die from cancer than any other ethnicity Percent of Washoe County Residents Told That They Had Skin Cancer 5.6% Yes No 94.4% Source: CDC Behavioral Risk Factor Surveillance System (2012e): Chronic Health Indicators Skin Cancer. Retrieved June Numbers may not add to 100 due to rounding errors Percent of Washoe County Residents Told That They Had Cancer - Other Forms 6.4% Yes No 93.6% Source: CDC Behavioral Risk Factor Surveillance System (2012): Chronic Health Indicators Other Forms of Cancer. Retrieved June Numbers may not add to 100 due to rounding errors. 42

51 Age Adjusted Death Rate for Cancer Per 100,000 Population Nevada Age-Adjusted Death Rate for All Cancers Individuals Ages Both Sexes Male Female Per 100,000 Population Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012f). Retrieved October Age Adjusted Death Rates for Selected Cancers Individuals Ages 65+ Washoe County Lung Cancer Female 38 Male 37.1 Both Sexes Per 100,000 Population Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012g). Retrieved October

52 Colo-Rectal Cancer Female 10.8 Male 15.5 Both Sexes Per 100,000 Population Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012h). Retrieved October Breast Cancer Female 16.6 Male* Both Sexes Per 100,000 Population Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012i). Retrieved October *Rates suppressed due to low counts. 44

53 Prostate Cancer * Male Per 100,000 Population Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012). Retrieved October *Rates for women not reported due to specificity of disease. 45

54 Psychosocial Needs Social Isolation Social isolation is one of the greatest risk factors for developing psychosocial problems (e.g., depression). As elder s age, they are at increased risk of becoming socially isolated due to increases in health problems (e.g., hospitalization due to hear attack or stroke) as well as declines in physical ability (e.g., increased risk of falls during physical activity). Elder s in Washoe County report increases in social isolation risk factors (e.g., decreased ability to drive). Across all age groups (65 85+) only a small fraction of elders (never above approximately 5%) reported that they were not socially isolated in any significant way. 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 5.3% 4.7% 4.1% 3.7% 0.0% Social Isolation of Elders in Washoe County 32.0% 29.7% 18.7% 27.8% 11.1% Not Social Isolated Somewhat Socially Isolated 45.3% 42.4% 39.8% 38.9% 31.5% Moderately Socially Isolated 21.9% 18.0% 26.7% 35.2% 47.2% Severely Socially Isolated Source: Washoe County Senior Services (2013). 46

55 Depression Although the majority of elders report satisfaction with their lives, some suffer from depression. Depression is a mood disorder that involves persistent feelings of sadness and loss of interest, and can cause cognitive and behavioral changes. Depression is experienced differently among elders that those at younger ages. In 2012, approximately 12% of Medicare beneficiaries received services for depression in Washoe County, which ranked 5 th in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012). Many elders have medical conditions (e.g., heart disease) or take medications for medical conditions that can cause depressive symptoms. Treatment (e.g., talk therapy, anti-depressants, or a combination) for depression is typically successful within this population. In extreme cases, left untreated depression may lead to suicidal behavior. Percent of Washoe County Residents Reporting Some Form of Depression 18.7% Yes No 81.3% Source: CDC Behavioral Risk Factor Surveillance System (2012g): Chronic Health Indicators Form of Depression. Retrieved June Numbers may not add to 100 due to rounding errors. 20.0% Percentage of Washoe County Elders Reporting Depressed Mood 16.9% 15.0% 10.0% 12.5% 8.0% 9.3% 8.3% % 0.0% Yes Source: Washoe County Senior Services (2013). 47

56 Suicide Suicide is a major, preventable public health problem. In 2007, suicide was the 11th leading cause of death in the United States. Based on 2007 age-adjusted death rates, men were nearly four times more likely to die of suicide than females, and White individuals were over two times more likely to die of suicide than Black or Hispanic individuals. Older Americans are disproportionately likely to die by suicide. An estimated 8 to 25 attempted suicides occur per every suicide death Nevada Age-Adjusted Suicide Rate for Individuals Ages Both Sexes Males* Females* Per 100,000 Population 1.3 Nevada Washoe County Source: Bureau of Health, Statistics, Planning, Epidemiology, and Response (2012k). Retrieved October *Rates suppressed due to low numbers. 48

57 Dementia Dementia is an umbrella term used to identify the cognitive/functional symptoms associated with neuronal death. Dementia is typically characterized by marked deficits in memory, as well as declines in the ability to speak coherently, ability to recognize or identify common objects, ability to perform motor functions (given that the individual is physically able to perform the task), or ability to think abstractly. To receive a diagnosis of dementia, these symptoms must be severe enough to interfere with daily life. There are several causes of dementia; with Alzheimer s disease the most commonly and most widely recognized form (i.e., approximately 60-80% of identified dementia cases are diagnosed with Alzheimer s type dementia) Nevada Age-Adjusted Death Rate for Non-Alzheimer's Dementia* for Individuals Ages 65+ Per 100,000 Population Both Sexes Males Females Per 100,000 Population Nevada Washoe County Source: Centers for Disease Control and Prevention (2014). Retrieved October *Includes vascular and unspecified dementia (F01 F03). 49

58 Alzheimer s Disease Alzheimer s disease typically presents as a significant increase in symptoms associated with dementia across a period of time (although the time course associated with the disease is dependent upon the individual). Currently the diagnosis of Alzheimer s is made in the absence of other causes of dementia, including tumor or neuronal death associated with stroke. Studies are currently examining the existence of biomarkers (i.e., increases in beta-amyloid and tau proteins in cerebral spinal fluid) that would identify the characteristic markers of Alzheimer s disease (i.e., beta-amyloid plaques and neurofibrillary tangles associated with tau protein in the brain) before the individual begins to display cognitive symptoms. Rates of Alzheimer s disease are expected to continue to increase over the next 40 years. The number of people with Alzheimer s disease within the state of Nevada is expected to increase by 73% by Other states with high rates of projected Alzheimer dementia cases include Alaska (80.3%), Montana (50.0%), Idaho (50.0%), Wyoming (52.9%), Utah (50.0%), Arizona (66.7%), New Mexico (55.9%), Vermont (54.5%), South Carolina (51.9%) and Florida (50.0%). In 2012, approximately 8% of Medicare beneficiaries received services associated with Alzheimer s disease/dementia in Washoe County, which ranked 3 rd in the state (see Appendix B for comparison to state/national rates; Centers for Medicare and Medicaid Services, 2012). Projections of Total Numbers of Americans Age 65 and Older With Alzheimer s Disease by State Projected Number w/alzheimer s (in thousands) 2014 Projected Number w/ Alzheimer s (in thousands) 2025 Percent Change Nevada Source: Table subset from Table 2 in 2014 Alzheimer s Disease Facts and Figures, Alzheimer s & Dementia, 10(2). 15 Projected Number of People Ages 65+ in the U.S. Population With Alzheimer's Disease Millions of People Year Source: Herbett, Weuve, Scherr, & Evans (2013). 50