1. Profile of Chinese American Elders Enrolled in a Geriatric Program at an NYC Community Health Center 10/1/2009 – 9/30/2011 APHA Annual Meeting November 1, 2011 Charles B. Wang Community Health Center

2. Presenter Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Ady Oster No relationships to disclose

3. Summary Chinese-Americans are fastest-growing elderly segment in NYC Face multiple barriers – language, poverty, education, culture We report on our experience in caring for 230 vulnerable elders in a primary care-based geriatric practice

4. Center Background  Charles B. Wang Community Health Center  FQHC founded in 1971  4 locations in Manhattan and Queens  40,000 patients making >200,000 visits in 2010 90% prefer language other than English

5. Manhattan’s Chinatown Pell Street, 2009

6. Manhattan’s Chinatown  Population 2006: 84,800  66% Asian  59% foreign-born  70% of Asians < high school education  71% elders: limited English proficiency  31%: below poverty line  Proportion of Elders in Chinatown growing: 30% increase over 10 years Asian American Federation of New York, 2004

8. Program Background  Needs assessment (2006): Chinese elders report difficulty navigating health and social service system Increased need for health care, social services, care coordination and outreach  Medical Home for Chinese American Elders: geriatric practice serving vulnerable elderly modeled on Patient-Centered Medical Home Two-year period Launched: October 1, 2009

9. Program Background  Enhanced services: Screen for vulnerability Comprehensive geriatric assessment Psychosocial assessment Individual care plans Medication management  Service goal Screen 1,000 seniors for vulnerabilities Enroll 200 for enhanced care  Funding Program Cost: total ~ 500K Fan Fox and Leslie R. Samuels Foundation contribution: 250K

10. Program Outline:

11. Demographics Male Female Gender n=230 Ethnicity n=230 Chinese Caucasian Other

12. Demographics Language n=230 Mandarin Cantonese English Other Birth Country n=230 China USA Taiwan Other

13. Demographics *Insurance status for primary or secondary insurance

14. Assessments Mini-Cog:Timed Get up and Go: N= 214

15. Assessments Scale N Mean (SD) ADL (Activities of Daily Living; Range from 0-12) 203 10.4 (2.1) IADL (Instrumental Activities of Daily Living; Range 0-16) 201 9.6 (3.8) K6 (Psychological Distress Assessment; Range 0-20) 177 1.63 (3.0) SF-8 Mental Score (Quality of Life; Range 30-70; US mean = 50) 49 55.0 (5.3) SF-8 Physical Score (Quality of Life; Range 30-70; US mean =50) 49 42.3 (9.3)

16. Services Utilized: Provider Visits Total = 2,633 Mean = 11.4 SD = 5.6

17. Services Utilized: Social Work Visits Total = 1, 614 Mean = 7.0 SD = 9.1

18. Services Utilized: Frequency of Mental Health Visits

19. Services Utilized: Frequency of ED Visits or Hospitalizations Limited to those with ED/Hospital visit: N = 29 Mean = 3.8 SD = 3.1 Overall: Total Visits = 111 Mean = 0.5 SD = 1.7 Elders with hospital visits = 7 Elders with ED visits = 22

21. Conclusions  Chinese Elders enrolled in a primary care geriatric program  Multiple visits with providers and social workers  High rates of dementia (mild), mobility difficulty, diminished capacity performing IADL’s  Low rates reported depression/other psychiatric illnesses  Low utilization of mental health services  Relatively low overall utilization of ED/Hospitals  Small group of high utilizers

22. Barriers: Lack of language-proficient social work support Need for language-proficient Home Health Aids Transportation barriers Cultural barriers accessing mental health?

23. Possible Future Programs: Patient navigation Travel companions Social work funding For FQHC For patients receiving care from private MD’s

24. We are grateful for the generous support from the Fan Fox & Leslie R. Samuels Foundation Thank You

25. Team Members  Clinical Director: Ady Oster, MD, MBA  Program Advisor: Susan Seto-Yee, RN, MPA  Program Manager: Jaclyn Tsang  Physician Champion: Ginger Wey, MD  Social Worker: Amanda Wong, LMSW  Social Work Assistant: KC Wong  Registered Nurse: Joyce Ling, RN  Care Manager: Cora Toa  Health Educator: Melissa Ip, RD Contributing managerial staff: Regina Lee, JD; Manna Chan-Espin, LCSW; Tracy Wu, RN; Ida Wong; Ina Elbaar; Shao-Chee Sim, PhD; Perry Pong, MD; Betty Cheng, LCSW

26. Geriatric Screening Tool

27. Vulnerable Elders Survey (VES-13)

28. Geriatric Assessment

29. Mini-Cog Dementia Screening

30. KATZ Activities of Daily Living (ADL) Scale

31. LAWSON Instrumental Activities of Daily Living (IADL) Scale

32. Medication Management Assessment

33. Psychosocial Assessment (page 1)

34. Psychosocial Assessment (page 2)

35. Psychosocial Assessment (page 3)

36. Emergency Room (ER) History

37. Hospitalization History