Perspectives: Driving Reform Through Times of Crisis


In his latest Perspectives, Dr. Chernof discusses opportunities to drive change in care services and delivery that meet person-centered needs during the coronavirus (COVID-19) pandemic and beyond.

Date Updated: 06/24/2020

Nearly six months ago, the coronavirus (COVID-19) epidemic landed on U.S. shores. Its emergence and infiltration in every American community has upended daily life across our social, demographic, political, economic, and health care landscapes. With well over 100,000 deaths and counting, COVID-19 has simultaneously exposed the underlying vulnerabilities of care systems serving older adults, those living with complex care needs, and their family caregivers.

Here is what is known at the six-month mark:

  • Nearly 80 percent of COVID-19 related deaths are among those age 65 and older.
  • Over 30 percent are among those age 85 and older.
  • Hospitalizations are six times higher and deaths 12 times higher for those with reported underlying conditions, such as cardiovascular disease, diabetes, and lung diseases
  • Communities that have historically experienced inequities and health disparities have been more severely impacted. For example, Black Americans represent 13 percent of the population, yet comprise 23 percent of COVID-19 related deaths.

As history reveals, crisis of this magnitude truly is a blending of danger and opportunity. The danger is apparent in measurable items, like infection rate and mortality statistics, and less measurable ways, such as isolation, disengagement, and fear of the unknown. Yet the opportunities to drive change in care services and delivery that meet person-centered needs are also apparent. This is the moment where leadership, grounded by clear vision and goals, can convert this terrible situation into the foothold of a new world. Here are a few strategic guideposts that must be addressed to meaningfully improve access, efficiency, and effectiveness of a service matrix that meets the needs of older adults, those living with complex care needs, and their family caregivers.

Address Equity

The tragic events and subsequent protests of the last few weeks has illuminated longstanding divisions in American life and culture that should no longer be ignored. Americans of all ages, backgrounds, and cultures deserve dignity, respect, and safety—as it is a fundamental right and necessity for healthy aging at any age. Uprooting discrimination and its effects relies on our collective ability to uphold and act on the value of equity. This vision was echoed in a recent report from the California Master Plan for Aging’s Long-Term Services and Supports Subcommittee that emphasizes the need for strong gubernatorial-level leadership to chart a path rooted in equity to eliminate disparities and increase meaningful access in the LTSS system through five bold objectives:

  1. A system that all Californians can easily navigate;
  2. Access to LTSS in every community;
  3.  Affordable LTSS choices;
  4. A highly valued, high-quality workforce; and
  5. Streamlined state and local administrative structures.

Advancing California’s Master Plan for Aging

Even while the state is facing a monumental budget deficit due to COVID-19’s impact, it has never been more vital to sharpen the vision and goals for aging in this state. It is well summarized in the opening of the LTSS report:

The devastating impact COVID-19 has had on the state’s fiscal outlook cannot dampen the urgency for creative thinking, bold planning and prompt action to transform California’s LTSS system. This pandemic was preceded by an acute need to accelerate preparedness for the state’s aging population and increased incidence of disability. Bold planning does not require immediate resources, but it does require strong leadership that outlines a vision for what California’s LTSS system should look like well beyond this moment…

Maximizing Federal Flexibilities to Transform Care Delivery

Recognizing COVID-19’s severe impact on health care and LTSS delivery, federal leaders allowed states and various providers unprecedented flexibility to meet person-level needs while minimizing human contact and hence virus transmission. California adopted many of these flexibilities since March, creating space in the care delivery landscape to experience innovations like virtual care, home-based support and care coordination, as well as increased scope of practice for certain health care professionals to address workforce shortages. These changes sanctioned by federal guidance create space outside of standard operating procedures, allowing for a fresh approach to meeting services needs outside of traditional program constraints.

Invest in Community-Based Alternatives Alongside Institutional Care

COVID-19 has exposed deep vulnerabilities in care locations where some of the most vulnerable people live: residential care and skilled nursing facilities. Their exceedingly high mortality rate demands scrutiny and reform. Yet, even if the spread of infection could be perfectly contained, most individuals still wish to live and receive needed services in their homes. To coincide with this desire, California announced development of a new “Long-Term Care at Home” Medi-Cal State Plan benefit that includes person-centered assessment, transition services, care management, and home- and community-based services (HCBS). While many questions remain on the benefit’s design and structure, its potential significance for those in the community needing LTSS cannot be overstated. For years, individuals have struggled to access services through a fragmented patchwork of HCBS programs often with long waitlists and lack of statewide capacity—leaving greater risk for unnecessary institutionalization. This new benefit could be a cornerstone of California’s integrated delivery system to meet an individual’s health care and LTSS needs with access to services in home-based and/or congregate settings.

A Way Forward

California can no longer afford to wait to address the pressing and long-neglected challenges facing older adults, people with disabilities, caregivers, and families. Despite, and potentially because of these challenges we face, system change is on the horizon. This is the moment to be part of the change, to engage in the conversation and to develop a path forward through a California Master Plan for Aging that enables ALL Californians to age with dignity and independence.

Bruce Chernof, MD, President and CEO of The SCAN Foundation, dedicated to creating a society where older adults can access health and supportive services of their choosing to meet their needs. The Perspectives Series provides opinions and observations about transforming the way in which we age. Follow Dr. Bruce on Twitter @DrBruce_TSF.


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