Older adults are at increased risk for poor health outcomes and have higher rates of mortality than other groups.
Research shows that older adults face disparities in access to care due to factors like socioeconomic status, race/ethnicity, gender, and disability. Caregivers and nurses play a critical role in the provision of high-quality healthcare services to this population.
To improve higher quality of care, we need to increase awareness through policy change so that our nation’s aging population can be provided with equal access to quality healthcare regardless of race or socioeconomic status. In addition, we must increase funding for research grants which will allow us better understand how best to treat diseases prevalent among older adults such as Alzheimer’s disease and dementia. Finally, we must continue efforts aimed at improving vaccination coverage among vulnerable populations including older adults who may be less likely to receive recommended vaccinations because they are frail or live alone.
What are some of the biggest disparities that we see in the senior living space today?
Do most of these disparities come from a lack of access to quality health care? Or is it that once people have access to healthcare they're not treated or they're treated differently by the staff or is it both?
Have we been able to see the impact of healthcare disparities in situations like how COVID vaccine was disputed was dispute was distributed?
Can you talk a bit about your research and what you've discovered about improving health outcomes in the vulnerable older, older adult groups?
What is the importance of training the healthcare workforce to recognize and combat these issues?
What is the role of long-term care policy in resolving these issues?
How can older adults set goals and expectations around aging?
Dr. Jasmine Travers is an Assistant Professor at New York University Rory Meyers College of Nursing. Her career is dedicated to designing and conducting research to improve health outcomes and reduce health disparities in vulnerable older adult groups using both quantitative and qualitative approaches.
Over the years, Dr. Travers has built a strong foundation to address the health and well-being of a rapidly growing, diverse older adult population requiring long-term care. As a health services researcher, she has leveraged many datasets to investigate these issues and has published widely on the topics of aging, long-term care, health disparities, workforce issues, and infections.
Prior to joining the faculty at NYU, Dr. Travers completed a postdoctoral fellowship with the National Clinician Scholars Program at Yale University and a T32 funded postdoctoral fellowship at the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. She completed her doctoral training in health services research with a specialization in gerontology at Columbia University School of Nursing.
You can learn more about Jasmine on LinkedIn: https://www.linkedin.com/in/jasmine-travers-phd-agpcnp-bc-rn-aa2032a1/
I've seen in my research as well as other research that there are disparities in just programs that older adults have access to. So, for example if an older adult is leaving from a hospital, and either ready to be discharged home or to the nursing home, more older adults, say white, older adults saying that they were part of the decision-making when it came to being admitted to a nursing home where you see black, older adults, more so likely to say I was tricked into coming to the nursing home.", or "Someone else made the decision for me."Hanh:
Dr. Jasmine Travers joins me today on Boomer Living. She is an assistant professor at New York University, Rory Meyers College of Nursing. She has dedicated her career to designing and conducting research to improve health outcomes and reduce health disparities in the vulnerable older adult groups. Over the years Dr. Travers has built a strong foundation to address the health and wellbeing of the rapidly growing diverse older adult population requiring long-term care. So, I'm very excited to talk to her today about her work in this field. So, Jasmine, thank you so much for being with me today on Boomer Living.Jasmine:
Thank you for having me Hanh. I'm very excited to be here as well.Hanh:
Great. Great. Okay. So, what are some of the biggest disparities that we see in the senior living space today?Jasmine:
Oh, my goodness. There's so many, so much disparities. Particularly my area of research focuses on racial, ethnic disparity. So, we see disparities within the nursing home setting related to pressure ulcers among black residents having and experiencing pressure. Also there's more than white residents. We see black residents being restrained more often when compared to white residents. We also see disparities in influenza and pneumococcal vaccination. So, black residents not being offered the vaccination as often compared to white residents and also not being, not receiving the vaccination at the same time. In addition, black residents are frequently more hospitalized. They report lower quality of life in nursing, home settings as well. And particularly a lot of these disparities can also be rooted and seen in a geographic segregation. So, the racial segregation of a nursing home where the nursing home resides, whether it be in communities that are high proportion of black residents, or if the nursing home, itself has a high proportion of black residents or residents who are on Medicaid. So, those are some of the. Disparities related to quality of care and specifically racial, ethnic disparities. And then I'd also like to bring in the disparities that we see among the nursing home workforce in particularly their nursing assistant. So, we have the nursing assistant workforce who does not make a living wage, does not have opportunities to advance in their careers. They are undervalued, disrespected, maltreated, and just are exposed to just like a violence, I would say. Environment just alone last year during the pandemic. There were headlines that said that nursing assistants are in the most deadliest position compared to all positions during the pandemic. So, that's just a, it's just a significant disparity in itself when thinking about the resources that they have access to and the amount of care that they provide to the nursing home resident and how important and critical they are. But we're not doing what we need to do to support this population and this workforce.Hanh:
Now, do most of these disparities come from a lack of access to quality health care? Or is it that once people have access to the healthcare they're treated differently by the staff or is it both?Jasmine:
I would say it's both, definitely. So, the lack of access, and that goes back to this toll geographical segregation, residential segregation. And we don't just see this within nursing homes. Of course, we see this with like public schools education just access to grocery stores and parks and things of that nature. So, what happens with access? Those who are in communities that are, maybe low-income socioeconomic disadvantage, communities, communities where there might be a higher proportion of racial, ethnic minorities. They have less access to quality settings of care, nursing, home settings, or home and community-based settings for one. So, that's just like that physical access. But then as when it comes to knowledge of available services, knowledge of available programs, that's different between populations. And then when thinking about access and the wealth and income gaps that we see between black populations and white residents white population, so that in itself is going to affect access. But then we also see disparities at the individual level. So, where we see, when we control for all of the, characteristics of for example, a nursing home setting, so things that would drive a poor quality of care, we control for that. And we still see differences in processes of care, such as administering influenza vaccinations. So, we asked, "Why do we still see differences in care delivery?" So, it must mean that there are differences, in the approach when it comes to providing this vaccination.Hanh:
Now, have we been able to see the impact of healthcare disparities in situations like how COVID vaccine was distributed?Jasmine:
So, if you have a white resident and then you have a black resident, you may change the way you offer that vaccination, right? So, you may give a strong or hard recommendation for the vaccination where you say, "I have the influenza vaccination for you today. It's good for your health. It's gonna help prevent the flu. It's something that is highly recommended. Would you like to receive it today?" So, that might be the recommendation that's given to a white resident, but then when you have a black resident, you may have biases in your mind that say "There's a lot of mistrust around this population and they're not going to get it anyways." So, you come and approach that resident and say "There's this vaccination that you can have, but you don't have to have it." And then if you tell me that, then I might just say "No." So, that's the kind of the differences that we see. So, we see disparities in the actual being offered the vaccination and then also receiving the vaccination. That's on the individual level. So, just speaks to how we see these disparities.Hanh:
Sure. Can you talk a bit about your research and what you've discovered about improving health outcomes in the vulnerable older adult groups?Jasmine:
Yeah. So, my research and it spans the gamut. So, it's a lot of disparities again. A lot of workforce issues, but particularly, and bringing it back into that access piece as well, and thinking about knowledge of services. It comes from one layer where we think about healthcare providers. I've seen in my research as well as other research that there are disparities in just programs that older adults have access to. So, for example if an older adult is leaving from a hospital, and either ready to be discharged home or to the nursing home, more older adults, say white, older adults saying that they were part of the decision-making when it came to being admitted to a nursing home where you see black, older adults, more so likely to say I was tricked into coming to the nursing home.", or "Someone else made the decision for me." So, it starts way before this, where we might see white older adults having more opportunities for planning and saying "If I get this sick, then we're gonna go into an assisted living or I'm going to go into a nursing home.", where that planning doesn't happen for the black, older adult as much ahead of time. And then when it comes to these situations, they were not a part of the decision making. And then we see how that may play out in the progression of their care. And when you feel like "I was tricked. I was misled. I did not want to be here.", that's going to affect how you, kinda of receive the services that someone is trying to provide to you. This whole idea of specifically when it comes to nursing homes and the poor quality of care that we see with the nursing homes based on the proportion of black residents within a nursing home and the proportion of those residents who, their care is funded by Medicaid. So, now we see this more at a, we see this structural inequities at play and at this systemic level, right? And these policies that affect the care that is provided to specific groups. So, that's low-income groups and that's racial, ethnic minority groups. So, in these nursing homes, we see poor quality of care. We see lower staffing, as well. And that ends up carrying out to the resident. So, then that's now how over the course of the pandemic, and we're all just bringing all these things to light that has been there. And we say, "Oh my goodness nursing homes with high proportion of black residents, they're seeing more COVID cases and they're seeing more COVID deaths." But this has been, the issue over the course of the years. Yes, COVID infections and COVID deaths are just another indicator of poor quality of care. But this is a type of quality of care that we've seen among these nursing homes and among these populations. So, in that whole idea of things and thinking about the systemic and policy issues, Medicaid, for one, can help support, the care that is provided to these institutions. So, more intentional, more investment in these institutions, as well as the communities where these institutions are at. So, thinking about, can we increase Medicaid reimbursement, which when we see that happening better quality of care happens. And, also not just increase the Medicaid reimbursement when thinking about the quality level, but we also have to, spend time at the institutional level. So, it's not just increasing money, but making sure those within these institutions are doing the right things with the money. Ensuring that the money is going towards resident quality care. It's going towards staffing. And people, are intentional about the services that they are providing to this population.Hanh:
Yes. So, what is the role ageism plays in terms of health care inequities?Jasmine:
So, thinking about ageism. Yeah, there's definitely the inequities that I talked about when it came to socioeconomic inequities and racial inequities. But just taking a step back and just thinking about COVID all of last year, 80% of those COVID infections were deaths among older adults, 65 years of age and older. And then particularly we saw nursing homes being, getting, experiencing the brunt of the COVID deaths. So, this whole idea of ageism, if we saw that type of impact, when it comes to deaths among a population specifically among our children, we would have never allowed for, low resources, insufficient staffing to go on for as long as it did. We would've never, Live to talk about how many lives of children we lost. And yes, granted older adults were a little bit more susceptible of course, to COVID and thinking about the congregate settings and, the co-morbidities, but it's just our view when it comes to the older adult population. Where it's like, "Oh, okay, you're older. That's why you're dying. And it's okay." And in a sense, not so much in all those words, but I'm just saying if it were the other way around, when we looked at our child population, then I'm sure it would not have played out the same way. We wouldn't have been so forgiven, forgiving of those lives.Hanh:
I think the whole world sees that. It's such a shame and this is just one more example of ageism that exists, for many decades. So, what is the importance of training healthcare workforce to recognize and combat these issues?Jasmine:
That's extremely important. Oh my goodness. That's a couple of different layers too. But definitely, we have racism that takes place in the nursing home setting, particularly. And there is ageism. And then there is, populations that we were not I guess historically trained to care for. So, the LGBTQ population. Where, it's hard when you're an older adult, clearly to be able to communicate, your needs, if you are a part of the LGBTQ population. And, because of fear and stigma and all types of just is barriers. So, there's so much comprehensive training that we need among our workforce. But then we also need the supports to provide that training. Training is costly. We need to ensure that we are providing training comprehensively, meeting all of the different aspects of that. And then also paying for the time that workers are going to be out of work to attend those trainings. When it comes to nursing assistants specifically, and I did some work, trying to understand the social based discrimination that they experienced in nursing homes. And some of the qualitative work that came out of it, in other literature says that nursing assistants, they, for one experience, more racism within the nursing home institutionalized setting compared to outside of this setting and that they would have workers and supervisors witness their experiences of racism and not step in. So, it's one thing when you have a resident, and this is what the nursing assistants say, you have a resident that you know, get says racial slurs or just words that are very hurtful, but at the same time, they're attributing it to their their diagnosis. Maybe if they're dementia, have a dementia diagnosis or they're confused. So, they attributed to that. But then when they experienced, these of racism from family members, or other peers or supervisory staff, and people witnessed that and don't step in. And sometimes it's because they don't know what to do, what to say, right. To step in. So, that's, it that's an issue. So, we need to first train our staff on how to step in when these issues happen, but also create this culture in an environment that this is not acceptable, among anyone. And then how do we have these conversations in a way that we feel safe also?Hanh:
Okay. Now, do you think these changes can be made on an individual level or are they more systemic and require bigger solutions? All the key stakeholders.Jasmine:
So, I would say it's both individual and a systemic level. So, that kind of goes into this whole idea of quality of life. Quality of life for residents, quality of life for staff. And how do we measure that? How do we incentivize that? And how do we ensure that is what's being experienced within a nursing home? So, thinking about the environment within a nursing home. So yes, that culture, happens and is created within the institution, but at times you are going to have to really facilitate that culture on a systemic level. So, as we have these quality metrics in place, a nursing home compare, they say, you have to make sure you meet these metrics. Pressure ulcers falls, restraints, vaccinations, but how do we capture the way that staff are being treated and how they appreciate, the environment that they're working in. That's something that needs to be captured inside these metrics as well, so that you're holding nursing homes accountable, right? You're not just relying on a specific institution to say "You know what you need to do well by your employees and your your staff and your residents." But having that incorporated in these metrics so that people know, "You know what, this is a good place for my loved one to be cared for. And this is a good place for your staff members to work in, right? This is a safe environment. This is an environment where people enjoy coming into and they feel respected and they feel themselves cared for." So, that's something that's going to need to happen from the top up and from the systemic level, as well as the institutional level and ensuring that those who are in higher positions are people that are intending to do right by, both staff and residents. And it's not to say there aren't people in those positions because they're most definitely are, but we have to ensure that, across the board. And then also being able to understand these issues, being trained in cultural sensitive sensitivity. And we're not going to know everything. But just being able to approach that in a more sensitive and intentional manner.Hanh:
So, everyone is a key player. We all can contribute. We all can contribute because how I look at it is, we're all heading in the same direction. So, at an individual level corporations central authority, like the government NGOs, for example. So, it's all levels. That's my take.Jasmine:
No. Yeah. MmmHmm.Hanh:
And also I think, as far as combating ageism, it isn't pointing the finger who's at wrong, or who's the culprit. It's all of us having these kind of conversations like you and I are having to bring that awareness, and to support one another because in my mind, aging is a gift. Let me tell you nowadays, living and aging is a gift because many people didn't make it through COVID. So, I think to bring awareness, to have these kinds of conversations and amplify it, whether it's with your family, with your workers, social media. Raise the awareness.Jasmine:
Right. Right. Right. I agree. You talk about aging as a gift and it's changing our perspectives, and changing the ways that we think about aging and getting old. AARP has a campaign going on the Disrupting Aging Campaign, and one thing that they've done, which is so cute with students is they'll go and they'll ask students, "How old is old?" And you'll see all these ranges, they say 25, 30, 35, 40 50. And then the question is, "Okay, if old is old.", right. And you ask, "All right, how many people want to get old?" And then no one raises their hand. So then that means then you must want to die at the ages that you said old is if it's 21, if it's 25, it's 30, and then they changed their mindsets about that. And they're like, Oh, wow, no, I don't want to die at 21. I do want to get old. So, it's just like how you're saying aging is a gift, right?Hanh:
It sure is. Okay, so what is the role of long-term care policy in resolving these issues? What's your take on that?Jasmine:
Yeah. So, as long term camp policy, I would say there are a number of areas where we can see a little bit more support in regards to policy. So, in the workforce space. So, thinking about that training that we talked about before, and not just training specific to addressing issues of racism ageism and all these other inequities, but just training to provide care to this complex population that is in long-term care. Thinking about what that training looks like, what it is, what it consists of and the number of hours that the workforce is receiving training. And then ensuring that training is just not one time, but ongoing the staff wants to receive training. They want to better care for the populations that they're responsible for, but they need that education. That's one area where long-term care policy can support. And then I would say also long-term care policy can support the financing of a long-term care system. Right now we don't have a long-term care system. Medicaid is for the low income. And then, those who are self pay, they can afford it, right? They're a part of the higher income group among the middle income. Long-term care is difficult, especially in nursing homes where it's a hundred thousand, it could be a hundred thousand plus a year for a nursing home stay. So, that's an area that we need to really be supported in better when it comes to long-term care to have the financing, to be able to support older adults who are going to need long-term care because that's increasing. Two out of three older adults are going to need some form of long-term services and supports by the time they age, 65 years of age or older. So, that's important as well. So, I would say, the workforce recruiting of developing our workforce, increasing the workforce in long-term care, and then also the financing of long-term care, and then ensuring that we're able to provide better resources and support for our long-term care programs, services, and settings.Hanh:
Yeah, those are good points. Also, how I see this too, is that the sector first of all, it isn't one sector. It isn't about senior living. It's all across because when you're dealing with healthcare, it's across the board and the fact that it's in the media. I think we all to remove these silos and just work together, right? Whether it's technology, hospitals, long-term care, there's abundance of folk that needs to work in harmony. And the fact that we are in the media and there's a lot of, let's say retail and tech giants that are interested in serving older adults as well. So, I think the goal is not to be threatened of each others professions, professionals or the different sectors that we're working together. It's really, how do we work in partnership and really leverage the fact that this is one, a much needed investment, much needed effort to serve 10,000 baby boomers or 10,000 people turning 75 plus for the next several decades? So there is a wide need for it. So, I see it as how do we work together across the board? But I appreciate your thoughts. I think it's it's spot on. Now, so, how can older adults set goals and expectations around aging?Jasmine:
So, I would say that aging well is something that older adults, we don't give older adults the credit that we, that they are due when it comes to them wanting to age well. Age with purpose. Cause we sometimes can see as we grow older and that's why there's a stigma against growing older is that, there's like life ceases. That life is it can't continue. I would say, there's one aspect of it when it comes to older adults and them aging well and helping them with that. So, it's this whole idea of aging well is increasing the length and quality of life. But allowing and ensuring that those who are within long-term care settings, long-term services and supports, understand that older adults, or wants to age well. That more often than not, that is a priority of, there is an understanding, what does it look like for older adults to age? What is it, what are their goals and expectations and how do we incorporate that into our setting to ensure that is happening? I did a study recently looking at the goals and expectations specifically across long-term services and support settings or home and community based the assisted living and nursing homes. And so, just to read about this was a qualitative study, so to read the transcripts and see all of the goals and expectations that older adults have. They wanted to maintain contact with family. They wanted to, transition. If they weren't in a nursing home or an assisted living, they wanted to be able to transition back to the home. They wanted to have purpose that whether that was civic purpose, meaning that they wanted to give back to the community. They wanted to open up a grocery store or are they wanting to write a book? They want to maintain voice, Live active lives. So, when thinking about that, remaining engaged with social activities, playing tennis, playing cards, meeting new friends, engaging with old friends. When thinking about that, how do we create environments? Whether it be in the home and community setting, which I think we're starting to look at that a little bit more when it comes to these Age Friendly Neighborhoods and Age-friendly Environments to say, ensuring that neighborhoods are walkable for older adults and across the age spectrum and there's activities for those across the age spectrum to participate in. But not forgetting that this same concept needs to be in the assisted living and the nursing home setting as well, because it doesn't change, going from home and community to the nursing home or to the assisted living. So, that's one thing I think. Older adults are going to be able to set their goals and expectations, but it's our job to actually ask, the question.Hanh:
Go directly to the source. I got to tell you, I hear so much and don't get me wrong. I respect and I admire everybody's excitement to offer their services and products. But I also think too often, how do we come up with these products? Okay. Is it top down or bottom up? In my mind, it needs to be bottom up because here's the thing, you start with the user in mind and that the user is the older adult. Go directly to them. And then also everything that you do described as far as aging, I got to tell you I'm in my mid fifties, I want the same thing. So, whether you're an older adult or a baby boomer like myself, it's humanity. We all want the same thing. But the unfortunate thing is with society because as people age, perhaps when they don't contribute to, let's say, society or have a job with regular income, but you know where I'm going with this, they are perceived as less valued suddenly. Oh my gosh. What do you want since you're less of a value to society, now. You see what I'm saying? Because I agree everything that you're saying. I also believe, at a higher level it's what every single person wants. You and I, whether you're in your thirties, forties, or mid fifties, like myself, I want the same thing.Jasmine:
Exactly. Exactly. So again, So, it's not so much the focus on the older adults, but focus on, those who are providing, they can exactly, it's a humanity.Hanh:
And then another thing I want to make, I guess this point is it's so important that when the older adult, your loved one goes into nursing home long-term care and so forth. I got to tell you their temperament, their emotional need is so huge. And they are not defined by their illness, although that may be the reason why they're there, but they're much more than that. You know what I'm saying? They're so much more than that. And it, it takes another heart to understand their journey, okay. Don't come in here and look at my charts and see me as I am overweight with diabetes. They're much more than that. It just boils down to, it takes a special person, whether it's a caregiver or a loved one daughter, family member to dig in and understand their journey of how they got there. And I think if you can do that, you can better serve them and understand, and for them to trust you, They got to trust you to open up. And you can't gain that trust when there's such a high tone or turn over in caregivers. I appreciate your time. Do you have anything else that you would like to share?Jasmine:
I really appreciate you having me on here, Hanh and for allowing me to be able to share a little bit about my work and some of the issues that I've been seeing, over the course of the years within the long-term care space.Hanh:
I appreciate you. I appreciate your work and your dedication. And being another leader in this industry and doing your best and bringing awareness on very important topics. So, thank you so much.Jasmine:
No problem. Thank you, Hanh.