|Triangle J Council
Co-Chair: Melvin Jackson, Project DIRECT
Co-Chair: Gibbie Harris, Wake County Human Services, Community Initiatives
Charles King, Human Services Board
Robin Temple, Director of Community Services, Hospice of Wake County
Penny Shelton, Clinical Pharmacist, MEDS Program, Resources for Seniors, Inc
Maura Marini, Human Services Leader II, Wake County Human Services
Celestine Beatty, Human Services Board
Alan Kronhaus, owner, Physicians Making Housecalls
Willie Mae Prescott, consumer
Access to Healthcare
A recurring theme throughout the process was that senior adults in Wake County are concerned about remaining
independent as they age. A strong component of independence was the ability to access affordable health care.
Wake County is fortunate to have high-quality healthcare resources available, with three hospital systems and
numerous physicians in a variety of specialty areas. Nonetheless, a major concern expressed in senior focus groups
and recognized by the Aging Services Committee was the lack of access to affordable healthcare. The key to this
apparent paradox lies in the sources of funding for seniors’ care. Both Medicare and Medicaid place strict limits on
physician reimbursements for medical services, well below rates paid by private insurers; as a result, many physicians
have either declined to see Medicare and/or Medicaid patients altogether, or have limited the number of these patients
in their practice. Consequently, seniors may have a very difficult time finding a physician who is open to new patients.
The issue of premature aging in adults with developmental disabilities compounds the access issue. Research
suggests that the aging process in people with developmental disabilities is seen around the ages of 45 – 55. In
persons with Down Syndrome, the aging process may be seen as early as age 35. Many of these individuals only
have Medicaid. Again with Medicaid, provider choice is limited due to reimbursement rates. Often times, there is a
long wait or difficulty accessing a physician who accepts Medicaid and has some expertise in the needs of the
developmentally disabled population.
Wake County also has a significant group of seniors who are uninsured or underinsured. Although the median
retirement age is 62, Medicare coverage does not begin until age 65. Thus, seniors who retire earlier may experience
years during which they have no health coverage at all. Unless they are able to access coverage through a former
employer, individual coverage may be nearly impossible to obtain at an affordable price, especially if there are pre-
existing chronic medical conditions such as heart disease or diabetes.
Even if they have Medicare, most seniors find it necessary to carry a “Medigap” policy -- a private insurance plan, which
covers the deductibles and coinsurance amounts that are not covered by Medicare. These supplemental plans can
cost hundreds of dollars a month in some cases, making them out of reach for many low- and moderate-income
seniors. The Medicare-Aid program, an extension of Medicaid, pays deductibles and copays for a small group of
seniors whose financial resources are just above Medicaid limits, but eligibility requirements are very restrictive.
Transportation issues also present barriers to care. “Great advances in healthcare mean little to those who can’t
access them. The Medicare program’s restrictions on transportation expenses have resulted in reduced access to
medical services and preventative care, increased use and expense of emergency room care and the unintended
consequence of isolation for seniors on fixed incomes” (Community Transportation Association of America Magazine,
Volume 20, Number 6). In addition, senior adults living in long-term care settings must often rely on staffing resources
to get them to numerous and time consuming medical appointments. The more that staff resources are devoted to
providing medical transportation, the less those resources are available to assist senior adults in participating in
community based leisure and retirement activities.
Based on focus group results, an extremely pressing issue of concern for seniors is the cost of prescription
medications. Medicare provides no prescription coverage at this time, and Medigap policies which include meaningful
coverage are usually prohibitively expensive. Medicare Reform legislation recently passed by the federal government
promises some limited coverage, but full benefits will not begin until 2006.
Even then there will be significant gaps in coverage. In the meantime, many seniors face impossible choices between
paying for medicines and paying for other basic needs such as food and shelter.
Health Promotion: Physical Activity and Nutrition
Healthcare includes not only access to doctors and medicines, but also access to services that promote health and
prevent disease. Practicing a healthy lifestyle with regular physical activity, healthy eating, and avoiding tobacco can
prevent much of the illness and disability associated with age and chronic disease. Physical inactivity can increase a
person’s risk of heart disease, colon cancer, diabetes, and hypertension. In contrast, regular exercise is known to
contribute to healthy bones, muscles, and joints; help relieve the pain of arthritis, and reduce symptoms of anxiety and
depression. Only 25.5% of North Carolinians age 65 or over meet the recommended level of exercise (30 minutes of
brisk walking five times per week.) Individuals must take responsibility for making these kinds of lifestyle changes for
the sake of future health and well-being.
Good nutrition is also critical. Many older adults have difficulty preparing adequate meals as they encounter increasing
physical limitations. Furthermore, special dietary requirements can force changes in the eating habits of a lifetime,
making it even more difficult for seniors to eat right. The maintenance of good nutritional health is essential to the
prevention or delay of chronic disease and disease-related complications, and to the maintenance of high quality of life
for older adults. Several studies have linked poor nutrition to various health consequences such as diminished
immune response, longer hospital stays and more frequent readmissions, impairment in physical and cognitive
function, and increased severity of disability.
Health Promotion: Influenza and Pneumonia Immunizations
Pneumococcal pneumonia, which is a bacterial infection, is a leading cause of preventable death among those age 65
and older. It is blamed for up to 45,000 deaths each year in the United States, and approximately 50 percent of these
deaths can be prevented through the use of a pneumonia vaccine. One pneumonia vaccination protects most people
for many years, however, a booster may be recommended for those at higher risk. Medicare pays for the pneumonia
shot every five years.
Influenza is another major health risk for older people and those with weakened immune systems. Flu shots are
recommended annually, because the predominant strains of the virus change from year to year. Medicare will pay for
annual flu shots.
One of the most vulnerable groups of seniors are those with dementing illnesses, which include Alzheimer’s Disease,
Parkinson’s Disease, multi-infarct (stroke-related) dementia, and a number of other syndromes. Approximately 10% of
the over-65 population, and 40-50% of the over-85 population suffer from dementia of some kind. The North Carolina
Division on Aging estimated that there were 2,774 individuals living in Wake County in 2000 with mild, moderate, or
severe cases of Alzheimer’s disease. Since adults are living longer and longer, more and more individuals are
expected to be diagnosed with Alzheimer’s disease some time during their lives. Alzheimer’s disease is the most
common cause of severe progressive loss of recent memory and thinking ability in previously well middle age and
older adults. These individuals present huge challenges to their families, caregivers, care facilities, and the
community at large. In addition, research suggests that between the ages of 40 – 60 an adult with Down Syndrome
has a 22% risk for developing Alzheimer’s Disease. This percentage jumps to 56% at age 60 and older. Transitional
screening tools used with the general population often do not work for persons with developmental disabilities due to
the fact that that those individuals may never have had baseline skills (i.e., reading, memory, etc). There is a need for
support professionals in traditional senior related settings (i.e., adult day care centers, nursing /adult care home
facilties, senior centers) to have additional training regarding persons with developmental disabilities. Many of these
professionals are experts in the area of aging but not necessarily with issues related to developmentally disabled
To live with damaged thinking and judgment is to live at risk. Individuals suffering from dementia cannot predict
outcomes of their actions or evaluate risks. They can become lost, ill from exposure, dehydrated, malnourished or
become easy prey for exploitation. They can be convinced to sign things they don’t understand, buy things they don’t
need, give money away, and be sexually abused. They can succumb to self-neglect or die from neglect by others.
They can choke on food and fall easily. An adult who suffers from Alzheimer’s disease must be appropriately
supervised and evaluated for risk. Even in the best of circumstances, protection or anticipation of risk is not always
According to the American Psychological Association, an estimated 20% of older adults living in the community, and
50% of adults living in nursing homes, suffer from depression. Late-life depression affects about 6 million Americans
age 65 and older, but only about 10% receive treatment. Symptoms of depression are often confused with the effects
of multiple illnesses and the medications used to treat them. Depression is a serious matter. It tends to last longer in
elderly adults, doubles the risk of developing cardiac disease and substantially increases the risk of death from
illnesses. Depression can also lead to suicide. Older adults have the highest suicide rate of any age group. Elderly
white men are at greatest risk, with suicide rates for 80 to 84 year olds more than twice that of the general population.
Depression can be caused by many life events including loneliness, chronic or acute pain, grief, economic insecurity
and loss of self-esteem.
Substance abuse affects more than three million men and women over the age of 60. The Center for Substance Abuse
Treatment has estimated that up to 17 percent of the elderly population in the United States abuses alcohol and drugs.
Drug use among institutionalized senior adults is even more prevalent. Because of their advanced age, senior adults
are at even greater risk for the health problems and trauma associated with substance abuse.
Symptoms of alcoholism and drug abuse are difficult to detect in the elderly.
Sleeplessness, shaky hands, memory loss and chronic health complaints may be misread merely as signs of aging.
As a result, family, friends and the doctor are often not aware of a senior adult’s drinking or drug use. Why don’t seniors
seek treatment on their own?
Many elderly adults were raised on the philosophy that they should be able to solve their own problems and are
embarrassed to admit they need help. Even if senior adults do seek help, they most likely will not find programs
tailored to their special needs.
In addition to alcohol, the most common drugs used by adults over age 65 are cardiovascular, antihypertensive,
analgesics, anti-inflammatory, sedatives and gastrointestinal. These drugs are often mixed, leaving senior adults
vulnerable to adverse drug reactions, addiction, and toxic loads on the liver and kidneys.
Existing Resources and Challenges
Access to Care
As noted above, Wake County does have a large number of practicing physicians. Medicare’s website (www.medicare.
gov) provides a means to search by specialty and location for physicians who are signed up to accept Medicare
payments. This database currently lists 17 physicians who specialize in geriatric medicine, 398 in internal medicine,
and 230 in family or general practice. (Note: there may be overlap in these groups, as physicians can list more than
one specialty.) Of the number of physicians listed, few have expertise in supporting persons with a lifelong disability.
This compounds the issue of access to care for persons with a lifelong disability. Also, this database does not include
information as to physician availability. Many of the doctors listed are not currently accepting new patients, leading to a
frustrating experience for a consumer seeking a new doctor. There is no centralized local information source that
tracks physician availability.
For seniors who are not yet Medicare-eligible and do not qualify for Medicaid, there are no available resources to assist
with purchasing health insurance. These individuals must either spend a crippling proportion of their income on
private coverage, or go without. Needless to say, if they do become ill, they face financial disaster and place great
strain on public health resources. The Open Door Clinic in Raleigh, operated by Urban Ministries, does provide some
healthcare services for these clients with no insurance, but availability is limited.
For seniors who can meet the stringent eligibility requirements of Medicaid, up to 6 prescriptions per month are
covered, with a modest copay. For those whose incomes exceed Medicaid guidelines, the only state-sponsored
assistance is the NC Senior Care program, which is limited to a maximum benefit of $1200 per year. Some seniors
who are veterans have access to prescription coverage through the VA; however, this benefit can be difficult to access
and there are extensive wait lists. Some seniors have coverage through health insurance programs linked to their
former employers; trends suggest that these benefits are vulnerable to reduction or disappearance as retirement
benefits are being modified by many companies.
Resources for Seniors’ MEDS program has been very successful in assisting low-income seniors to apply for free
medications offered through pharmaceutical companies’ Patient Assistance Programs. The program serves Wake
County seniors who do not have any prescription coverage and have incomes less than or equal to 150% of the federal
poverty level. In addition to prescription access, the program also provides medication evaluation and education
services. As 2004 comes to an end, the program is providing close to $100,000 worth of free medication to Wake
County seniors each month. Unfortunately, due to limited funding for staff, this program is able to address only a
fraction of the demand, leaving hundreds of vulnerable seniors on waiting lists for assistance.
The FIGS (Filling in the Gaps) program, a nonprofit service funded by community contributions and administered
through Wake County Human Services, provides essential one-time medication assistance, but cannot provide
ongoing assistance for routine medications. Other sources of short-term help include samples obtained from
physicians, and emergency funds provided by church or community groups. A variety of other small programs exist, but
overall the need remains unmet for most seniors.
Health Promotion: Physical Activity
Seniors can participate in healthy exercise and physical activities in a number of environments such as neighborhood
groups, church programs, YMCA, YWCA, City of Raleigh Senior Programs, hospital-based fitness classes and
memberships in private fitness clubs. Wake County seniors are fortunate in that there are five full-service senior
activity centers located in Raleigh, Garner, Wake Forest, Wendell, and Cary. At each of these Centers, numerous
fitness, exercise, and health and wellness programs are offered daily at little or no cost to the senior. The survey and
focus group results indicated that Senior Centers offer many types of activities designed to help senior adults remain
healthy and active. Focus group participants reported that they enjoy those activities but note that the centers do not
attract the younger and more active seniors.
The focus groups also agreed with survey results that senior centers are well distributed through the County, although
group participants would like to have a senior center in every community. Holly Springs, Apex, and Fuquay-Varina have
no senior centers, and Raleigh, despite its size and recent growth, still has only one for the entire city. One of the
biggest barriers to the access and utilization of the physical activities and health and wellness programs, at the centers
and elsewhere, is the lack of affordable transportation. Additional centers would bring programming closer to
participants, making it more accessible to many.
Health Promotion: Nutrition
Providing meals to older adults in group settings and individual homes is the primary focus of the Elderly Nutrition
Program in Wake County. Many adults with lifelong disabilities have never been able to cook for themselves due to
cognitive and/or physical support needs. Meals on Wheels of Wake County, Inc. has efficiently operated the large
congregate and home-delivered meals programs in Wake County for thirty years. The senior nutrition program serves
hot nutritious meals to older adults, many of whom are at moderate to severe risk of malnutrition. In Wake County,
51% of clients receiving home-delivered meals are at high risk of malnutrition. These services are more than a meal
and include related services including nutrition screening, education and counseling.
The eight congregate meals programs across Wake County offer older adults opportunities for social interaction,
mental stimulation, and informal support. The home-delivered meals program allows volunteers who deliver meals
an opportunity to check on the status of the homebound older adult and to alert Meals on Wheels to involve other
appropriate agencies if additional assistance is needed. Referrals are frequently made for transportation, in home
aides, home modification, and food assistance programs such as food stamps.
Currently there is inadequate funding for the meals program to meet the needs of Wake County’s seniors. Meals on
Wheels provides one hot meal per day, five days per week, but many vulnerable older adults need more than this. In
addition, home-delivered daily meals are not available in all areas of the county. In some areas, only frozen meals are
available, while in other areas there is a waiting list for home-delivered meals due to the need for additional
volunteers. Also, although volunteers have the opportunity to observe and make referrals for seniors who are in need,
Meals on Wheels currently has no in-depth case management capability for those clients who need ongoing
On a positive note, Meals on Wheels and the InterFaith Food Shuttle are engaged in a collaboration that will result in a
state of the art meal preparation site. This will enhance the congregate and home delivered meals programs, and
make frozen meals, fresh produce, hot meals and shelf-stable meals available to more adults in Wake County.
Health Promotion: Influenza and Pneumonia Immunizations
Fewer than two-thirds of the nation's senior citizens are getting vaccinated against flu and pneumonia - well short of the
government's goal of 90% by 2010, the U.S. Centers for Disease Control and Prevention (CDC) reports. In a 2001
survey of nearly 40,000 elderly people by the CDC, only about 65% said they had received a flu shot in the preceding
year, and only 60% had ever received a shot against the most common form of bacterial pneumonia. According to the
most recent data available (year 2000), Wake County had 47% influenza vaccination coverage for individuals over 65
years influenza vaccination coverage for individuals aged ³ 65.
Wake County has some excellent local resources to assist patients and families who are dealing with dementia. The
Eastern North Carolina Chapter of the Alzheimer’s Association is located in Raleigh, and provides essential education
and support services for patients and families. Specialized dementia evaluation is available from clinics at Duke and
UNC-Chapel Hill, and professionals such as social workers and nurse practitioners offer assistance with behavior
management and care issues. A number of the local long-term care facilities offer specialized dementia care units,
which seek to provide the added security and individualized programming needed to maintain quality of life for these
Significant gaps in service still exist, however, especially for younger developmentally disabled adults suffering from
Alzheimer’s Disease. Most Alzheimer’s patients are cared for at home, or in long-term care settings that are not
specialized for their needs. In many facility settings, they are housed with younger/older adults suffering from chronic
mental illness; this is frequently problematic due to the very different needs and behaviors of these two groups. When
behavioral crises arise, as they often do, dementia patients may simply be sedated or restrained, because the care
providers are not sufficiently trained to do otherwise and there may not be a trained professional available to come to
the home or care facility. If the crisis becomes severe, the dementia patient may be transferred to a hospital setting for
stabilization; unfortunately, Wake County lacks a geriatric care unit that can provide this specialized care. Such
hospitalizations may also be very traumatic for both patient and family.