Conference on the Well-Being of Asian American Senior Citizens – Session 1A

Rochelle Holland: Welcome everyone to Breakout Session 1, today’s speaker will be Tracy Luo, the Director of Asian Outreach and Public Education of Mental Health for the Association of New York City; Betty Chen, who is the Chief Operating Officer at the Charles B. Wang Community Health Center; Heidi Chan from the Visiting Nurse Services of New York. First up is Tracy Luo.

 

Tracy Luo: Hi everyone! I’m just going to summarize some of the issues regarding mental health issues relating to the elderly population. According to the 2000 US Census, in New York State, the Asian Pacific Island older adult population is expected to significantly increase over the next quarter century from 79,000 to 321,000. Another, analysis of the 2000 US Census data by the Asian American Federation shows that about 94% of the Asian elders are foreign born. 54% arrived in the U.S in the last 20 years. 70% have limited English proficiency. 24 % are living in poverty. 59% have not completed high school. And 45% have not finished the 9th grade. In addition to these numbers, I think there are a significant number of undocumented immigrant elders who have not been included in these figures. And of course, this group of elders is ineligible for many of the benefits in New York City, especially Medicaid or Medicare. This statistics indicate that many Asian elders in our community are not fluent in English.

 

I also want to explain some of the issues that cause Asian elderly to develop mental health disorders. The first is of course the language barrier. If they don’t speak English, it is very difficult for elders to access the mental health system, especially because we’re lacking in bilingual, services. Another thing is minimal social and emotional support. The reason why I say that is because when we do screening and outreach in the community, especially in the housing projects, we find a lot of the elders are quite isolated and lack of social and emotional support. Many of them have low social economic status. Also they have limited access to welfare and residential programs. Lacking access to health care, limited knowledge and awareness of mental illness, lost of significant relationships, and suffering from physical disease all these problems will cause Asian elders to develop mental and emotional problems in their late lives. Depression is a really prevalent disease among these elderly. Right now, I want to talk about the prevalence of mental disorders. As the size of the population grows, the number of the Asian older adults with mental disorders in the United States will increase from at least 160,000 in the year 2000 to at least 640,000 in 2030. The number of older adults with mental disorders will also increase from 16,000 to at least 54,000.

According to the study by Asian American Federation, depression is experienced by Asian American elders at a higher rate than the general population. The study shows that women at the age of 65, especially those over 85, have the highest suicide rate compared to all other groups at the same age group in the US. I think 2004, there acre about 28 suicide cases in the Chinese community. At least 5 cases involved people over 65 years old, and almost all of them had chronic and physical illness.

 

Asian patients in general, tend to be much more severely ill when they reach the mental health care university system. This is perhaps because of the delay in getting treatment. I’m working with the Asian Life hotline services. A lot of elders call us to seek help, and according to the information we gather, many of them have depression for at least 5 to 20 years. They probably will go to see a primary care physician, for medication, but never seek psychological to help them to solve their problem.

 

Unfortunately, mental health disorders in the Asian American elder’s population often are under-recognized and under-treated, due to the ignorance of social and cultural factors. For example, like older adults, Asian elders with mental illness usually have chronic physical illness, and many Asian older adults with physical illness have related mental illness. However, because some Asian cultures don’t draw a hard and fast distinction between mind and body, there’s a lack of recognition in emotional issues and a tendency to report more psychosomatic symptoms than to see physical remedies.

 

Now, I want to talk about the utilization of mental health services. According to statistics, only 20 to 25% of older adults with mental illness disorders get services from mental health professionals. For Asians, is probably even lower, because the mental health system is really limited in capacity to serve ethnic minorities. The concept of the mental illness is different in each Asian culture. For example, in New York City, only 1 % of the people who receive services from the public mental health system are Asian. Asians tend to identify and report psychosomatic problems rather than emotional ones. Asian American elders are more likely to turn to primary care physicians for help with psychological problems than are other ethnical groups. Moreover, Asians especially those who haven’t assimilated into American culture often turn to alternative forms of assistance in their community. For example, many Chinese elders told me that they’d rather drink herbal tea to cure their emotional problems than to take the western medication.

Now, I want to talk about some of the barriers to utilization of the mental health system. The first barrier is the lack of knowledge about mental health. One of the reasons for low organization of mental health and substance abuse services is that many aged Asian American elders have limited knowledge about mental health including what mental health treatment service entails, where to seek help, and under what circumstances help is needed.

The second barrier is that the elderly believe that mental illness can’t be treated. Many Asian elders tell me that talking to a psychologist or psychiatrist isn’t going to cure them because they can talk to their friends or family members. When I am doing community outreach, I usually spend a lot of time explaining to seniors, it’s different between talking to professionals verses family members. It’s just like if you don’t know how to fix your home washing machine, you’re not going to try to fix it yourself, you call a technician. So, after listening to analogy, they start to think of the situation in an entire new way.

The third barrier is the stigma of mental illness. In the Asian American community, it’s very common for mental illness to be associated with the feeling of shame, humiliation, and dishonor. For our hotline services, I find that many Asians and even the elders, delay seeking help because they feel it’avery difficult for them to accept that they or family members have emotional problems. I remember, a 70 year old lady from Hong Kong, until today, she still thinks that if she tells me that she feels depressed, a psychologist will send her to the medical psych ward and she won’t be able to see her family members again. She was reluctant to tell us about her problems until I explained to her the details of the mental health system, and that, even the mental healthy people can talk to a psychiatrist.

 

The fourth barrier is the shortage of the geographic mental health services, which includes severe shortage of bilingual and bicultural service health providers and treatment settings. Also, there is a shortage of the community services and limited outreach of mental health education. I’m actually doing outreach on mental health education in the community, but sometimes I feel that I’m the only person doing it. Of course, the Charles B. Wang Community Health Center has outreach workers too, but New York City is big and less than ten persons that I know are doing mental health education. Another area that’s lacking is family support services. So far there’s only one program. They’ve existed for 3 or 4 years, and they have mental educational programs and supporting groups for members.

Also there is a lack of family care professionals trained in mental health care. The Charles B. Wang Community Health Center has a really good program to train primary care physicians and mental healthcare systems. Other hospitals lack this kind of program. In the Asian community, especially for the elders, they’d rather go to their primary care physicians when they have an emotional disorder rather than to a psychologist or psychiatrist.

 

An important issue to look at is the cost of the mental healthcare. Medicare and most private insurance plans require 50% co-payment for outpatient mental health services compared to the 20% that is required for the treatment for physical illnesses. This lack of funding makes mental health treatment too expensive for many people of limited means, and discourages mental health provider from treating them because of the ability to cover the co-payment.

 

Ultimately, there are many barriers that prevent elders from getting treatments. However, compared to the last ten years, I think things are improving right now. I believe we’ll continue to improve in the future. Along with our other services and programs, Mental health services were frequently used by Asian elders when they were offer nonclinical symptoms provided by professionals who shared the clients’ cultural and language background. Elderly only trust individuals such as relatives, friends, or a social service provider. They also get their information from the media for example if the newspaper writes that the Charles B. Wang has a very effective service for treating mental health disorders, they’ll believe in it and will got to the center to get these services. Another thing is Asian elders are not entirely receptive to the idea of using mental health services. It is imperative that the information about mental health issues and appropriate services be communicated to them in their own language, in a way that is not stigmatizing.

 

Asian elders require higher level of service to make them comfortable and to create a trusting relationship. Just a couple of days ago I received a call on the hotline from a 75 year-old Chinese lady. We usually don’t give out their name, but I want. Ms. Chan and her family came to USA for about 10 years now. She doesn’t speak any English and therefore likes to stay in Chinatown. Ms. Chan’s husband passed away 2 years, and right now she’s living alone. She has three adult children and because after 9/11, with the Chinatown economy is going downhill, they had to go out of New York City to find jobs. They usually visit their mother, probably, once a month. To me, that’s pretty good. After the husband passed away, Ms. Chan felt lonely, and has all the symptoms of depression including loss of appetite, inability to sleeping, lack of interest in doing anything she used to like, worry about money issues because she is not working anymore. Three days ago, she fell from a chair when she tried to change the light bulb on her own, and injured her back and arms. Now when she tries to close the window, and she finds she can’t do it and helpless. Fortunately, she used to listen to radio show everyday and got our hotline number and decided to give us a chance to listen to her problems and direct her to the appropriate services.

In the Asian American community, many don’t feel comfortable seeking help for emotional distress. Just because they don’t talk about it, it doesn’t mean that it’ll go away, and will probably manifest itself in other forms such as trouble sleeping, alcoholism, physical problems like stomachaches, headaches, and also fight with their family members. I just want to say, help is available. The 9/11 Mental Help Benefit provide those living in Chinatown and who worked near the World Trade Center during 9/11, with out-of-pocket costs for treatments including counseling, medication, acupuncture, and hospitalization. If you’re eligible for this program, you can call Asian Life Net, at 1-877-990-8585 to enroll in this program.

 

Another program that’s available, funded by the American Red Cross, is called Asian Mental Health Project. The project is not just for families of Asian World Trade Center victims and Chinatown elders. It provides mental health education, group sessions, and mental health screenings in ten senior centers throughout Chinatown. Again, if you want to find out more about this program, you can call Asian Life Net.

I mentioned Asian Life Net several times and want to now briefly talk about it. Asian Life Net is culturally competent bilingual hotline staffed by Asian speaking mental help professionals who can listen, provide emotional support and mental health crisis intervention. We’re available Monday to Friday 6 AM to 10 PM. During the weekends and holidays, it’s from 12PM to 7PM and also in the holidays. Asian Life Net is part of 1-800-LIFE-NET, which offers us 24/7 in use of language services for Asian callers when Asian Life Net professionals aren’t available.

Before I wrap up, I share a bit with support groups and media outreach really works well in terms of helping the elderly, by engaging them and also directing them to getting help from clinics and other mental healthcare systems. If you have more questions feel free to contact.

 

Rodelle Holland: Our next speaker is Betty Chen.

Betty Cheng: Thank you Professor Holland. I work for the Charles B. Wang Community Health Center. Some of you may know us as the Chinatown Health Clinic. I’m the Chef Operating Officer. However, I’m a social worker at heart. What I want to discuss with you today is medical social work. We talk about social work all the time but don’t hear too much about medical social work.

Medical social work usually entails patient discharge planning. Charles B. Wang Community Health Center is a federally qualified community health center, we make sure that the underserved population is getting the kind of health care they need.

Nowadays, you hear stories about manage care where people go in for two minutes and get kicked out. But that’s really not true. I think most of the physicians practicing will give whatever time that is necessary to their patients. At Charles B. Wang, because we are an organization, in addition to seeing patients by the doctors and nurses, we have health educators and social work services.

Let me give you an example of why we provide social work services. An 86 year old man came in to see our doctor because he tripped and was on the floor for several hours in his home. Somehow, he was managed to come to the clinic and we treated him. But, we thought it was really important for him to be fully examined, so we sent him to the emergency room, for a battery of tests. We discovered he was suffering from dehydration.

The man’s doctor called his social worker that the man was going to be discharged. The social worker tried to think of solutions to help the man since he lived alone. Home Care isn’t simple nowadays. You have to fill out this and that form. But the good thing is the Visiting Nurse Services when you call them up, they kind of put things in first and to get the paperwork going. Once that’s done, what else do we need to do, right? This man is 86 years old, with no family, and lives on the third floor walk up.

Audience: Deliver meals.
Audience: Home care attendant, you need somebody to look after him.

Betty: Those are all very valid, suggestions, but who is going to do it in the doctors’ office? Who is going to help this man? Community agencies can’t really do it because you need doctor’s orders to get the insurance to pay for it. Then the issue becomes who is going to pay for that? Fortunately this man has the best insurance in the world, Medicaid and Medicare. If you don’t have insurance, then what do you do? If someone is eligible, you start applying for them. We work with Chinese American Planning Council because they have a Medicaid outstation there, or you can go to Gouvener Hospital also. So you’re really talking about the coordination of those services. So, all the concrete things are done? But this man is still alone, what else can we do?

Audience: Have friend’s visit
Audience: Someone to talk to.
Audience: Home visiting nurse

Betty: These are all suggestions that require coordination. Usually the visiting nurse does that, right? On a short term basis, but in the long term, what do you do? Help him to build his network. Maybe pulling him into a senior citizen center? Those are the kind of things that you have to slowly put together.

Something, I want to help you all to think about is long-term planning, without help from a nursing home. He probably doesn’t want to go to a nursing home. So what’s going to happen is that one day, he’s going to get real sick and go to a hospital. Then, the hospital social worker has to call all over the place to find out who his relatives, are and for other information, such as what are his wishes? It’s a social worker’s responsibility to talk about that.

We don’t talk about death and dying that much, but in some way, when you build trust, you have to start talking about it. One of the things you really have to talk about ishis wishes, advance directives and healthcare proxies. If he doesn’t really have anybody else, then he can put something down on paper. Do you know what happens after he passes on? He probably doesn’t have much money because he’s on Medicaid. What about burial? Where is he going to be buried? What happens is that if we don’t do this kind of thing with the person, maybe he’s going to Potter’s Field on Hart Island because there’s nobody to bury him. We don’t want that to happen to someone who has worked in this community and has paid taxes.

Those are the kind of things that medical social workers do in our origination. Usually when you’re so busy, you don’t just do those kinds of things because you manage crisis whenever things happen. But, those are the kind of things that needs to be done when the patient comes in to see the doctor.

When someone is really depressed, they need to talk to a mental health professional. At Charles B. Wang, knowing that mental health is a stigma in the community, we’ve trained our primary care physicians, mental health team to help identify problems and symptoms. All our senior citizen patients who are depressed don’t have to feel that they’ll be sent somewhere else for mental health treatment. There are a lot of barriers in terms of working with seniors. First of all, you have to build trust. Secondly, often times, their educational and literacy level is low, so if the nurse is explaining certain things to reinforce what the doctor said, they can’t remember because they basically don’t understand. So, it requires a lot of that social support, having to sit down and talk about different things.

Some of the cultural beliefs that Tracy talked about like herbal teas, is part of the healthcare that social workers need to be aware of so that they can bring certain issues up with the physician. The worst thing to say is “Don’t take it”. This is a part of their culture. How do we work with them to help the patient? So the issue about working with elderly is that you have to have a lot of heart for the patients. It’s not going to happen in one visit.

Talking about advance directive, healthcare proxies, long-term planning is an on going process. We have to do this kind of work with our seniors because many of them don’t have much family support, to plan to take care of elder parents or knowledge on what to do when they’re sick and dying.
Rochelle Holland: Thank you, Betty. Our next speaker is Heidi Chan.

Heidi: Good afternoon. Today I’m going to discuss about hospice care. It’s a very difficult topic and I think the first thing I ask myself is “Do I want to face this question?” Before you approach the person that you want to talk about death and dying in the hospice, if you’re uncomfortable, then there’s no way that you can talk about it with a patient. So that’s the kind of challenge, I want to encourage all of you to think about. To summarize for you what hospice care is all about, the first comprehensive services in what we call case manage care in the United States. Even nowadays, we’re being given 169 dollars a day to provide this 24-hour service to each person who either have Medicare or Medicaid. A person in hospice care is getting what we call medical, psycho, and spiritual services. We have a medical director go to see the patient what is included in those 169 dollars. You get nursing visits, what we call intermitting visiting nurses, at least once a week. The nurse will come in and see the patient as often as it is needed. I what many time of day it is, if the patient isn’t feeling well, call this 24-hour number and they’ll send a nurse to the home. This person will also be getting home health care services, not exceeding 20 hours per week. As you can see, there is a guideline that we set, of how many hours of home care services a person receives. They’re getting what we call durable medical equipment, the hospital bed, oxygen tank, the walkers, diapers, gloves, etc. All of this is inclusive in these 169 dollars, plus on top of that, they’re getting the medication related to the terminal illness delivered to their home. Whatever is the best for the patient, for pain management, will be delivered to the home.

It’s a lot that this person is getting, including social work intervention. Everyone gets a social worker that is goes to their home and assesses what their needs are. This is what we call the “window of opportunity for healing”. There’s so many, unspoken issues that we’re talking about that needs to be addressed. Again, in our culture, we have seen that, there are so many differences between father and mother, that we need to look at that as well.And they are also getting spiritual services? Who is qualified?
Audience: Can you explain a little more about spiritual services?
Heidi: We have a limited distinction between what is spiritual and what is religious. That’s a very critical issue here. Spiritual doesn’t mean it’s religious, but then the person who is religious, for example, if they are Roman Catholic. They want a priest to come by. So that’s very distinct, and we can do that. But if they’re talking about spirituality as in, “I am just a very good person”. That is a spiritual issue. Then, you’d have somebody who is comfortable addressing the issue. It could be a nurse, social worker, volunteer, anybody.

One last thing, Visiting nurses have a little card called the health care proxy. I keep it in my purse. They’re small business cards just to tell people who your proxy is. If you’re interested, I do have them available. I’m not saying anything will happen, but at the same time, anything can happen. Thank you

 

Rochelle Holland: Are there any questions?

 

Betty: I have a comment about what Heidi was saying, and what she said is very true, that sometimes we aren’t comfortable ourselves dealing with death and dying. And, if we’re not comfortable we aren’t going to talk to our clients about it. I think first of all, we have to reflect on our own comfort level, and then we can do a good job about it with our clients. But often times we’re not comfortable, therefore we say, “Well, the clients don’t want to talk about it, so we don’t do it.”

 

Betty: When discussing this matter with parents, I often compare it to with talking to adolescents about sex and drugs? You have to really know who you’re talking to. Your mom may be different than my mom. And so, you have to use opportunities. I want to share something with you about my mom. She never talked about death and dying, but she often says, “Oh, I want to get this done.” So this was an opportunity to talk about I things before they happen. It’s hard to do, but they’re really relying on you in someway to take the lead when you get older, and you have to show respect for them.

 

Audience: For me, it’s easier with mom, but with dad it’s really very hard. From your experience, how do you approach someone who is very proud, and wouldn’t give in, and always wants to be in control?

 

Tracy: I have experienced in the Senior Center. It’s very common for the elderly to talk about death or facing it. Sometimes we just hand out some information about on, what they can do. You can just place it in his drawer or any obvious place that he can see it. I know many of them are thinking of it, but sometimes the lack of information and also fair of dying, cause them to avoid facing the truth. But if you give them enough information, they’ll figure it out, or talk to their friend sometimes about it and say “Wow, its so expensive for a funeral and everything.”

 

Rochelle Holland: I have a recommendation. I would assess exactly what I’m trying to help them do. Are you trying to prepare, like what Tracy said, the funeral arrangement? And then I would try to work around him and then get that done. I know a lot of people, and this is of course cultural, really do not like to talk about death, but if you’re trying to plan something, then I would try to assess what am I trying to get, what type of information do I want from my father or from my mother, and then try to work it out from that direction.

Are there anymore questions or comments? I think this was a very good session. I would like to thank Tracy, Betty, and Heidi. I know I definitely learned something new.