SOCIAL DETERMINANTS OF HEALTH AND BARRIERS TO ACCESSING CARE FOR OLDER ADULTS Older adults seek mental healthcare 40% less than younger populations (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019). Mental health treatment for instability or illness for the older adult is multifaceted. How the older adult views their collective health can determine the level at which they will seek care to maintain or restore their mental imbalance or illness. The U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion (ODPHP) in Healthy People 2030 names five areas related to social determinants of health: education access and quality, healthcare access and quality, neighborhood and built environment, social and community context, and economic stability (ODPHP, 2022). Each will be expanded upon for potential barriers and benefits of care.
Determinant 1: Education access and quality On average, people who have greater levels of education live longer and healthier lives (ODPHP, 2022). Educational opportunities are often focused on younger populations, and older adults might be beyond the point of increasing their educational status level. However, the healthcare worker can identify and help them overcome this deficit. The healthcare worker should assess health literacy in the older adult client and plan written materials accordingly. Further assistance might be necessary for people with disabilities that severely impair cognition, hearing, or vision. The Centers for Disease Control and Prevention (CDC) states that 71% of adults over the age of 60 struggle to read printed materials (CDC, 2021a). This is often due to naturally declining vision. With recommendations to help older adults who struggle with poor vision, the healthcare worker can help mitigate hindrances related to vision. Determinant 2: Healthcare access and quality Older adults often delay addressing mental health needs until the problems become chronic or severe. While access to mental health services is problematic for many people across the mental health spectrum, it is critically important for those that suffer with severe mental illness (SMI) (Sadock et al., 2015). To address the healthcare access and quality social determinant for the older adult, the healthcare worker can review the frequency, ease, or difficulty of accessing mental health services. Available options for care, transportation, technology, and stigma will be discussed related to the role they play in the older adult client accessing or being prohibited from accessing mental healthcare. If access to healthcare or decreased quality of current care is an issue for the older adult, the healthcare worker can propose federally qualified and/or local community-based options. The following recommendations are from the U.S. Department of Health and Human Services (HHS) and provide recommendations and tools to increase healthcare access and quality of care for the older adult. The older adult client, family, or caregiver can search for local options using the official benefits website of the U.S. government. One website to explore is Medicare. The older adult client can sign up for benefits that include preventative screenings and services; check what services are covered; submit claims; compare providers; find physicians, group practices, hospitals, home health agencies, and facilities based on star ratings, services offered, and quality of care; and get a replacement card if needed ( United States Department of Health and Human Services [HHS], 2022). Another website to search is Medicaid. The older adult client can access information about state programs (HHS, 2022). The website Eldercare can connect the older adult to local and community-based care. The older adult, family, or caregiver can use their ZIP code or city and state to find resources in the local community that provide information and assistance for older adults and caregivers (HHS, 2022). Sometimes access to care is hindered by awareness, and the healthcare worker can increase awareness by providing federal and local sources for care. Transportation A crucial component of face-to-face access and quality of healthcare is transportation. The older adult may access public, community-based transportation options or a privately owned vehicle. If options are lacking, the deficit can be noted and further assistance sought. The need to assess an older adult’s ability to safely operate a vehicle will be addressed in depth in the psychosocial assessment section.
Ensuring health literacy in the older adult with visual challenges includes the following practices (CDC, 2021a): ● Ensure the written material can be read by the client (have them read it to you). ● Use high contrast (black words on a white background are best). ● Use an average font size of 16 to 18 (increase if needed). ● Use extra white space between lines of information (make the space of the lines at least 25% of the point size). ● Do not use glossy paper (it creates glare). ● Use the least amount of text necessary. ● Use audio instruction in addition or as a substitute (see NIA recommendations listed prior for best outcomes). ● Adjust needs accordingly and reduce screen glare if electronic materials are used. Technology The use of technology for healthcare dramatically increased with the COVID-19 pandemic. Telemedicine decreases direct contact and limits disease transmission while providing access to care. The WHO (2021) classifies its use as advantageous for vulnerable populations such as older adults. Telemental health has been found to reduce the number of emergency department visits for older adults with comorbid depression and chronic obstructive pulmonary disease or congestive heart failure (Tusaie & Fitzpatrick, 2017). It has also been effective for psychotherapy interventions. One study found that older adults who suffer from depression and insomnia had positive outcomes from cognitive- behavioral therapy administered via telemental health (Tusaie & Fitzpatrick, 2017). Telemental health can benefit the older adult in many ways. The American Psychiatric Association (APA) collaborated with the American Telehealth Association (ATA) to address telepsychiatry. The healthcare worker is encouraged to reference the APA and ATA for clinical tips, tools, guidelines, and more, while continuing to follow all policies at their place of employment. The APA (2018) has specific recommendations for the healthcare worker caring for the older adult population: include family members on video calls when clinically necessary (with patient permission); adapt technology and assessment for cognitively, visually, or audio impaired patients; modify cognitive testing carried out via videoconferencing. Although telemedicine ensures access to care, it is not always available for the older adult client. It is estimated that 40% of older adults on Medicare are unable to receive video care and 20% are unable to receive phone care (Chu et al., 2022). This can place an older adult needing virtual mental healthcare in a difficult position. The healthcare worker must perform a baseline assessment of the infrastructure required for and attainability of this option for the older adult. Deficits in cognition, hearing, or vision may present greater challenges for the older adult client using telemedicine. The ATA has created guidelines for telemedicine. However, the guideline only addresses live video conferencing for mental health services (Tusaie & Fitzpatrick, 2017). Other forms of communication such as phone text messaging, social media, apps, and emails are not covered by the ATA. The healthcare worker is encouraged to refer all questions to their place of employment. The same considerations the healthcare worker would utilize for in- person visits for securing protected information exist for telemedicine.
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