Building Back Better: Going Big with Emancipatory Sciences.

This commentary argues that precarity and inequity across the life course and aging has accelerated via the COVID-19 pandemic. President Biden's vaccination efforts, $1.9 trillion American Rescue Plan Act, and Build Back Better framework reflect a paradigm shift to restore faith and trust in government that boldly confronts entrenched austerity ideologues. We offer emancipatory sciences as a conceptual framework to analyze and promote social structural change and epic theory development. Emancipatory sciences aim to advance knowledge and the realization of dignity, access, equity, respect, healing, social justice, and social change through individual and collective agency and social institutions. Epic theory development moves beyond isolated incidents as single events and, instead, grasps and advances theory through attempts to change the world itself by demanding attention to inequality, power, and action. Gerontology with an emancipatory science lens offers a framework and vocabulary to understand the individual and collective consequences of the institutional and policy forces that shape aging and generations within and across the life course. It locates an ethical and moral philosophy engaged in the Biden Administration's approach, which proposes redistributing - from bottom-up - material and symbolic resources via family, public, community, and environmental benefits.

Professionalizing gerontology: why AGHE must accredit gerontology programs.

The aging of society requires more trained aging specialists. Are higher education institutions prepared? Results of a comparison of gerontology programs in 2000 and 2010 indicate that the number of programs has declined and that higher education is not prepared. To address this challenge, the authors propose that gerontology be professionalized. To do so will require the accreditation of gerontology programs, the credentialing of gerontology graduates, and the employment of professional gerontologists. The authors offer a model that describes these relationships. The authors make the case, using a symbolic interactionist approach, that the Association for Gerontology in Higher Education must accredit gerontology programs.

Access barriers to mental health services for older adults from diverse populations: perspectives of leaders in mental health and aging.

This project is based on the results of telephone surveys with 52 local, state, and national informed respondents including policymakers, county leaders, planners, and advocates in mental health and aging with a particular focus on the states of California and Florida. This article addresses challenges to access to mental health services for diverse older adults including barriers related to race and ethnicity, socioeconomic status, location, age, gender, immigrant status, language, sexual orientation, and diagnosis. The article also highlights broad themes that emerged including (1) the importance of outreach and transportation tailored to diverse elders, and (2) recruitment of diverse staff and training related to diversity. The article concludes with policy and practice recommendations to reduce these disparities in access to mental health services for diverse populations of older adults.

Integrated specialty mental health care among older minorities improves access but not outcomes: results of the PRISMe study.

OBJECTIVE: In this secondary data analysis of Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRIMSe) study, we hypothesized that older minorities who receive mental health services integrated in primary care settings would have greater service use and better mental health outcomes than older minorities referred to community services. METHOD: We identified 2,022 (48% minorities) primary care patients 65 years and older, who met study inclusion criteria and had either alcohol misuse, depression, and/or anxiety. They were randomized to receive treatment for these disorders in the primary care clinic or to a brokerage case management model that linked patients to community-based services. Service use and clinical outcomes were collected at baseline, three months and six months post randomization on all participants. RESULTS: Access to and participation in mental health /substance abuse services was greater in the integrated model than in referral; there were no treatment by ethnicity effects. There were no treatment effects for any of the clinical outcomes; Whites and older minorities in both integrated and referral groups failed to show clinically significant improvement in symptoms and physical functioning at 6 months. CONCLUSIONS: While providing services in primary care results in better access to and use of these services, accessing these services is not enough for assuring adequate clinical outcomes.

Social security politics: ideology and reform.

OBJECTIVES: The purpose of this study was to examine the distribution of dominant values, actors, and ideological advocacy coalitions influencing the Social Security debate across two presidential administrations. METHODS: Through content and cluster analyses, we analyzed federal legislative hearing testimonies on Social Security reform spanning 11 years. RESULTS: Witnesses consistently expressed six dominant values: (a) advancing the market, (b) self-interest, (c) generational equity, (d) belief in market activity, (e) recommendations for market solutions, and (f) favoring the replacement of Social Security with private accounts. We identified three advocacy coalitions: conservative, progressive, and nonaligned. Conservatives dominated the hearings and were more consistent in their expression of market values when compared to progressives, who expressed social contract values less frequently. Congressional Democrats were inconsistent in upholding Social Security's social contract values. The distribution of testimonies paralleled historical, political, and economic events. DISCUSSION: Our research indicates that one can interpret social policies as well as policy options as sets of values, and these as ideological models. We anticipate that the coherence on one political ideological view (market) and the relative lack of consistency in another (social contract) will be highly consequential for the future of Social Security, U.S. politics, and the public.

Recruitment and retention of older minorities in mental health services research.

PURPOSE: This article reviews the problems associated with recruiting older minorities into mental health research studies and proposes a consumer-centered model of research methodology that addresses the barriers to recruitment and retention in this population. DESIGN AND METHODS: The authors discuss and compare the results of recruitment and retention interventions for two geriatric mental health studies, one that used traditional methods of recruitment and retention and another that used consumer-centered methods. RESULTS: Although the consumer-centered methods result in better recruitment of older minorities in general (chi(2) = 54.90, p <.001), it was not superior to the traditional method in recruiting older minorities (chi(2) = 0.82, ns). However, the consumer-centered approach yielded better retention of older minorities (chi(2) = 6.20, p <.05) than did the traditional method. Within both methods, recruitment through provider referral and face-to-face contact were the superior recruitment methods (chi(2) = 6.78, p <.05). Having an experienced recruiter or a community recruiter resulted in greater agreement to participate than simply having an ethnically matched recruiter (chi(2) = 36.00, p <.001). IMPLICATIONS: Although these data are observational, and rigorous research on the best methods for recruiting and retaining older minorities is still necessary, the results suggest that a consumer-centered model of research yields greater overall recruitment and retention rates than do traditional research methods.

State long term care ombudsman programs: factors associated with perceived effectiveness.

PURPOSE: This article reports findings from a nationwide study on factors associated with the perceived effectiveness of state Long Term Care Ombudsman Programs (LTCOPs). DESIGN AND METHODS: Researchers conducted telephone interviews with ombudsmen from the 50 state programs as well as from Washington, DC, and Puerto Rico. Data from the National Ombudsman Reporting System were incorporated into the study, and statistical tests analyze associations between self-rated program effectiveness and adequacy of resources, organizational placement-autonomy, interorganizational relationships, and other variables. RESULTS: Several factors limit the perceived effectiveness of state LTCOPs, including insufficient funding and insufficient LTCOP autonomy caused by organizational placement. Despite these problem areas, state ombudsmen report that their programs meet statutorily mandated requirements with varying degrees of effectiveness. Findings show significant positive associations between program funding and paid and volunteer staff levels and between the ratio of long-term care beds per ombudsman and the percentage of nursing facilities visited. Sufficient funding is positively associated with perceived effectiveness of work with nursing facilities. IMPLICATIONS: Sufficient resources, sufficient organizational autonomy, and a supportive political and social environment are key elements in achieving varying types of perceived effectiveness in the state LTCOPs. Research is needed to extend this work to local ombudsman programs and to compare self-rated effectiveness with other outcome measures.

The globalization of capital, the welfare state, and old age policy.

A new political economy is shaping the lives of present and future generations of older people. The key change has been the move from the mass institutions that defined growing old in the period from 1945 through the late 1970s to the more individualized structures--privatized pensions, privatized health and social care--that increasingly inform the current period. The authors examine the role of international governmental organizations in promoting this trend, with examples drawn from the work of the World Bank, World Trade Organization, and Organization for Economic Cooperation and Development, and the relationship between international governmental organizations and the state. The article concludes with an assessment of the changes to citizenship that accompany globalization and the implications for political organization among older people themselves.

Local Long-Term Care Ombudsman Program effectiveness and the measurement of program resources.

Local Long-Term Care Ombudsman Programs (LLTCOPs) protect the health, safety, welfare, and rights of residents in long-term care (LTC) facilities. This study examines the (a) existing resources available to LLTCOPs in Georgia, California, and New York, (b) relationship of resources to LLTCOP's reported effectiveness in meeting its federal mandates, and (c) state-specific mediating factors influencing LLTCOPs' resources and reported effectiveness. Quantitative and qualitative data from the National Ombudsman Reporting System (NORS) and a telephone survey of LLTCOPs in Georgia, California, and New York were collected and analyzed. Resource adequacy, as measured by beds per full-time equivalent staff (beds/FTE), is inconsistently associated with effectiveness in meeting federal mandates across and within the states studied. Analysis of alternate resource measures suggests a threshold of LLTCOP size, under which program effectiveness may be lower. LLTCOPs report the changing LTC environment and additional state mandates as factors influencing resource adequacy.

Factors associated with perceived effectiveness of local long-term care ombudsman programs in New York and California.

OBJECTIVE: Long-term care (LTC) ombudsman advocate for the health, safety, welfare, and rights of residents in LTC facilities. This article examines factors associated with self-rated effectiveness of local LTC Ombudsman Programs (LTCOPs) in California and New York across the five statutorily mandated activities under the Older Americans Act: complaint investigation, resident/family education, community education, monitoring laws, and policy advocacy. METHOD: Data were collected from telephone interviews with coordinators of local LTCOPs in California and New York and from the National Ombudsman Reporting System. Analyses examined factors associated with effectiveness: program size, resource adequacy, organizational autonomy, interorganizational relationships, and program outputs. RESULTS: Resource and autonomy measures are significantly associated with different effectiveness measures in each state. Staff full-time equivalencies and coordinator hours per week in New York and the quality of training in California are significantly associated with effectiveness in most mandated activities. DISCUSSION: Findings highlight variability within and between the local LTCOPs in California and New York.

PACE: has it changed the chronic care paradigm?

The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

Integration of mental health services into primary care overcomes ethnic disparities in access to mental health services between black and white elderly.

OBJECTIVE: The authors evaluated whether the integration of mental health into primary care overcomes ethnic disparities in access to and participation in mental health (MH) and substance abuse (SA) treatment. METHODS: The authors conducted site-specific analysis of a multisite clinical trial to compare participation of black and white elderly in an integrated model of care (all MH/SA services are provided at primary care clinics) versus an enhanced referral model of care (all MH/SA services are provided at specialized MH clinics). In all, 183 elderly (56% black) diagnosed with depression (82%), anxiety (32%), and/or problem drinking (22%) were randomized. RESULTS: Blacks in the integrated arm were significantly more likely to have at least one MH/SA visit (77.5%) relative to blacks in the enhanced referral arm (22%; adjusted odds ratio [OR]: 14.13; confidence interval [CI]: 4.76-41.95, Wald chi(2): 22.75, df = 1, p <0.0001). There was no statistically significant difference between whites in the integrated treatment arm (66.6%) and whites in the enhanced referral arm (46.9%, adjusted OR: 2.98; CI: 0.98-9.06, Wald chi(2): 3.72, df = 1, p = 0.05). In the enhanced referral arm, blacks had a significantly smaller number of overall MH/SA visits (mean [SD]: 2.08 [5.28]) relative to whites (mean [SD]: 5.31 [7.76], adjusted incident rate ratio [IRR]: 2.87; CI: 1.06-7.73, Wald chi(2): 4.37, df = 1, p = 0.03). In the integrated arm, there was no statistically significant difference between blacks (mean [SD]: 3.22 [3.71]) and whites (mean [SD]: 2.75 [4.29], adjusted IRR: 0.58; CI: 0.25-1.33, Wald chi(2): 1.64, df = 1, p = 0.20). For both groups, time between baseline evaluation to first MH/SA visit was significantly shorter in the integrated treatment arm (for blacks: mean days [SD]: 31.06 [28.66]; for whites: mean days [SD]: 22.18 [33.88]) than in the enhanced referral arm (mean [SD]: 62.45 [43.53], adjusted hazard ratio [HR]: 7.82; CI: 3.65-16.75, Wald chi(2): 28.02, df = 1, p <0.0001; mean [SD]: 63.46 [32.41], adjusted HR: 2.48; CI: 1.20-5.13, Wald chi(2): 6.02, df = 1, p = 0.01, respectively). CONCLUSION: An integrated model of care is particularly effective in improving access to and participation in MH/SA treatment among black primary care patients.

Implications of welfare reform on the elderly: a case study of provider, advocate, and consumer perspectives.

Whereas many studies of welfare reform have focused on effects on children and families, little research has examined the implications of welfare reform for the elderly. This case study incorporates interviews with service providers for the aging, members of advocacy organizations, and two focus groups of older consumers conducted in the multi-ethnic urban community of San Francisco. Study findings suggest that welfare reform has had both direct and indirect effects on the elderly and their services in the study community. Direct effects derive primarily from changes in the welfare reform legislation that had the effect of undermining both immigrants' eligibility for and claiming of public assistance benefits. Indirect effects on older persons include increased child-care demands upon grandparents. The case study data bear on a significant policy change within the broader trend of devolution at a historical point when anti-immigrant sentiment in the United States was running high.