Special report: Michigan prepares for a rapidly aging population by becoming more 'age-friendly'

AARP Michigan volunteer Howard Pizzo, AARP Michigan Communications Manager Mark Hornbeck, and AARP M
This article is part of State of Health, a series about how Michigan communities are rising to address health challenges. It is made possible with funding from the Michigan Health Endowment Fund.

Michigan is aging, and fast. The state has more than 2 million residents over age 60, representing about 25% of the state's population, and 37% of Michigan residents are 50 and older. Michiganders 85 and older are the fastest-growing age group of all. The state also has one of the top 15 oldest populations in the U.S.
Scott Wamsley.
"We do have a significant older adult population and calculations [show] that it is growing," says Scott Wamsley, director, Michigan Department of Health and Human Services (MDHHS) Bureau of Aging, Community Living and Supports. "One of the things that we want to do at MDHHS is have a robust continuum of community-based services for older adults." 

The state already offers a variety of services for older adults, ranging from the My Choice waiver program offering home care services for those on Medicaid to nutrition programs like Meals on Wheels. But Wamsley says the state wants to make people more aware of the services that are available. To accomplish that goal as part of Michigan's State Plan for Aging, MDHHS staff are traveling the state to gather feedback from older adults at senior centers, community centers, and Area Agencies on Aging (AAAs).

"We also did an online survey of older adults, allowing people that can't attend those public sessions to provide us with information about service needs and services that they'd like to see in the state," Wamsley says. "We also talked to key stakeholders within state government and across our service delivery network to ask, ‘What are the needs of older adults?’ and ‘How can we meet those needs?’"

MDHHS isn't the only Michigan organization finding innovative ways to meet older adults' needs. Here's a look at several Michigan initiatives that are working to create new age-friendly support systems as the state ages.

Age-friendly everything

AARP designates eight "age-friendly everything" domains of livability: outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, work and civic engagement, communication and information, and health services and community supports. The domains ultimately support older adults aging in place in their homes and communities.

In June 2022, Michigan Gov. Gretchen Whitmer announced Michigan’s Age-friendly Action Plan, a blueprint developed with the MDHHS and AARP-Michigan to guide communities through creating age-friendly-everything policies and infrastructure.

"All of the Michigan communities where AARP has a presence are now part of the AARP Network of Age-Friendly States and Communities — Grand Rapids, Lansing, Jackson and others. Detroit's coming on board, too," says Paula Cunningham, director of AARP-Michigan.

Paula Cunningham.
One barrier to aging in place is lack of access to home care services. For one, Medicare and Medicaid do not provide sufficient coverage for these services. In addition, the shortage of direct care workers — those who bathe, dress, toilet, and feed people needing care — leaves the state agencies and community organizations providing these services unable to meet demand.

"We're working with the state now in making a career path available for direct care workers," Cunningham says. "Maybe they become emergency medical assistants, [registered nurses], or [licensed practical nurses]. Having that kind of career path will attract more people to that field."

Affordable housing is another barrier to aging in place. As rents rise, some older adults can find themselves priced out of homes where they have lived for decades.

"First of all, you've got to have a home to age in," Cunningham says. "That's where affordable housing comes in."

For those finding themselves without a home or unable to remain in the one they have, AARP-Michigan is promoting the idea of "green house homes." These small, family-like homes provide care, equivalent to that in an assisted living facility or nursing home, for no more than 12 to 20 older adults.

"During COVID, a lot of the research has shown that these smaller, more intimate settings had a much lower rate of COVID. They weren’t nearly as deadly as a major nursing home," Cunningham says. "Residents have their own apartment-like space inside of a building. When money is available to build a nursing home, we would like to see more green houses versus that nursing home."

Age-friendly means dementia-friendly
Dementia is incredibly common in older adults. Nearly 200,000 Michiganders had Alzheimer's, the most common form of dementia, as of 2020, and one in three older adults will die with dementia. For people who live with dementia, the challenges of the disease are often compounded by a common perception that their life is essentially over. Elwell resident Brenda Roberts calls that a "tragedy narrative," and she's spent the past four years working to counteract it through the nonprofit National Council of Dementia Minds, which she co-founded.

Roberts was moved to action after her husband Mark, also a co-founder of the organization, was diagnosed with vascular dementia in 2014. Seeking resources and support, she was surprised by how many discouraging narratives she encountered about dementia.

Mark and Brenda Roberts with their dog Sophie.
"Everybody, doctors included, go to end-stage thinking," Brenda Roberts says. "They think of the person in that wheelchair staring off, you know. They're not thinking about the people like Mark and all the other ... people who have all this life to live between the beginning of your diagnosis to your end of your life."

Brenda Roberts was motivated to create positive support and community for people living with dementia and their caregivers, and to treat people living with dementia as the experts on their own experience. She began hosting virtual support groups for people living with dementia, known as Dementia Minds groups, in 2020. Demand for the groups grew quickly, and there are now numerous Dementia Minds groups that attract participants from across the country. Some of them cater to specific demographics, such as men, Black people, or physicians living with dementia. All of them are marked by honest discussion that doesn't gloss over the many challenges of living with dementia, but that incorporates a generous sense of humor and celebrates participants' successes.

"It's like a support group on steroids," says Ann Arbor resident and Dementia Minds group member Libby Ford, who was diagnosed with a rare variant of Alzheimer's in 2019. "There's always somebody in the group that can provide some laughter and some fun. And it's huge just to be able to be and talk with people."

National Council of Dementia Minds board member Monica Downer, who has been diagnosed with an unspecified dementia, gives an interview.
People living with dementia are heavily represented on the National Council of Dementia Minds' board, and they are often its public representatives. Dementia Minds group members regularly present to various groups on their experiences, and some of them are involved in political advocacy work at the state and federal levels. Dr. Arnie Beresh, a member of the Dementia Minds group for physicians, says the group gives people living with dementia a chance to "voice our opinions and have outside people listen to what we feel we need, what we desire to need, what we want the public to know."

"It doesn't just make us nod our head yes or no as somebody is talking to us," Beresh says.

Brenda Roberts stands behind a group of Dementia Minds group members (including Mark Roberts at far left) at a public presentation.
The National Council of Dementia Minds is currently in the midst of developing a needs analysis for people living with dementia, assessing what information and resources they need in their first year after diagnosis. That will be a two-year project, funded by a grant from Michigan Health Endowment Fund.

Mark Roberts says the National Council of Dementia Minds has vastly improved his life, and he wants the organization to continue doing the same for others.

"We give hope," he says. "That's the best thing. People, we who have dementia, we need hope. We need to talk about it. Otherwise, you're just miserable."

For more on the National Council of Dementia Minds and other Michigan-based efforts to reframe the way society approaches dementia, stay tuned for the second season of our spinoff podcast: Michigan's State of Health, coming next month.

Michigan’s age-friendly health systems

In the move towards age-friendliness, many of Michigan’s hospitals are also prioritizing the needs of the state’s growing older adult population. 

"We're dedicated to working both with local and statewide agencies to ensure that there are age-friendly efforts going on so that we can advance older adults’ continuum of life,” says Sarah Scranton, executive director of the Michigan Health and Hospital Association's (MHA) Keystone Center.
Sarah Scranton.
Michigan’s age-friendly hospital systems are implementing "The Four Ms": Know what matters to the older adult; use age-friendly medication; promote mentation by preventing, identifying, and treating dementia, depression, and delirium; and ensure safe mobility to maintain function.

"Older adults have very complex needs. It's important that the medical field prioritizes what is important to the patient, not just what they think might be wrong," Scranton says. "It's really all about listening to the patient and taking what matters to them into consideration."

MHA is also partnering with Henry Ford Health to create a caregiver navigation toolkit that will be implemented within hospitals across Michigan.

"That's the other important piece when we look at age-friendly systems," Scranton says. "How do we support the caregiver that is caring for the patient? We think the toolkit is going to have a positive impact for both the health care providers, the caregiver who's helping the patient, and, in turn, the patient themselves."

Age-friendly at home: AAAs and PACE

One desire that nearly all of Michigan’s older adults have expressed is to be able to age in place in their own homes. Helping older adults to age in their homes also makes good sense. For one, the vast majority of older adults want to stay in their homes as opposed to living in long-term care facilities. 

"The moral imperative is there because that's what they want to do. And the fiscal imperative is there because that's the least expensive setting of care," says Christine Vanlandingham, CEO of Region IV AAA. "As we think about public policy in our state and in our country, providing support for older adults to be able to age in their own homes is the right fiscal choice. In fact, for people who need nursing-home level of care, care in the home is less than 50% of the cost of providing that care in the nursing home."

Christine Vanlandingham.
Vanlandingham notes that in 2022, in Cass and Van Buren counties, the state of Michigan saved $46,986 for each of the 808 people that used Region IV AAA’s services to live at home instead of in a facility. That’s a total of nearly $38 million in savings.

Region IV AAA helps people age in their homes by providing the information they need to connect to resources and services. Region IV AAA provides many of those resources directly. Community-based organizations deliver others.

"We help people stitch those together to create a plan of care that meets their own individual needs," Vanlandingham says. "We send out nurses and social workers to really understand that home dynamic and set a plan of care both for the individual and for the caregiver to make sure the whole family unit is being supported towards success."

Available throughout much of Michigan’s Lower Peninsula, PACE programs also help people age in their homes longer.   

"PACE stands for Program of All-inclusive Care for the Elderly. And it really is just that," says Stephanie Winslow, executive director of the PACE Association of Michigan. "We have a team of professionals who provide soup-to-nuts care for individuals to make sure that they are able to live safely in the community or wherever they call home."

A PACE participant is helped onto an exercise bike at the LifeCircles Center in Muskegon.
National PACE Association statistics have shown that older adults who participate in PACE programs are safer in their homes than in an institutional setting.

"We are trying to work with the legislature to obtain funding to have PACE be an option for everybody in Michigan," Winslow says. "When folks are looking for care for their loved one, it's hard to navigate. It's kind of a jungle. And it can be difficult. There are a lot of barriers."

The PACE Association of Michigan also is working with the legislature to remove enrollment barriers, so it is easier for people to enroll in the program. Winslow notes that a new statewide phone number, (877) 2-MI-PACE, will connect people to a live operator who can help put them in touch with their local PACE program.

"Providing PACE services is less expensive than traditional institutional care," Winslow says. "So it does save taxpayers money, and it's what people want. So it's a win-win."

Because PACE offers services in the home as well as day centers and activities, family caregivers of participants in the program are less inclined to suffer caregiver burnout.

"Caregivers have peace of mind when they leave and go to work during the day knowing that if there's a fall or something happens, they have a team that can be reached, that can help," Winslow says. "It’s all person-based care, what those individual families need."

Winslow advises older adults and their family members to inquire about PACE programs in their county sooner rather than later.

"It's hard to make a good decision when you're in crisis mode," she says.

Health literacy is an age-friendly essential

Health literacy is another important component of age-friendliness. Health literacy refers to a person’s ability to find, access, and understand health-related information. It does not make the patient responsible for understanding care instructions and medical advice, but rather asks the provider to make sure the patient understands. This can be done through sharing printed materials or videos that are produced in lay language with images to support comprehension. But it’s even more effective through conversations that avoid medical jargon and terminology that prevent the patient from grasping what they need to know to take care of themselves.

"As you age, you tend to see an increase in complexity in every facet of your life. You tend to see additional conditions or diagnoses, and you tend to see more medications or polypharmacy," says Janis Rood, PACE Southeast Michigan director of pharmacy and integrated clinical services. "Older adults may not even understand what we're trying to tell them, let alone make decisions based on that for however many years they have left. It's just so important that we take this into account. It offers dignity. And it's the only way to provide high-quality, informed care for our older adults."

More than 43 million adults in the U.S. cannot read, write, or do basic math above a third-grade level. For people with low literacy levels, health literacy becomes even more important.

"People with low health literacy use emergency services more often, which disrupts the continuity of care. They have higher health care costs, and they use fewer preventive services," says Laurie Arora, PACE Southeast Michigan vice president of public affairs, philanthropy, and organizational development. "In general, low health literacy means a higher mortality rate."

PACE Southeast Michigan trains staff members at all levels, from drivers to physicians, in how to create health literacy for PACE participants. They learn how to respectfully ask participants to relay the information back to them to make sure it was understood. Easy-to-comprehend materials, describing just about every condition affecting older adults, are available throughout PACE day centers.

Sarah Milanowski, marketing and communications specialist with LifeCircles PACE, accompanies a PACE participant.
"We focus on providing high-quality care and communicating with language that our participants can understand so they can make decisions for themselves," Arora says. "We have health literacy champions at each of our centers who serve as a resource for participants and for staff. And we've partnered with Henry Ford Health to use their health-literate brochures on certain chronic illnesses."

Health literacy initiatives have had extremely positive results at PACE Southeast Michigan. For one, racial disparities among participants with diabetes have been eliminated.

"More than that, we actually improved clinical outcomes significantly in both diabetes control, decreased emergency department visits, and hospitalization," Rood says. "Just by partnering with our participants, taking the responsibility of making sure they are understanding, and helping them to make informed decisions about their care increased equity in the delivery of care and improved clinical outcomes across every single person in our community."

To learn how you can help your Michigan community become age-friendly, visit AARP Network of Age-Friendly States and Communities.

Estelle Slootmaker is a working writer focusing on journalism, book editing, communications, poetry, and children's books. You can contact her at [email protected] or www.constellations.biz.

Patrick Dunn is the project editor of the State of Health series, host of the Michigan's State of Health podcast, and managing editor of Concentrate.

AARP photos by Roxanne Frith. Christine Vanlandingham photo by Taylor Scamehorn. PACE photos by Pat ApPaul. All other photos courtesy of the subjects.
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Q&A: Helping homeless older adults
Q&A: Helping homeless older adults
The Michigan Coalition Against Homelessness (MCAH) is a nonprofit association of emergency shelters, transitional housing programs, nonprofit housing and service programs, government programs, and concerned citizens from across the state of Michigan. We chatted with Gerry Leslie,  Homeless Management Information System project director for MCAH, about the increasing numbers of older Michiganders experiencing homelessness and how his organization and the state are responding.

Q: The number of older adults experiencing homelessness is on the rise. What are the root causes of this?

A: The real reason why we see senior adults becoming homeless comes down to a number of factors. If somebody has a significant medical or emergency health crisis, they typically tend to be a senior adult living around the poverty line. They end up with a disabling condition, which means that they are not able to work. And they end up with significant medical debts. About 50% of the population of general homeless persons have a significant disability. If they don't have the additional resources or support of family or close friends who can help them through the crisis, this ends up causing their homelessness. And, when you have seniors on fixed incomes, rising housing costs [contribute to homelessness].

Q: Why is being unhoused especially difficult for older adults?

A: Simply put, older adults have more significant health issues. They do not always have the ability to bounce back as quickly. Finding employment with a disability is often a significant challenge for them. And when you get to be a senior adult, unfortunately, that health issue is not going to go away. It’s going to continue to grow because of age itself.

Q: What is your organization doing to help older adults experiencing homelessness?

A: We're working on a couple of pilot programs around housing and health care with senior adults with the Michigan Health Endowment Fund. Also, with the projects that we've been doing around health care, acuity [need for care], and homelessness, we’re looking at the highest utilizers of Medicaid resources who have a chronic history of homelessness and using resources for housing them. Those are some of the things that we're doing at a statewide level.

Also, I’ve been looking at shared housing models, whereby you may have one, two, or three seniors living in a shared housing situation. That's not the way that typical homeless programs work because they typically seek to put a household in a standalone housing environment. With senior adults, oftentimes, they need both housing and continuous case management and health care. So a shared housing model works extremely well, especially when you have access to medical resources nearby that are directly linked to them that can continue to work with our senior adults who are experiencing homelessness.

Q: As Michigan seeks to be an “age-friendly” state, what can or should be done on a state level to reduce these numbers?

A: I think there should be a prioritization factor for senior adults experiencing homelessness. That's the first thing. Also, we should look for ways to create housing that prioritizes homeless seniors. We have youth homeless programs. We have veterans’ homeless programs. We have various programs that exist for families with children. One of the things that we need to seriously consider is developing programs for adults 55-plus who are experiencing homelessness.