By Dr. Marcy Adelman
The San Francisco Dignity Fund Community Needs Assessment (DFCNA) Report is now available online (https://www.sfhsa.org/about/reports-publications/older-adults-and-people-disabilities/dignity-fund-community-needs). The Dignity Fund, passed by voters in 2016, established a stable and sustained funding source for community-based services to assist San Francisco’s seniors and adults living with disabilities to live well in their homes and in their communities.
The legislation mandated the Department of Aging and Adult Services (DAAS) to begin the planning process in fiscal year 2017–2018 with a Dignity Fund Community Needs Assessment. The needs assessment, to be conducted every four years, would identify the strengths, challenges and services gaps of community-based senior services as well as the unmet needs of service participants. Results of the needs assessment will provide data driven criteria for the department’s service and funding allocation. This year’s needs assessment is the first survey in compliance with the legislation.
Research participants were consumers of current services and service providers. Participants were asked about their awareness of, engagement in and barriers to accessing different services. The study consists of an online, paper and phone survey from a total of 1127 consumers of current services and 298 service providers. An additional 744 participants took part in community forums and focus groups.
The results of the survey are a mix of service strengths and challenges. Utilization rates and concerns for services differed across diverse communities and groups, while many other concerns and needs overlapped. The research team, Resource Development Associates, developed an equity factor analysis that prioritized five factors: Social Isolation, Poverty, Limited or No English-Speaking Proficiency, Communities of Color and Sexual Orientation and Gender Identity.
Strengths
The majority of the people currently using services report having a positive experience and of highly valuing programs that promote community and social engagement.
Low to moderate income older adults reported high utilization rates of a diverse number of services with the highest utilization rates of Aging and Disability Resource Centers (ADRC). Results indicate the effective targeting of support services for older adults with income-based needs and disadvantages.
The diversity of research participants mirrors the diversity of the general older adult population. Older adults of color represent 60% of San Francisco’s older adult population. The majority of people currently using DAAS services represent San Francisco’s diverse ethnic groups: Asian or Pacific Islanders 51%; Whites 21%; African American or Black 12%; Hispanic or Latino 10%; unknown or other 7%.
Older adults living alone, low to moderate income older adults, older adults with limited or no English-speaking proficiency and communities of color participated more in services compared to all older adults.
Challenges
Research participants identified several barriers to accessing services, such as lack of awareness about what services are available, where services are located and whether they could meet eligibility requirements. In many instances, DAAS was already providing services survey participants were interested in receiving.
All groups of participants expressed much frustration navigating the system of services and many expressed interest in peer service navigators to facilitate connections to appropriate services. Adults with disabilities reported feeling more challenged than older adults in navigating the system of services.
Survey and focus group participants with limited or no English indicated that not seeing their cultural background reflected in staff and not enough staff who speak their language were barriers to engaging in community services. Older adults with limited or no English were two times less likely to participate in the Community Living Fund, Nutritional Counseling, Village Model and Home Delivered Meals. But they were more likely to participate in ADRC’s, DAAS funded Transportation, Congregate Meals and Food Pantry Services.
Utilization rates of services by adults with disabilities were mixed. Although adults with disabilities had a much lower participation rate compared to older adults, adults living with disabilities living alone and low to moderate income adults with disabilities participated more in services compared to older adults. Adults with disabilities with limited or no English-speaking proficiency participated in Food Pantry, Aging and Disability Resource Centers and Congregate Meals Services almost twice as often as older adults with disabilities, but utilized certain services such as Home Delivered Meals and DAAS funded Transportation services less often.
One in three adults with disabilities lives at or below the poverty level. Adults with disabilities need improvement in services in housing support services, employment transportation, dedicated service space, social engagement opportunities and improved safety.
Both consumers of services and service providers cited staff capacity as a challenge to accessing services. Participants talked about waitlists for programs, such as case management, food delivery and adult day programs.
Assisted transportation services were considered unreliable, inflexible and expensive across all groups.
Filipino, Korean, Japanese and Latino clients identified the need for mental health services.
The need for more services to prevent social isolation were cited in the Chinese, Latino and African-American or Black communities.
The need for affordable in-home services was identified by consumers of services in the Filipino and African-American or Black communities.
Filipino, Chinese and Latino clients expressed the need for permanent locations for Community Service Centers.
Both older adults and adults with disabilities expressed the need for guidance in resolving legal challenges and money management concerns and a need for resources and support to make home modifications because of disability needs and to continue aging in their homes.
Consumers and service providers both emphasized the importance of making the city more age and disability friendly by creating greater awareness of the needs and challenges of older adults and adults with disabilities in general, as well as specifically related to safety concerns on public transportation and street crossings.
Older adults of color were nearly two times less likely to participate in Village Model services and participated slightly less often in Community Living Fund services.
Although the distribution of funds spent across districts in the city seems related to the number of service sites, the average financial benefit did not always align with the level of need among older adults and adults with disabilities.
Absence of Data on LGBTQ Older Adults, LGBTQ Adults Living with Disabilities and Long-term Survivors of HIV
Although LGBTQ older adults are estimated to be 12% of San Francisco’s older adult population, LGBT older adults only accounted for 4% of survey participants. According to the survey, nearly 40% of DAAS clients had missing data on sexual orientation and gender identity or clients declined to identify themselves.
LGBTQ older adults participated more often in programs targeted to the LGBTQ community than in general older adult services, and were more likely to answer demographic questions about sexual orientation and gender identity. Research Development Associates (RDA) offer that LGBTQ people may be reluctant to disclose their identity. In fact, numerous studies have shown that LGBTQ older adults go back into the closet, or don’t access needed services at all, if they don’t feel welcomed and safe.
The historical LGBT Data Collection Ordinance that required five city departments—Department of Public Health, DAAS, Department of Human Services, Department of Children, Youth and Their Families and Mayor’s Office of Community Development—to collect demographic data on sexual orientation and gender identity (SOGI) was passed in the summer of 2016. A client’s participation in responding to the questions is entirely voluntary. This legislation was first proposed by the LGBT Aging Policy Task Force in 2014, and then was championed and initiated by DAAS.
The five departments have until the summer of 2019 to be in full compliance with the legislation. DAAS has taken the lead and is already collecting SOGI data and has also partnered with Openhouse to design an online training for DAAS staff and community based senior service providers on SOGI data collection. The timeline for this data collection, however, is too late to have an impact on the DAAS Service and Allocation Plan for the next fiscal year.
If LGBTQ older adults and adults living with disabilities don’t feel comfortable revealing their sexual orientation, it likely isn’t just about a question on a page or a question posed by one service provider. It is most likely emblematic of the organization’s culture. Some years back, Openhouse conducted a successful program at two senior centers, one in the Mission and one in the Castro, where an Openhouse staff person, imbedded in the senior center, provided outreach to LGBTQ older adults in the surrounding neighborhood to introduce them to and to bring them into the center and to help the center build internal capacity to serve LGBTQ older adults. Once those centers had a critical mass of LGBTQ older adults, Openhouse’s work was done.
Just as older adults with limited or no English indicated the failure to see their cultural background reflected in staff and not having enough staff speak their language were barriers to engaging in community services, not having out LGBTQ staff people and signs that reflect the acknowledgement and validation of LGBTQ people, such as images of LGBTQ couples and rainbow flags, would most likely contribute to LGBTQ older adults feeling unsafe, or at the very least, uncomfortable in revealing their authentic selves or even in continuing to utilize that organizations services.
The lack of data on LGBTQ older adults and adults with disabilities may indicate that, while an online training about how to ask sexual orientation and gender identity questions may secure more responses on a questionnaire, real change may require a greater commitment to diversity reflected in the staff and in the culture of the organization.
The needs assessment also lacks data on the service needs of long term HIV survivors and LGBTQ older adults with disabilities. In fact, there is little to no research on LGBTQ adults with disabilities. Once it was obvious that there would be insufficient LGBTQ data, further efforts could have been made to conduct more LGBTQ and HIV focus groups. This has been more than frustrating. Lack of data has for too long been an impediment to identifying and reducing health disparities in the LGBTQ and HIV communities. That is all about to change with the collection of sexual orientation and gender identity data by city departments.
In the meantime, it isn’t necessary to wait on prioritizing services to LGBTQ older adults and adults with disabilities or the HIV community. There are more than a few national, state and local studies that can serve as a guide in setting priorities for services for HIV long-term survivors, and programing could be introduced that increases or supports staff diversity in community-based senior serving non-profits. When community-based senior services center LGBTQ older adults, LGBTQ older adults will participate and engage in those services.
The first Dignity Fund Community Needs Assessment has its limitations, but it also has provided much important information to guide future planning. It was a huge effort on the part of all involved to meet the very aggressive timeline of delivering a final report by April first. The assessment provides a baseline for future surveys.
Dr. Marcy Adelman is the Co-founder of Openhouse, a Commissioner on the California Commission on Aging, a member of the San Francisco Dignity Fund Oversight and Advisory Committee, and a leading expert on LGBTQ dementia care and policy issues.
On behalf of our members and our community, the Dignity Fund Coalition wishes to acknowledge and to thank the following organizations for their aid and support of the Mayoral Town Hall:
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