Can Nurses Solve Our Nation's Problems?
aarp president-elect jennie chin hansen '70 discusses her work with older americans - fall/winter 2007
Lately, it’s hard to pick up a newspaper that doesn’t mention the aging of the baby boomer generation. As boomers begin to retire, many pressing social questions have arisen: Will the social security system survive the huge influx of beneficiaries? How will massive retirements impact the workforce? And, closer to home for nurses and other healthcare professionals: how will the aging population burden a heathcare system that is already characterized by staffing shortages and economic challenges?
Among the policy makers working to answer these questions is Jennie Chin Hansen ’70, who will become President of AARP in 2008. AARP has 39 million members and is one of the largest and most influential voices that represent the interests of older Americans. Hansen’s history of policy and advocacy for older Americans made her an obvious choice to lead AARP.
After graduating from the Boston College School of Nursing in 1970, Hansen pursued a community heath career path. She explains, “It was just my propensity to think about how to…have an impact on larger groups. I found that there was more ability to affect change by thinking more broadly about populations rather than about techniques and specific research methodologies. Affecting change ultimately happens at the population level.”
Hansen began her career as a public health nurse in Idaho. “In community health, one cares for the whole age continuum. So when I was a public health nurse in the ‘boonies,’ I was intrigued with older people and their fierce independence. These people had no resources, were so isolated in rural communities, but had an absolute tenacity and dignity to make it on their own. They would appreciate my coming by but, heck, they would’ve done fine without me. My interest was piqued in the appreciation of older people who really wanted to maintain their abilities and their dignity to live as strongly and as independently as possible.”
Hansen brought this appreciation for older people with her when she accepted a position as a researcher for On Lok, a then-small nonprofit organization providing community-based heath services in San Francisco. Hansen stayed at On Lok for nearly 25 years, eventually serving as Executive Director of the organization, building it into a robust family of organizations, and developing it’s program into the prototype for PACE (Program of All-Inclusive Care for the Elderly), now a Medicare/Medicaid program available to all 50 states.
“In developing On Lok, you could say we identified the core ingredients, and maybe the sauce has a slight variation, a regional variation. We identified the ways that existing services didn’t come together really well and the way things were paid for didn’t come together well when you were actually the person trying to navigate through this. What we did was take the same ingredients but re-formulated so that it really worked for the local community. The ingredients were still the same—flour sugar and eggs—but we recombined them in a way that made sense and yet cost no more or actually cost less. [Our approach] actually produced a quality [of service] that people were happier with.”
I think the visible racial component is one that’s rather right out there [with On Lok], so people say ‘Oh my gosh this is a wonderful little Asian program.’ But the reality is that it was [originally developed in] a part of San Francisco called North Beach which was comprised at that time of Italian immigrants, Phillipino immigrants and Chinese immigrants. So we actually had three initial immigrant populations. Their commonality was that English was not their first language and they each had their own cultural mores that were very deep for people who were older. So what we were able to do was maintain that; this was the early days before talk about cultural competence as a concept, and we had people who spoke their language, understood some of the value systems that were important, understood what foods and practices were important to them, understood their family dynamics that came with populations and be able to factor all these variables and create something that had the universal, flour and eggs to it and it was just then baked a little differently but with core points of accountability all throughout.
“When we became a national program, it was these core principles of accountability and these structures that were universal; it played out a little differently in El Paso, Texas which was a lot of Mexican-Americans to Milwaukee, Wisconsin that had kind of classic Midwest population to Portland, Oregon to the Bronx. Those core ingredients were found to be universal needs by people regardless of their ethnicity. We tapped into the fact that when people get to this stage in their life they still want to be their form of normal, a part of their community, and still do as much as they can possibly to do. They want to be able to be part of the fiber of their local neighborhood.
We facilitated those principles in the form of the PACE program and provided the technical pieces that made it possible. That to me was the beauty of having a community program become the national [model] rather than having the policy wonks design something and say ‘make this work at the local level.”
Hansen set out to become a nurse—not a policy maker—but her approach dictates doing whatever is necessary to achieve her goals. “I don’t think I intentionally went into tackling Medicare and Medicaid but the irony is, that’s what you find out you have to do. I didn’t go in there thinking I was going to create federal legislation but that became the by product of creating a system that made sense for people.”
Although she initially stepped into the policy world accidentally, her experience reveals a depth of experience in that world. Hansen’s resume reads like a “who’s who” of heath care policy makers. She’s a Commissioner of the Medicare Payment Advisory Committee (MedPAC), board member of the National Academy of Social Insurance, and the Robert Wood Johnson Executive Nurse Fellows Program. She also serves on boards of the Effective Healthcare Stakeholders Group of the Agency for Heathcare Research and Quality (AHRQ), Lumetra (California’s Quality Improvement Organization) and the California Regional Health Information Organization (CalRHIO). She is also past president of the American Society on Aging.
In 2004, Nancy Pelosi, now Speaker of the House of Representatives, said of Hansen, “A visionary and a fierce advocate, Jennie has greatly influenced how our nation has come to regard care for the elderly. She has shown us the richness of caring for our seniors.” Clearly Hansen had made a name for herself in the policy world. Still, her most visible role was yet to come.
Hansen first became involved with AARP as a member of the board of directors of the AARP Foundation, AARP’s charitable organization dedicated to enhancing the quality of life for all as we age. She was invited to serve in this role by Dr. John Feather, who had served with Hansen on the board of the American Society on Aging. “One of the things he was trying to do was diversify the board in terms of thinking” Hansen explains.
Seeing her work with the foundation, the AARP leadership was impressed by Hansen’s thoughtful approach and encouraged her to apply for a position on the AARP board of directors. Even at this point, Hansen knew little about what AARP was all about. Hansen notes, “Up to that point, I kind of thought of AARP as this big lobby. [My awareness] was really limited.”
Today, as she prepares to lead the organization, Hansen’s understanding of how AARP organizes it’s policy work is a bit more nuanced. “There is a whole policy institute within AARP, there are also advocacy staff, but then what people probably do not know is that we have a cadre of 25 volunteer policy people who divide up into health and long term care, into consumer issues and into economic issues. This group of people are often former heads of Medicaid in their states and…really know about these domains extremely well; they volunteer their time to help look at the policy issues that we have. [AARP policy work] also generates from the staff.”
As a board member, one of Hansen’s roles is to synthesize all of the information coming in, understand its relationship to the mission of AARP, and set a direction for the organization. She notes, “The board of directors is the final arbitrator on the policy positions.” Right now seems to be an ideal moment for Hansen to take a visible leadership role with AARP, as their current policy positions seem to match her own approach to policy work.
“One of the things I love and so honor about the opportunity to be a part of the AARP right now [is that the organization’s positions are] really practical and tie back to being a nurse; lets get something done that is right at all levels for the individual to society, and so being in this position is a phenomenal privilege and responsibility. How do we help a society move positively on issues that have huge conundrum considerations to them? It’s kind of awesome.”
Hansen believes that asking key questions as a society is a first step to change. She emphasizes that “we need to have a real public discourse on this, as well as to reflect on our country vis-à-vis other developed countries. Why is it that we spend nearly double of our country’s GDP on healthcare and yet seemingly get very modest returns compared to how other countries spend their resources? Using benchmarks of empiricism—death rates, birth rates, and chronic disease management, things [here] are certainly no better. We need to ask the critical questions that a society should face. What choices do we make with our resources, given the principles of our democracy and market economy? How do we think about caring for our society now and in the future?
“This is to me the exciting component of mobilizing regular people. I think [we] need a new movement in our society. Its not about the politics and not only about ideologies, but whether people are going to have decent ability to live and thrive and have some of the common themes—a core of hopefulness and a future of security—and whether its for our future grandchildren or for ourselves. We have to take the issues and have ‘kitchen table discussions.’ It has to be at that level because at this point the ideologues are at each other’s throats. I think its been proven stuff just doesn’t happen with ease, just because of all the huge vested interests of all different kinds. So at some point we need to ask, ‘What’s the people’s interest?’
“We have to be intelligently informed and have the capacity to discuss this, whether we have an 8th grade education or whether we have a doctorate. There are some common themes that bind us in terms of what a decent life for our population is and our hopes for our future. I think right now it needs to be a populist understanding and a movement that calls for some ways to address the hard questions that all of us face—whether its hard questions individually, but really when you add all these hard questions together it is a collective societal set of hard questions. We have to make sure people understand there are decisions to be made that involve some hard looking at things that we often times have taken for granted.”
“First is knowing that it is elected officials who get to make decisions about the issues of healthcare and economic security. I think part of it is focusing on and shining the light on the fact that these are the people in our democracy elected to steward our well-being. With elections coming up, [we need] to underscore this with each of the candidates. [Political candidates are] having to talk about it regardless, but the ability to really commit to it publicly, in terms of what they say they’re going to do, and then staying accountable for the decisions they end up making. Just even shining a light on it is a very important thing. You can’t just keep putting it off to other people.”
According to Hansen, even these basic steps might be challenging initially. “I think it’s going to be messy for a while. I think there are some things that are going to be about the art of doing and the art of compromise just so that we keep moving on it because what we have now clearly doesn’t work. I think that’s something that AARP has the ability to do and we’re just speaking about the efficiencies of the system let alone changing the system.
“There are a huge amount of efficiencies shown over and over again that can be achieved by existing systems. Why not call for accountability? Why does a care provider or a hospital benefit from the fact that a mistake was made on a patient? When the patient goes back to the hospital, Medicare and the insurance companies just pay for it. There is something very flawed about that kind of thinking that there’s no consequence for not doing what should’ve been done correctly in the first place. Why don’t people wash their hands when they know that’s a main way of infection passing in hospitals? Why are medications not looked at as a system when some places have figured it out; the VA hospital system has a 99% rate of accuracy where on the other hand most hospitals have a 1 in 5 chance of medication errors. We know this data—it’s, kind of, staring at the states saying, ‘Do something!’ How do you do your business better, period?”
Hansen believes that these problems can be solved with smart solutions, not necessarily expensive solutions, a belief that she traces back to her time at Boston College. “I remember taking a nutrition class in the school of nursing. [For one exercise] all of my classmates and I were divided into three groups and we were given budgets to prepare a nutritious meal—to go shopping and cook this—but we had three different types of budgets. Some of the lucky folks got a high-end budget, some of us got a somewhat moderate budget and some of us got a very small amount of money. Our charge was to meet the Required Daily Allowances, and we all met the test and did it well. Needless to say, the common denominator was having a balanced nutritious diet for a day. It was possible to do it on the low-end budget [and still] achieve the principles. We have to be appreciative of the fact that sometimes we’re going to be on that low-end side and that to achieve the results, you just have to do it differently than if you had all the money to spend for a high-end meal.”
“I think we have a moral obligation to do well by the opportunities that have been given to us and to always realize that our ability to do what we do is in the context of a larger society. And I just never forget that. I am probably always a cup half full type person and I just feel blessed as well as awed by the fact that I have these opportunities. And having these opportunities and venues, I need to use it for the good of society. It’s really important to me.”