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May 26, 2022

By S. Liliana Oakes, MD
Supportive Care
San Antonio, Texas

Opening a door to understanding

I grew up in a multigenerational home that included my grandparents in Colombia. My grandparents were my best teachers, as they overcame so many adversities. Their stories were amazing, and I always found the profoundest wisdom in them. I saw all the strength and beauty in my grandparents, but also their experiences with chronic illnesses.

My grandfather developed Alzheimer’s disease, but back then, we didn’t know about the condition like we know about it now. We thought all people developed that way, and we didn’t take him to the doctor.

Growing up, my grandfather would take me to the park with my brother and cousins. He would offer to buy us whatever food we wanted and then realize he forgot to bring money. He would leave to get money and then return three hours later, saying he got lost. We waited for him in the park and thought, “Wow, he really has a memory problem.” Also, he went through painful delusions, which I couldn’t understand as a teen. I was always very curious as to why his disease happened and whether we could have done something better. I was the first person in my family to go to medical school, and it opened a big door to understanding my grandfather’s situation.

Providing care in the home

After earning my medical degree in Colombia, I came to the University of Texas Health Science Center in San Antonio, where I pursued my residency in family medicine and completed a geriatrics fellowship before becoming a faculty member at the university for 10 years.

In 2014, I joined WellMed to help co-lead the Supportive Care program. We felt that care was going well in the clinic, but when patients went home, all the progress they had made would disappear. Why? Because there was no visibility of what was happening in the home. So, we began offering care at home, too, which increased patients’ access to care and allowed us to assess social determinants of health. Patients want to be seen at home and to avoid making an extra trip that’s unnecessary. They also appreciate our social workers, who connect them to community resources and services when needed.

One of the things I love about our team is that we don’t see or treat people only as their illnesses or disabilities. With ill older adults, we understand that we are seeing them in only a short period of time, and there is a beautiful, larger story not related to their illnesses — a story within a story of their upbringing, challenges, family, kids, pets, professions, accomplishments and more.

A lot of what we do in palliative care and geriatrics is focused on seeing the whole person. Older adults can bring more complexity, but it’s about focusing on how we can align to prioritize what’s important to them. It’s putting together that puzzle to facilitate the best care for the individual and their goals.

Enabling aging in place

As people are living longer, with more treatments and ways to prolong life, the question we need to ask is, “How can we start investing in our health earlier?” It’s an important discussion because a lot of health problems start early on — not just in the last five years of someone’s life.

We really need to look at the whole package — including the psychosocial aspects. When you are loved and have strong social connections, if you are eating as healthy as possible, if you are physically active, you are going to have a much higher likelihood of remaining independent where you are.

It’s vital that we train providers to understand social determinants of health. Before we ask to refill a prescription, we need to ensure patients have access to food, running water and money to pay for their basic, daily needs. Our company has programs that help address barriers to better health, including food insecurity and lack of transportation.

We need to think beyond health care — all levels of society need to be mindful of how to accommodate people with physical limitations and varying cognitive needs. It even involves how homes are designed for older adults. We need to see patients as humans in the context of their trajectory — their past, future and contributions — and to think globally. What else can we do so older adults can remain living longer at home?

Empowering patients and their families

Most of the time, nobody raises their hand to say they want to go a nursing home. People want to be home and stay there, so we should be supporting that to the extent we can.

Our team of physicians, nurses and social workers work together to empower patients and their families and to help them with advanced care planning. We ask, “Who will help make decisions if things get worse? How much would you want to go through to gain more time? What are your fears, your hopes?”

Currently, almost 40 percent of older Americans die at home with hospice care, compared with over 80 percent of patients in the WellMed Supportive Care program in Texas or Florida. Our patients’ families are so grateful that their loved ones received the appropriate end-of-life-care and were able to stay at home. (cdc.gov/mmwr/volumes/69/wr/mm6919a4.htm)

Cultivating cross-cultural care

The data about health disparities among minorities is so hard to swallow. If we can do anything to decrease those gaps in health care, we have a huge responsibility to do so. It starts with understanding the differences in cultures — where people are coming from, what are their beliefs.

In addition, there are tendencies in minority populations that we need to be aware of. On average, Latinos develop symptoms of Alzheimer’s seven years earlier than people of other races. Culturally competent health education and community outreach can play an important role in helping patients and their families to better manage their health, enabling preventive care and earlier intervention in diseases.

At the University of Texas, I helped create a Spanish-language program, “Cuidando con Respeto,” which has been adopted by several Alzheimer’s associations to support Latino family caregivers of people with Alzheimer’s disease. The program includes a short film that depicts a Latino family struggling with a loved one’s dementia — the intent is to help caregivers gain a better understanding of the effects and challenges of someone diagnosed with dementia. When families watch the telenovela, they start opening up, and it’s very healing for them. It’s much easier to share their experiences when they see it in others. There’s so much that we can do now to support caregivers and to help them enjoy their family members and stay close. We are empowering minority communities to take charge of their health and to be active participants in understanding how to navigate complexities in health care.

Looking to the future

I’m very proud to be part of WellMed and the Optum family. I appreciate the leadership support, innovation and continued discussion of opportunities for improvement. We are always trying to think in advance of where we need to provide care, at the right time and with the right resources.

We enable people to have longer, healthier life spans, with a better quality of life. It is humbling and inspiring to see what colleagues are doing, and it’s gratifying that we all speak the same language: “What else can we do to improve the health care of America?”

Interested in reading more? Liliana came up with the idea for “Faces of Resiliency: Courage Through COVID-19,” a collection of intimate photos and stories of seriously ill WellMed patients and their families bravely meeting challenges during the COVID-19 pandemic with help from their WellMed care teams. The book provides a platform for healing, and it highlights hope and humanity amidst adversity.

Dr. S. Liliana Oakes is a geriatrician and palliative care physician and medical director in the Supportive Care program at WellMed in San Antonio, Texas, serving patients with chronic or life-limiting illnesses through both in-clinic and home-based care. Liliana’s interests include culturally competent care and education.

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