A pioneering S.F. program seeks to keep rapidly aging immigrant population out of nursing homes

San Francisco Chronicle​

30-04-2025

When Jennifer Lai's mom was diagnosed with Alzheimer's in 2021, she scrambled to find a residential care facility where the Cantonese-speaking 88-year-old could live. Lai retired early to care for her mom, but she knew she'd eventually need around-the-clock help. Her mom had lost her English-speaking ability by then, a common effect of dementia. The pair visited one facility after another that only had English- or Spanish-speaking staff.
'How could I put her there?' Lai said she thought to herself. 'Without language, she cannot communicate. How could people help her?'
Lai's mom, Lai Mooi, is one of the Bay Area's many monolingual Asian American immigrants who need culturally competent care as they age.
But the Bay Area faces a shortage of culturally competent residential elder care facilities due to high costs and a lack of bilingual workers, said Anni Chung, CEO of the San Francisco nonprofit Self Help for the Elderly.
Amid these challenges, a unique model of home-based care offers an alternative: supporting older adults to age in place rather than enter a nursing home or long-term residential care facility.
When Lai discovered On Lok, the nonprofit that runs the Program of All Inclusive Care for the Elderly, or PACE, she couldn't believe it would take care of virtually all her mom's needs, covered entirely by MediCaid and MediCare.
A Cantonese speaking caregiver started coming weekly to help her bathe her mom, who became resistant to showering after developing dementia. Home-cooked Chinese meals are delivered regularly. Three times a week, Lai's mom goes to a specialized day center for adults with Alzheimer's to play mahjong and socialize. A driver takes her to her medical appointments.
'Before On Lok, everything was on our own,' Lai said. 'It is very lucky I have On Lok…She settled down, she is happy, and I have released a lot of stress.'
This kind of home care will be critical as the Bay Area's population aged 85 and older is projected to more than double from 2020 by 2040, according to state projections analyzed in a January report by the Public Policy Institute of California.
Elderly Latinos and Asians will see the highest population growth, driven in part, by the significant migration waves from Latin America and Asia in the 1980s. By 2040, 88% of California's Asians aged 65 and older will be foreign born and about 81% won't speak English at home, the Public Policy Institute of California estimated.
California and San Francisco have generally seen a decline in assisted living and elderly residential care beds in the past decade or so. A 2019 city report found that San Francisco had 26% fewer senior living facilities than in 2012 and the numbers are even lower today.
There are often long waitlists for culturally sensitive residential facilities for monolingual older adults.
Self Help for the Elderly runs an assisted living facility for Alzheimer's patients called Autumn Glow that has Chinese-speaking staff, freshly prepared Chinese meals like braised pork belly and ginseng chicken soup, and regular mahjong games.
But 33 people are on the waitlist for 15 beds, said Kit Fong, the director of housing and community development at the nonprofit.
The nonprofit struggles to hire staff who often choose higher-paying hospitals, Chung said.
'There's not enough bilingual nurses, doctors, you name it,' Chung said.
Another challenge is funding. Residential care facilities for the elderly aren't covered by MediCare or MediCal, so older adults and their families must pay out of pocket. Costs are often prohibitive so nonprofits like Self Help for the Elderly seek government grants to try and keep monthly fees at around 50% of market rate, Chung said.
The Autumn Glow facility costs about $1.5 million annually to operate but only collects about $1.2 million in fees, Chung said. The rest comes from a government grant.
Financial woes were partially responsible for the recent closure of at least one major residential care facility tailored for older immigrants. Before J-Sei Home in Hayward closed in January, it operated for three decades as a Japanese residential care facility for up to 14 older adults, offering comforting Japanese meals and Japanese-speaking staff. But the nonprofit was losing money on the facility.
'The trend that we're seeing is that it's much harder for small facilities to break even and function,' said Diane Wong , executive director of J-Sei, the Emeryville-based nonprofit that ran the home, who added there was waning interest and the facility never filled all its vacant beds. 'There are fewer nonprofits running homes because it is not possible to raise money to close the gap.'
J-Sei, which still offers a variety of services including home-delivered Japanese meals for seniors, receives money from Alameda and Contra Costa Counties' Area Agency on Aging, which is partially federally funded.
Without access to culturally sensitive options, older immigrant adults may be left in the lurch. Those with the highest medical needs often end up in nursing homes, which historically have been beset with staffing and safety challenges.
'Nobody wants to go into a nursing home and we want to keep people out,' said Charlene Harrington, a professor emeritus of nursing at Univeristy of California, San Francisco. 'What we're trying to do is develop a system that supports people at home or in more home-like settings.'
On Lok opened one of the country's first adult day health centers in San Francisco during the 1970s.
In the 1980s, the state and federal government and On Lok began testing a new financing system in which a fixed, per person monthly payment from Medicare and Medi-Cal covered all primary, acute and long-term care services for individuals who needed nursing home-level care.
Today, the model has been replicated nationwide, adopted by organizations in 33 states with 83,000 participants. Nationwide enrollment in PACE has increased 50% since 2019, according to National PACE Association data, and more than doubled in California.
'We want to support these seniors to live a life that they want,' said Ben Lui, chief medical officer of On Lok. 'Most of them would say that they would prefer to be as independent for as long as possible.'
Studies have shown this model saves taxpayer money, costing MediCaid less per patient on average, by preventing illness, injury and hospitalization. It also prolongs lives. A five-year study that ended in 2010 found participants in PACE lived a median two years longer than people who entered nursing homes.
On a Friday in April, Huie Siu Kuen, 96, shuffled on her walker through her apartment lobby to welcome her On Lok caregiver, Yan Hua Yu. Over two years of weekly visits, the pair forged a strong bond, sharing a language and Christian faith.
Yu has learned Huie's habits. The retired sewing factory worker prefers to shower by herself. Her favorite activity is coloring, Yu said. Huie has pinned her drawings of sunflowers and pumpkins from an On Lok day center in her living room wall.
Huie, who has high blood pressure, diabetes and high cholesterol, decided to enroll in the PACE program to ease the burden on her daughters, who previously had to take time off to bring her to doctor appointments.
Before, Huie spent long days alone at home in front of the television. Now, she said, she has an active social life, with twice-weekly day center visits to have lunch with friends. On Lok doctors help with her dentures, glasses, hearing aids. Caregivers help clip her toenails.
'When I was at Kaiser, they didn't help me with my toenails,' she said in Cantonese, laughing. 'I'm very happy. Better than being just by myself at home.'