I Wish I had 9-Lives like a Cat!

My Life Just Passed before my Eyes!

Pooch says:  “What was she thinking?  Didn’t she even see that STOP sign or hear the siren as that emergency vehicle went through the intersection?”

Carolyn Rosenblatt, RN, BSN and former personal injury attorney from AgingParents.com identifies a growing problem with “Dangerous Older Drivers”.  Newer generations of “older people” (such as the Bobby-sox generation) are living longer with a greater percentage driving and owning their own car.  Ms. Rosenblatt points out that the rationale of “She only drives to the store” isn’t a valid justification for allowing an unsafe older driver to continue driving since “most accidents happen within 3 miles of home”!  The National Safety Council has recognized this issue and published “Time to Hand Over the Keys” in its Fall, 2012 Family, Safety + Health journal.

Recently in California, “a 100-year old man … struck and injured 11 people, nine of them children.”[i]  The related article rekindles the debate as to whether there should be a maximum age for driving.

Restricting the older adult’s ability to drive, although necessary, definitely causes a loss of independence and may increase depression as the individual copes with feelings of “entrapment” in their own home.  Professionals and family members should recognize this as a significant LOSS for the senior and help them understand and work their way through the 5-stage Grief Management process.   Attempts to minimize the impact of this decision will generally only lead to further expressions of Denial and Anger at the person making the comments.  As discussed in the “Beyond Death and Dying” series on the Progressive Retirement Lifestyles blog, these reactions are perfectly normal and a necessary part of the grieving process before reaching acceptance of the loss.

HOW CAN THE SENIOR LIVING COMMUNITY HELP?

Many “seniors” consider the move into a senior living community – be it called independent or assisted living – as a loss of freedom and independence.  Prudent operators understand that in probably 99 out of 100 cases, the move-in is a compromise decision for the prospective resident.  They are willing to give up a certain amount of the freedom that comes from living in their own home in exchange for something.  That something is the VALUE that the senior living community offers to the prospect and their family and may be different from one resident to the next.

For instance, security may be extremely valuable for one family when the elderly loved one’s home is located in an area with an increasing crime rate.  For others, it’s making sure that “Mom” is getting 3 good meals a day and/or not having to worry about whether she remembered to turn the stove off.  Socialization with others of the same age and interests may offer value for others.

In the above situation where the individual has surrendered their car keys and driving privileges, the transportation services of the senior living community may give the senior MORE independence than staying in their own home.  On a scheduled basis, the resident will be able to get to their routine doctor’s appointments and go shopping.  They won’t need to depend on family and friends to transport them or have to use cab service or public transportation for these essential trips. Of equal comfort to their families, all trips will be supervised and monitored to make sure that the senior doesn’t “get lost”.

In this common scenario, what appears as less independence (i.e. moving into the senior living community) may actually provide MORE freedom and latitude for the aging adult whose physical or mental limitations make it unsafe for them to continue to drive.

[i] John Rogers, Associated Press article, August 31, 2012 http://www.tennessean.com/viewart/20120831/NEWS08/308310073/Crash-rekindles-debate-about-age

Working With NORC Programs And Villages– An Aging-In-Place Option With Opportunities For Providers

Article by Jane E. Zarem, Editor; reprinted with permission from Irving Levin Associates,Inc.–Senior Living Business[1], September 2011 issue:

The term “Naturally Occurring Retirement Community,” or NORC, describes a community not specifically developed for seniors but having a significant proportion of older adult residents. In a dense urban area, a NORC may occur in a single apartment building, a housing complex with common management, or a cluster of apartment buildings in close proximity; in a less urban area, it may be a neighborhood of apartments and/or single-family homes. Generally, a NORC forms as one of two quite-different models:

1. NORC supportive-services program. A public/private partnership involving a housing or neighborhood organization, health-care providers, social-service providers, and the residents themselves, the purpose of a NORC supportive-services program is to coordinate a broad range of free or low-cost social, health management, and wellness services and to provide educational and recreational activities for the residents in order to maximize the health and wellbeing of the community as a whole. Funding for a NORC program may come from a combination of government agencies, housing authorities, grants, philanthropies, corporations, and/or local hospitals. Residents pay fees for certain services such as nursing care.

Eligibility is based on residence and age; all older adults living within the geographic boundaries of the NORC are served. Legislative criteria, regulations, and language vary from state to state; e.g., half the residents in the defined area must be over age 50, or 40% of the heads of households in a defined area of at least 200 qualifying individuals may be age 65 or older. NORC programs have been established in more than half the states; New York has about 50, with more than half of those in New York City.

NORCs are not about senior living communities; rather, they’re about communities in which seniors are already living, according to Fredda Vladeck, Director of The Aging In Place Initiative at the United Hospital Fund in New York City and one of the founders of NORC programs in New York State.

“A senior living provider will continue to appeal to a segment of the population that desires to be in an age-specific community and that also has the means to pay for it,” she said. “It remains to be seen, though, what will happen to future generations. While they may be more numerous in terms of sheer numbers, I’m not sure they’ll be in the same economic position as people who are 10, 15, or 20 years older.” That situation has consequences for senior living communities across the country, and that’s where a NORC program or a Village model can work.

NORC programs do not duplicate existing service groups, but are for seniors who need more than just help managing event-based care or even their primary condition. They need help understanding their medications, negotiating assistance, and managing other types of services not covered by Medicare. “A NORC program is not about medical care,” Vladeck stressed. “It’s about health-care management—counseling, navigation, education, support, training, and some hands-on services.”

A NORC program is also not fixed in stone. It reflects and responds to what’s happening in the community, both demographically and according to the needs. Back in the 1990s, for example, about four NORCs in New York City dealing with a very old population had set up onsite adult day programs funded through user fees. The population changed after about 10 years and no longer had that need, so the adult day programs were dissolved. A NORC program is able to determine which resources, strengths, and social capital can help shore up and support the community.

“Some segment of the senior population will always require assisted living or skilled nursing care,” Vladeck acknowledged. “It may be in the business interest of nursing homes, therefore, to get to know their potential patients by becoming a NORC health-care partner—perhaps donating the services of a nurse.” It’s not clear whether the partners actually benefit from referrals; but when community service is part of a facility’s mission, a local NORC may be an obvious recipient. Also, as nursing homes begin to think about their role in the expected transition to accountable-care organizations and the new requirements for those facilities, building a relationship with the community may be a very important move. And since some NORC programs receive foundation support or other kinds of grant money to support the nursing function, not all health-care partners fully donate those services.

“Getting very old and more and more frail is a natural progression,” Vladeck remarked, “but are NORC programs making it less catastrophic? I hope so. If you’ve got diabetes, you don’t necessarily need to have your leg amputated. NORC programs are all about helping people maintain their functionality and manage their health as much as possible.”

2. NORC village concept
A NORC village is a self-governing, membership-based organization that coordinates services for adults ages 50 and up residing in a defined geographic area. The single goal of a village model is to help seniors remain within the community, in their own homes, and to avoid institutionalization. It works best in an affluent urban or suburban community; it’s less clear, at this point, how well it might work in a low-income community.

The village provides concierge services—vetting vendors and negotiating discounts, making recommendations and referrals, providing social connections, and perhaps coordinating transportation, housekeeping, and other ancillary services. Most members don’t require regular assistance with their personal care or household chores, according to A Demographic Profile of Village Members, a report published in June 2010 by the University of California Villages Project. Fewer than 10% of members, on average, were hospitalized in the year prior to the study, suggesting that members tend to be in good health.

A concept originated in 2001 by Beacon Hill Village in Boston, Massachusetts, nearly 50 villages are now operating throughout the country; hundreds more are being formed. Membership ranges from a few dozen members to nearly 500 per village. While 90% of current members are age 65 or older—mostly female and mostly white—about half the villages target people age 50 and older. Annual membership dues range from $50 to $900 for an individual or $100 to $1,200 for a household, with the average about $600. Some villages offer discounts based on income.

Ecumen’s “NORC village” relationship
If it looks like a NORC and acts like a NORC, is it a NORC? Mill City Commons is a not-for-profit membership organization founded by a group of residents living in a redeveloped district that stretches along the Mississippi River in Minneapolis, Minnesota. Except that its membership is not age-restricted, the organization’s description and mission (“to build community and meet the lifelong health and lifestyle needs and desires of our members”) certainly resemble the NORC village model. The organization is an aggregator/navigator of services for its members and builds relationships with providers—medical, compassion, and other services.

Steve Ordahl, Senior Vice President of Business and Fund Development at Ecumen in nearby Shoreview, doesn’t see much difference. Mill City Commons was naturally occurring, there’s a geographic aspect, and people have gotten together to follow through on things that they need. “Any difference between that and a NORC is a little blurred,” he said. Ordahl’s view is significant, because Ecumen—which currently operates nearly 70 senior communities in Minnesota and elsewhere—is a strategic partner, sponsor, and supporter of Mill City Commons. Jumping on board at the initial stage, back in 2008, Ecumen  provides office space and contributes telephone and other services. And while the executive director of Mill City Commons works, in practice, for the organization’s board of directors, she is an Ecumen employee who reports to Ordahl. “They do reviews and reimburse us for her salary,” he explained, “but she participates in our staff meetings and in our benefits program. It’s a good relationship.”

For annual dues of $750 ($950 for a couple), members are entitled to full website access and participation in certain activities, programs, and events. Whether the need is for an electrician, a dog walker, medical care, transportation, or assistance with activities of daily living, those services are vetted by the organization and, because of the potential customer volume, often discounted.

“A NORC is really a concept rather than a thing,” said Ordahl, “and I believe that senior living providers should embrace them, as we’ve done with Mill City Commons. To the extent that a senior community can develop a relationship—perhaps providing meeting spaces, programming, transportation, and/or other services, it’s a great way to remain relevant.” Ecumen provides seminars on various health-care issues, for example, so that members know about and are comfortable with Ecumen.

“We’re not selling to them,” he emphasized. “It’s a passive relationship…a matter of trust. We want them to share issues with us and to know that we’re thinking about something other than nursing homes.” Ecumen’s mission is, in fact, “to create a home for older adults, wherever they choose to live.” So if Mill City Commons members want to continue to live in their condos, Ecumen wants to do everything it can to help them do just that.

“We don’t mind if they don’t move into our communities,” he added. “Given the demographics, we couldn’t build enough, finance enough, nor have enough money for the expected influx of demand for senior housing. There’s no way that we—or any other senior living provider—could build enough bricks and mortar to accommodate all the seniors, so why not embrace the fact that people want choices. Let’s do it on their terms.”

Competition for CCRCs—or not?
If providers continue to build and operate their properties the way they’ve done for the last 25 years, then it won’t just be NORCs that take away market share, observed consultant Art Carr of Progressive Retirement Lifestyles in Franklin, Tennessee. “The aging-in-place concept is a significant challenge to senior living communities, which will have to treat residents a bit differently as we move into succeeding generations,” he said.

NORCs are really attempting to formalize the lifestyle of 50 years ago, when families were much larger and not as geographically diverse as they’ve trended in recent years, according to Carr. “Daughters and daughters-in-law, who used to take care of parents and parents-in-law, are now in the workforce,” he noted.

Clearly, moving into a CCRC is a life decision, the main selling point being that the provider will take care of the resident’s needs for the remainder of his or her life. Would individuals with those concerns be attracted to a NORC? And would those attracted by a NORC concept ever have chosen to move into a CCRC? In Carr’s opinion, the controlled environment offered by a CCRC may do a better job meeting all of the mental, physical, and spiritual needs of its residents with less risk than a NORC setting. But an aging person who moves into a CCRC gives up some control over his or her independence in exchange for that peace of mind. A NORC allows the independent person, especially the younger elderly individual, more latitude to make decisions.

In addition, the onsite health-care partner (usually a nurse) in a NORC supportive-services program can evaluate situations and assess the member for medication adherence, hypertension, gait, balance, and proper fitting of mobility devices over a sustained period of time. “In fact, that’s not too dissimilar from what the best CCRCs do: taking into account the overall health and wellbeing of the residents and helping them maintain a healthy status as best they can.

So NORCs are simply another option—and smart senior living providers will find ways to get involved. (For further information: www.NORCBlueprint.org.)

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[1] Senior Living Business is a monthly newsletter focused on best practices, growth strategies, and financing analysis for senior living providers and suppliers. Whether their interest in the senior living sector is financial, operational, or service-oriented, readers of Senior Living Business—and their organizations—benefit from the advice and experience of industry experts and successful senior living providers. Each issue explores best practices, growth strategies, and financing analysis in original, in-depth articles that focus on developing, managing, improving, and/or growing senior-care facilities. The goal of the publication is to provide information that will help organizations provide quality care to seniors effectively and in the most financially successful way. Subscribers to Senior Living Business become privy to actionable ideas and information that are important to them and to the operation of their businesses. Click here for a free trial: http://www.levinassociates.com/freetrialslb

SENIOR LIVING ALTERNATIVES

The senior living industry is highly fragmented and characterized by numerous local and regional operators.   It covers a wide spectrum of care services and locations – including the individual’s personal residence – as indicated in the following chart:

As the individual ages[1], their medical and/or mental condition may necessitate certain lifestyle and living space adjustments.  For instance, only 9 percent of 65 to 69 year olds need some form of personal assistance; compared to 50 percent of those 85 years old and over. Initially, the senior – or their family – may choose to retrofit the residence and utilize both technology and paid or volunteer (family & friends) caregivers to provide supplemental support to meet the needs of the aging adult.  Certain of these services are covered by Medicare and sometimes provided through a certified Home Health Agency.  At some point, however, the individual and/or their family may wish to consider some form of communal living and support for the senior.  Factors that influence this decision frequently include:

• Lifestyle Choice.  The senior may elect to move into a community where they will be able to socialize on a daily basis with others of their same age, with similar interests, etc.  A widow or widower, for instance, might choose this option to offset the feelings of loneliness and isolation that they may experience from living alone.  Or, a couple could decide that they no longer value the benefits of or want the responsibility for maintaining a large house, yard, etc.

• Economics.  The Installation of safety and mobility features such as modification of steps, bathrooms and narrow 3-foot hallways in an older home may be impractical and cost-prohibitive.  Thus, the use and value of ambulation aids (e.g. electric scooters, wheelchairs, walkers, etc.) is severely restricted.  In addition, the cost of technology and paid caregivers on a daily basis can quickly exceed the total monthly cost of a full service package (including food and shelter) at a senior living building.

• Safety.  As the individual’s condition(s) worsen, their mental capacity, risk of falls, etc. while living alone could necessitate their move into a more structured, supervised environment.

• Strain on Family.  Assuming the primary responsibility for the care of an aging relative often places a tremendous emotional strain and produces unacceptable levels of stress upon a spouse or adult child.  Studies have shown that the health of the spouse is often negatively impacted as a result of their caregiver responsibilities.  Adult children serving as primary caregivers for their parents are often caught in an especially stressful situation.  This “sandwich generation” must balance their responsibilities for their parent(s) with the needs and demands of their own children.  The move of the parent into a senior living community may be the only practical solution to the natural conflicts that arise within the family.

Independent living options include age-restricted, “active adult” housing (55+ years old), active retirement complexes geared to golf, tennis and other active adult lifestyles, senior apartments and designated independent living retirement facilities.  These properties meet the needs of seniors who choose to live in an environment surrounded by their peers with access to general services such as one or more meals per day in a common dining area, periodic housekeeping and linen service, group activities and scheduled transportation for things such as medical appointments.  Some properties may also provide a non-medical emergency response system[2].

The first category of independent living is communities that are age-targeted or age-restricted to people aged 55 or older.  Housing is often provided in patio homes / duplexes with a shared wall and usually designed for complete single-floor living.   Generally, landscaping, yard maintenance, snow removal and home exterior maintenance are provided as part of a monthly service fee.  These communities attract younger, mature adults who are often “empty nesters” and are characterized by higher density per acre and the absence of kids’ swing sets in the back yard and toys on the lawn and sidewalk.  Residents may or may not be retired.

An alternative is an active retirement community such as the Sun City properties developed by Del Webb.  These developments are generally large, master-planned communities characterized by individual houses (generally owner-occupied) and significant outdoor amenities such as golf and tennis facilities.  Often these are considered destination locations for retirees, especially those established in Sunbelt areas.  These projects generally appeal to younger retirees who are seeking an active lifestyle with access to a resort-like environment to enjoy their retirement years.

Whether the senior has elected one of the above housing options or elected to remain in their historical residence, they will often reach the second stage of retirement where they become more concerned about access to services.  They may consider one of the congregate living options described below.  These senior housing communities are not considered health care facilities and the resident population is generally considered able to function independently.  The facilities do not provide direct assistance with activities of daily living (for example, bathing, eating and dressing), although some residents may contract with outside individuals or organizations for those services.

• Senior Apartments fall into two categories:  Market Rate and “affordable” housing, and are designed to allow “frail elderly” to live independently but in an environment that provides support for daily activities such as cleaning, cooking, transportation, etc.  A large number of these projects are financed and governed by Federal subsidized housing programs such as HUD’s Section 202 financing and low income housing tax credits (LIHTC) under the IRS code.  Under these scenarios, the vast majority of age-restricted residents (62 and older) pay an individualized monthly rent based upon a percentage of their monthly income.  A portion[3] of the units may be offered to the general public at “market rates”.

• Independent Living Retirement Facilities generally provide housing and supportive services with certain amenities in return for an all-inclusive monthly rental fee.  Almost all of the residents in these facilities are considered private pay.  Housing is typically provided in studio/efficiency, one-bedroom and two-bedroom apartments in a multi-story building, although some facilities may include detached villas and cottages.  Amenities include 3 meals per day – often served restaurant style – in a central dining room, a daily program of scheduled age-appropriate activities, weekly housekeeping and linen services, and local transportation.  In most buildings, a limited number of units will be “barrier free” and designed to comply with the requirements of the Americans with Disability Act (ADA).

• Continuing Care Retirement Communities (CCRC) offer another form of independent living, frequently with a sizable up-front entrance (buy-in) fee[4] and a lifetime rental/services contract. These communities offer a variety of living arrangements and services to accommodate all levels of physical ability and health needs, generally on the same campus, and are sometimes referred to as life care centers.  Seniors traditionally enter the independent living portion (apartments) of these facilities with guaranteed access, and possibly a reduced rate, to on-site health care facilities as their medical condition worsens. Assisted living or nursing home beds are generally physically segregated from the independent living quarters with oversight by various state licensing and regulatory agencies.

Nursing homes are on the other side of the senior care spectrum and – depending on the  state – may include skilled nursing (SNF), intermediate care, non-Medicaid nursing home and separate Alzheimer’s care designations.  The common criteria for each of these classifications are that a) they provide 24 nursing care under the direction of licensed RNs and/or LPNs and a licensed nursing home administrator, and b) admissions are medically driven based on a required doctor’s order.  Many if not most of these facilities have at least a portion of the building certified for Medicare services.  This enables seniors and other Medicare beneficiaries to receive up to 100 days of skilled nursing and/or rehabilitation care after a discharge from an acute hospital. However, the vast majority of nursing home patients are considered “medically indigent” because of the high cost of care and have their care provided by the state and federally funded Medicaid program.  .

For many people, the terms “senior living” and “assisted living” are synonymous.  In fact, in a survey^[5] done in preparation for the 2010 National Conference of the Assisted Living Association of America (“ALFA”), only about 15% could correctly identify assisted living as “long-term care with medical & daily activities and entertainment”.

Assisted living falls in the middle of the senior living spectrum and evolved as a widely accepted option to nursing homes by the mid-1990’s.  It meets the needs of seniors (predominantly privately paying individuals from the middle and upper class) who don’t require regular medical care and 24-hour nursing service for an illness, injury, or disability.  Services typically include housing in a group living arrangement with personal care and supportive services[6] and help with activities of daily living.  More than 900,000 people nationwide live in assisted living settings[7] and the typical resident is an 86-year-old woman who is mobile[8] – with or without assistance (i.e. walker, wheelchair, motorized chair).  According to NCAL, over 80% need help managing their medications and with other activities as shown below:

Assistance Provided with:
Food Prep	86%		Toileting	26%
Bathing	64%		Transferring	19%
Dressing	39%		Eating	12%

 

There are two different models for assisted living: the medical model and the social model.  The medical model essentially offers lighter care nursing services without all of the regulations and oversight of nursing homes and gives rise to the “junior nursing home” description.  Under this model, the resident’s admission is primarily need-driven with adult children heavily involved in the decision-making process.  Emphasis is placed on providing around-the-clock assistance with administration of medications, bathing, dressing, toileting, eating, and transferring in and out of their bed or a chair.

The social model is based more on landlord/tenant concepts and is sometimes referred to as independent living with services.  There is a somewhat greater likelihood that the move in decision will be influenced more by choice (vs need) with a far greater input and statement of personal preferences by the prospective residents themselves.

Under either model, the facility completes a functional needs assessment for each resident to determine their ability to perform (with or without assistance) activities of daily living (ADLs) and instrumental activities of daily living[9] (IADLs).  Staff members are expected to provide assistance in accordance with this assessment, but are not permitted to dispense or administer medications.

Alzheimer’s disease is the most common cause of dementia[10] and often requires specialized care in designated treatment locations – in stand-alone buildings or segregated units of larger facilities.  Half of those 85 years and older suffer from Alzheimer’s disease and nearly half of all nursing home residents have Alzheimer’s disease or a related disorder even though Medicare and most health insurance plans consider it as custodial care and a non-covered service[11].

Therefore, Memory Care (Alzheimer’s / dementia) units – as a sub-set of assisted living – have been established as the most common option for those individuals whose condition necessitates their placement in a protective environment outside of their personal residence.  For their own safety and security, as well as that of other residents, these individuals are generally placed in a separate, access-restricted unit that has been specifically designed to meet their unique needs.  The caregiver-to-residents staffing ratio is generally considerably higher than the remainder of the assisted living facility.  Meal service and activities are customized for the needs of these residents and are provided separately from the remainder of the resident population.

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[1] For this purpose, we will discuss the virtual age instead of chronological age.  A 62 year old, sedentary person with several morbidities (e.g. COPD [chronic obstructive pulmonary disorder] and a hip replacement) may have a virtual age greater than another individual who is 80, but very alert and active.

[2] The individual responding will not generally be trained in emergency medical care, but will instead call 911 and/or arrange other medical services if requested by the resident or if the resident is unable to respond.

[3] The maximum number of market rate units is mandated by the rules and regulations of the Federal and State agencies providing subsidies.

[4] Although some portion of this fee is generally touted as  “refundable”, there is some risk to the resident as discussed in the June 2010 Report presented to the US Senate Special Committee on Aging by the US Government Accountability Office (GAO) entitled “Continuing Care Retirement Communities Can Provide Benefits, but Not Without Some Risk”.

[5] Phil Lempert, CEO, Consumer Insight, Inc., Keynote Address on May 26, 2010, Phoenix, AZ

[6] Meals, housekeeping and laundry services, transportation and social activities are typically provided.

[7] In some states, these facilities are sometimes referred to as personal care homes.

[8] National Center for Assisted Living (NCAL); http://www.ahcancal.org/ncal/resources/Pages/ResidentProfile.aspx

[9] These are defined as activities to support independent living including but not limited to: housekeeping, shopping, laundry, chores, transportation, use of the telephone and management of money.

[10] Alzheimer’s disease represents around 70% of all cases of dementia according to  the American Health Assistance Foundation; http://www.ahaf.org/alzheimers/about/understanding/facts.html

[11] ibid