Recently in Senior housing Category

Money Follows the Person is a cornerstone of the federal government's effort to move Medicaid beneficiaries from nursing homes into the community. But a new study commissioned by Medicaid itself shows how difficult those transitions can be. In the 30 states that have been testing the program over the past three years, only 8,500 people have used MFP to return to their communities.

That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.  

The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.     

Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly. 

Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.

Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.  

Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.

Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.   

Prepare yourself for big new cuts in government support for elder care.  

In his State of the Union address last evening, President Obama called for a five-year freeze on a narrow slice of the federal budget. Unfortunately, programs subject to the freeze would include many that are critically important to the frail elderly and younger people with disabilities--especially those living in the community.

This is only the beginning of what will be a very difficult period. Yet it is an opportunity for communities to pull together to provide services that government may no longer offer.

The freeze would not include Medicare or Medicaid, although Medicaid long-term care benefits are already being cut at the state level. However, it is very likely that programs such as meals-on-wheels, adult day care, transportation, housing, aging and disability resource centers, and Area Agencies on Aging would all be hit by this freeze.

It is not clear exactly how the freeze would work. It could be an across-the-board cut in all so-called domestic discetionary programs. These are programs that are subject to annual congressional review, but exclude entitlements such as Medicare, Medicaid, and Social Security. Alternatively, Congress could pick and choose which programs to cut, as long as the total amount of all domestic non-entitlement spending did not rise from year to year.

Either way, a freeze will inevitably result in fewer services since demand for this assistance is growing as the population ages and the cost of services rises.

Congressional Republicans are already criticizing Obama's plan as too weak and vow to cut even more deeply into these programs. Some would return spending to 2008 levels, others to 2006 funding. However it finally works out, there is little doubt that many of the long-term care supports and services that seniors now rely upon are in line for major cuts.

With a national debt of $14 trillion and annual deficits of more than $1 trillion, there is no doubt that government spending is going to be trimmed--perhaps quite substantially.It is also likely that sooner or later, federal payments for Medicaid services will also be slashed. One can hope that an eventual budget deal will eventually include tax increases as well, which would help soften the spending blow. But in the current political environment, that is not likely--at least until after the next presidential election.

So what do families and advocates do? I believe we need to begin to look for community, non-government solutions. If transportation services are cut, we should pull together to create volunteer ride programs. Senior villages are one way to build such an infrastructure. So are more informal groups organized around neighborhoods, churches, synagogues, or fraternal organizations.

If budgets for government-funded resource centers are slashed, we should support private non-profits that pick up the slack.(Full disclosure: I serve on the board of one of these--the Jewish Council for the Aging of Greater Washington--and as an adviser to another--Caring from a Distance). 

As needs grow and government services shrink, we all face a huge challenge. But it is also an opportunity to rethink our obligations to, not only our own parents, but to our neighbors and friends. I hope we will be creative enough to take up this challenge.    

It is an article of faith among many in the elder and disability advocacy communities that aging in place is always the best alternative for someone who needs personal care. I don't believe it, and I recently heard an important panel discussion that confirmed that view.

The panel, sponsored by Washington Grantmakers, was especially interesting because the participants were all supporters of community caregiving. But they agreed that, without a strong infrastructure of family, community, and public support, it is not always possible for people to live at home. Indeed, it can often be lonely and even dangerous.

University of Florida professor Stephen Golant, who has written extensively on housing and care alternatives for seniors, reported that his research finds six major challenges to the frail elderly living at home. They include affordability, physical deficiencies of homes, lack of social supports, neighborhood changes, difficulties accessing community assistance (especially in both inner cities and cul de sac suburbs) and vulnerabilities of old age including greater risks of accidents, poorly trained family and paid caregivers, and even abuse.

Golant concluded that those most at risk staying at home are low-income, very frail, poorly educated women who are 85 or older and either living alone or with a frail spouse. This seems obvious, but these are the very people who have the fewest alternatives. For most, high-quality assisted living or even independent living are far beyond their financial means. Golant says those at most risk are not the very poor but the nearly one-third of seniors he calls "tweeners," who do not qualify for public programs but can't afford to private pay for housing with supportive services. 

Golant suggests that addressing these issues requires "changing the aging in place dialogue." Doing this will require society and families to recognize that living at home is not always the answer, and that focusing on group care may make more sense. This can mean thinking about senior villages and other naturally occuring retirement communities where care can be better coordinated and delivered much more efficiently. 

Charles Smith of the Montgomery County (MD) department of aging and disability services said that it is increasingly difficult for government to deliver the services necessary to support people aging at home. Budgets are being slashed and physical distances make it tougher to provide assistance, especially in the suburbs. Smith said that in sprawling Montgomery County, it costs five times at much to deliver a meal to a suburban house as it does to buy it. Transportation services, the single most common need for those at home, face the same difficult combination of smaller budgets and greater distances.

"We are creating expectations that you should age in place,"  Smith says, but government doesn't have the resources necessary to meet those expectations. 

Rev. Joseph Williams, executive director of Emmaus Services for the Aging, a private non-profit in the District of Columbia, added that grassroots community support is essential for people to age at home. "It can't all happpen in the department of aging," he said.   

None of this means those of us caring for our parents should not do all we can to help them stay at home, if it is appropriate. It does mean that just saying the words won't make it happen. Rather, it will require communities and families to work together to back up the sentiment with real resources, including both time and money. It is a fantasy to believe that assistance will come entirely from government, which will be increasingly strapped for funds in coming years. It will also require us all to recognize that some of our parents will be far better off in a congregant care setting.        

Among the great challenges we all face as we age is where to live. We may be a bit too frail to stay in our suburban colonial, but are not nearly ready for assisted living, to say nothing of a nursing home. We could move to a traditional large retirement community such as a Leisure World, but that would mean moving to a gated community where we'd be surrounded by thousands of other seniors. No kids except for visitors. No real neighborhood beyond the clubhouse, the pool. and the shuffleboard court.

So how about this: Imagine sharing a residential home with about 10 others. The homes are located in urban or suburban neighborhoods. Each resident gets her own studio apartment with a private bath, and shares a communal den and dining room. The building is acccessible for both people with disabilities and the frail elderly, with grab bars, ramps, railings and elevators. While it is designed for those who can still live independently, it is fully staffed and you have access to a local community health center for both medical care and supportive services. The home is also set up for convalescent care, should you need it. And the cost for a typical resident: less than $2,000 per month, including meals.

The houses are private, and are not operated by the government. They can be started by non-profits such as service clubs, churches, or community groups. 

What's remarkable is that the idea of these homes is not new. Called Abbeyfield Houses, they have been operating in England since the 1950s and there are now more than 900 worldwide.

So where do I sign? Well, there are 27 in Canada, including the Parkdale House in Ottowa. But Beth Baker, who told me about Abbeyfield, says that as far as she knows, there are none in the U.S. Beth, author of the terrific senior housing book Old Age in New Age, would know.

It would be great if a local non-profit opened one. Imagine, for example, if it was linked to a senior village (a community group started by seniors to help one another) perhaps with a partnership with a local hospital or community health center. Imagine if the model became so well established that groups of friends could use the template to create small communities of their own as they aged.

We have similar models here. Small group assisted living homes and co-housing come to mind. But none quite fit the niche that Abeyfield does. If someone builds it, we will come. 

I spent yesterday with more than a hundred elder care professionals at the Seven Acres senior care campus in Houston. For a while they listened to me, but for much of the time I had the opportunity to listen to them. And what I heard was striking, and an important addition to the HSC Foundation's recently published study based on listening to family caregivers.

We had a wide range of professionals at this program, the 24th annual Lou Lewis Symposium in Gerontology: executives from nursing homes, assisted living facilites, and home health agencies; case managers, social workers, nurses, and maybe even a physician or two. Early in the program I asked how many had also been caregivers for their own family members. At least 80 percent raised their hands.

After I spoke, the participants broke up into a dozen small groups to come up with their own ideas for improving today's long-term care system. Not surprisingly, there were many suggestions. But there was also a striking consensus on a few broad themes.

Participants were tremendously frustrated at how poorly the system works today. Their biggest frustration may have been over the lack of communication between families and professionals and the absence of care coordination within the health system itself.

A word I heard over and over again was education. These professionals felt passionately that family members, aides, doctors, and--yes--politicians need to learn much more about how elder care works, not at a broad policy level but for individuals. The resources out there today, such as Area Agencies on Aging and Aging and Disability Resource Centers, help. But the participants thought they need to do much more. 

We talked about the need for better training for all caregivers, both family members and aides.

The participants felt strongly that community groups, local businesses and, especially, faith-based organizations need to play a greater role in caring for the frail elderly. We talked about the village movement, where seniors join together to form community non-profits to help one another. But many participants felt that churces, synagogues and other religious institutions could do much more to aid their own congregants. This assistance could come from volunteer committees who help arrange rides, friendly visits, and phone calls.

We also discused the importance of financing long-term care. This group, at least, was skeptical about whether young people would enroll in the voluntary CLASS Act. Even though this was Texas, some even felt the country would do better with a social insurance design for long-term care. But, once again, they felt that better education is the key to encouraging people to begin preparing for future long-term care needs.

I learned a lot yesterday, and I hope the participants follow up on some of their teriffic ideas. 

The Stanford University Center on Longevity has just released a trove of information on the health, living arrangements, and demographics of an aging America. The study, "New Realities of an Older America" tells the story of an independent, remarkably healthy population, but one that will present unique challenges as it lives well into its 80s and, eventually, reaches frail old age.

For example, authors Adele Hayutin, Miranda Dietz, and Lillian Mitchell paint of picture of serniors increasingly living alone and in the suburbs--housing patterns that will make caregiving especially difficult.These seniors want to age in place, but providing assistance to a population that may become trapped in their own subdivisions will be a huge challenge. Caregivers battling traffic. Elders no longer able to drive to the doctor or the grocery store, or to even visit with friends. These are not pleasant images.

Yet, the current population of elders has made their opinion clear. In 2005, even among those with functional limitations, 85 percent lived at home or with a relative. Just 10 percent lived in skilled nursing facilities and only five percent lived in assisted living facilities. Even among all those 85 or older, three-quarters lived in traditional housing. 

The great challenge will be finding new ways to deliver care to this population--a challenge that will be compounded by the growing prevalence of dementia among those 85 or older. While this study finds that disability rates among the elderly are falling (a conclusion that is disputed by other research), it also estimates that the population with dementia will more than double, to nearly 11.4 million, by mid-century. 

There is lots more to chew over in this paper. Take a look at it.

The Senate Aging Committee held an important hearing today on Continuing Care Retirement Communities (CCRCs) where the panel's chairman, Senator Herb Kohl (D-WI), urged that both state regulators and the CCRCs themselves provide more information about their financial risks to residents, as well as other consumer protections. This is what Kohl said:

The fact is that while CCRCs are a good residential option for many retirees, entering into an agreement with one can pose financial risk. "If these companies are going to take the life savings of seniors, they need to be able to guarantee they will be around to provide the lifetime of care they promise.

There are many models of CCRC, but in several designs residents make large up-front payments, known as entrance fees, in return for the right to stay in the communities throughout their old age. Although many residents believe they are buying their apartments, they usually are only making an interest-free loan to the operator. They have no ownership interest in their units. In most communities,residents are supposed to get some or all of that fee back when they die or move.

These facilities are becoming increasingly popular. Today, almost 750,000 seniors live in 1,800 communities.

However, some high-profile CCRC operators have failed lately, raising questions about the security of these deposits. In some communities, residents only get back their entry fees when their unit is re-occupied and if the next resident pays a fee at least as large as they did. 

As a result, residents often bear the risk that their unit may drop in value but, because they are never owners, they have no opportunity to share in any gains. Units can lose value if management changes hands, if a more attractive competitor opens in the same area, or if a poor economy makes it difficult for new residents to find the financial resources they need to move in--the circumstance that many face today.

Kohl did not propose additional federal regulation, but instead urged states to increase their oversight. Because CCRCs combine independent, assisted, and skilled nursing facility living, they often fall between the regulatory cracks. The federal government regulates the nursing facilities, and states may oversee assisted living. But independent living are usually unregulated.

As Kohl says, CCRCs can be an attractive option for many well-to-do seniors, but residents need more protections against the possibility that the operators may fail.     

Receiving personal care at home, as opposed to in a nursing facility or other institution, is not possible without two things: Somebody to provide the assistance and an appropriate place to live. A southern Virginia minister has come up with a possible solution to the second.

MEDCottage is a portable, modular self-contained 24x12 dwelling that could be attached to the home of a family member, friend, or other caregiver. The home contains a small kitchen, bathroom, and bedroom, as well as high-tech assistive devices, video monitors, and a lift. It is designed to rent for $2,000-a-month. The Washington Post ran a nice article about it yesterday, or you can check out the company's own Website here.

This seems to be an ingenious solution to a vexing problem. Some people may be able to retrofit an existing space to care for a frail or disabled relative. But that can be expensive and complicated. A solution such as a modular add-on may be less costly and, in many cases, more appropriate. This may be especially true for people who need intensive personal care for a relatively short time--perhaps because they are recovering  from a severe illness or because they are dying.

Modular living spaces such as this are no panacea. They are probably not suited for very long-term care arrangements, and family caregivers need to be well-trained in how to use all the equipment.

They also face two other issues, One is money: Will Medicaid or private long-term care insurance pay for dwellings such as this? The newly-enacted CLASS Act will since will offer a cash benefit. 

The second issue, reports The Post, is the NIMBY problem. Sadly, but not surprisingly, local Virginia officials oppose the dwellings, claiming they violate zoning laws. Here is what one Fairfax County (Va.) official had to say:  

"Is it a good idea to throw people into a storage container and put them in your back yard?" said Fairfax County Supervisor Jeff C. McKay (D-Lee). "This is the granny pod. What's next? The college dropout pod?" 

This sort of thinking is beyond depressing, but it is out there. I hope that as time goes by, technology, financing and perhaps even some good common sense will combine to create some important new alternatives for people to stay at home.     

Today, The Washington Post and Kaiser Health News jointly published an article I wrote on aging in place villages--an important element in the effort to help seniors remain in their communities. 

There are close to 50 villages now operating around the country, and at least 600 communities interested enough to send representatives to workshops held over the past year by the non-profit community development group NCB Capital Impact.

Villages come in many shapes and sizes, but there are three basic models. One, pioneered by the Community Without Walls in Princeton, N.J. is an all-volunteer group, with modest dues (just $30 for a couple). Beacon Hill Village in Boston relies on a professional staff, provides concierge services to link members with vendors (for services from home health aides to plumbers), and charges substantial dues. The third model, created by the Maryland non-profit Partners In Care, is based on the concept of time-banking. In this design, members  receive credits for their volunteer time which they, in turn, can exchange for the help of other volunteers. 

Different models may work in different communities. But the key to the success of the village movement will come from their bottom-up, community-based nature: Local people pulling together to help one another as they age. It is a powerful concept with a promising future--both for elders and for adult children caring for our parents.       

Lots of buzz about the Oct. 20 Chapter 11 bankruptcy and sale of Erickson Retirement Communities, one of the nation's premier developers of Continuing Care Retirement Communites. CCRCs are campus-like settings that promise lifetime care for seniors, from independent living to assisted living to nursing home care.

These facilities operate on several different business models but Erickson, like many others, requires a hefty, refundable, entrance fee (often hundreds of thousands of dollars). Residents also pay an additional monthly fee depending on their level of need. For instance, an independent living apartment may run $2,000 per month, while a nursing facility stay may cost $300 per day.

In the Erickson model, the entrance fees are fully refundable but only after a resident leaves their apartment and it has been reoccupied. Residents never own their units, but are instead buying lifetime access to the comunity's services. The fees serve as, in effect, an interest-free loan to the operator. Erickson Communities has 23,000 residents in 19 states. 

CCRCs have been under tremendous pressure in the current economic downturn. Their business model relies on new residents selling their homes and using the proceeds to the pay their entrance fees. With the collapse of the real estate market, fewer upper middle-class seniors have been able to sell. At the same time, highly-leveraged CCRC operators are being squeezed by impatient lenders. According to Erickson's bankruptcy filing, available here, the firm was driven into Chapter 11 by its bankers.

The consequences to residents are unclear. Erickson says their entrance fees are safe, but what happens if a current occupant dies or moves and a new resident is allowed to move in with a lower entry fee? Jay Hancock at The Baltimore Sun takes a good look at this issue. So does the Wall Street Journal's Anton Troianovski.

These problems highlight the complexity of resident agreements with CCRCs, arrangements many seniors simply do not understand. I am also concerned with the quality of care and services residents will receive as operators of these facilities face growing financial pressures. This is especially important for those living in the assisted and nursing facilities in the communities. 

The Erickson bankruptcy is likely to accelerate questions that lawmakers have been asking  about CCRCs. The U.S. Senate Aging committee has been investigating the business model for the past several months, and is likely to hold hearings on CCRCs sometime next year.