The Business of Aging

Nursing Homes: How to Find a Quality Facility

General Qualities
When visiting a facility, the following are things you should ask questions about and observe.

Patient Care

Be sure to ask about prospective facilities’ staff to resident ratio for each of the following staff types:

• Registered Nurses.
• Practical Nurses.
• Licensed Vocational Nurses.
• Certified Nursing Assistants.

Inquire about how many hours a facility’s staff spends with their residents on a daily basis and if residents typically have the same nurses daily.  Also ask how often the facility’s doctors are in the facility, and how often residents receive physical check-ups and are weighed.

While visiting the facility, observe:

• The level of respect staff members give to residents when speaking to and assisting them.
• The way staff members discuss residents with other staff members.
• Whether residents seem comfortable with staff members.
• Whether residents are carefully supervised by staff members.
• How available water and other liquids are to residents.  Dehydration due to neglect is too commonly the culprit of nursing home residents’ deaths.

Staff Quality & Quantity
Find out if staff members undergo background checks and abuse prevention training; and if they screened for a history of abuse.  Ask to see the facilities most recent state survey as well as past surveys; state surveys report abuses and deficiencies in facilities, and all facilities must legally show them to you if requested.    Inquire about the home’s and administrator’s licensing status, and how often the administrator is on-site.

Quality of Life
While visiting a given facility, ask to see the cafeteria and the food; some facilities even allow visitors to try their food.  As people get older, some develop issues with eating so you want to be sure that your loved one will want to eat the food at their new home.  If your loved one attends religious services regularly, ask if the facility either offers services or transportation to services.  Find out how prospective facilities allow residents to get exercise; some facilities actually offer exercise classes.  Exercise is very important to the elderly as it helps them sustain their mental and physical capacities.  Observe the nursing homes’ environments while visiting.  Are they positive, or dreary?  Psychological health is also very important as people age.  The longer the elderly stay active physically and mentally, and happy, the longer their life will be.

Facility Cleanliness
Observe how clean the facilities you visit are, both internally and externally.  This is not an instance where you shouldn’t judge a book by its cover; how well facilities are maintained is a telling indicator of their quality.  Ask how often residents’ bedding and rooms are cleaned.

Safety
Take notice of safety precautions the facility has, such as:

• A sufficient number of wheelchair ramps.
• Adequate lighting.
• Alert systems for patients who are at risk for wandering or falling.
• Bed rails.
• Computers: Some facilities use digital medical records to prevent staff from giving residents foods they are allergic to or the wrong medications.
• Easily accessible emergency alarms.
• Safety rails.
• Security systems.

Ask the facilities you visit:

• If special service units are available.
• If the facility has isolation rooms for residents who catch a contagious illness.
• What the facility’s procedures are for emergency situations. 
• Where residents are taken in a medical emergency.
• How the facility handles residents with a history of violence or verbal aggression.

 

Beyond the Minimum Qualities
The facility you choose for your loved one should first and foremost provide good care, but it is also important that your loved one be happy at the facility; it will, after all, be their new home.  Many facilities offer activities to engage residents and promote their health, like:

• Recreational activities, e.g. picnics, fitness classes, etc.
• Social activities, e.g. holiday celebrations, coffee hours, etc.
• Arts activities, e.g. local music performances by schools, library book rentals, etc.

Amber Paley is a guest post and article writer bringing to us information to ensure your loved one lives in a quality nursing home. Amber also writes about nursing home abuse.

Where to Live When We Get Old. Help!

The Wall Street Journal Sunday does a great job at covering a variety of "elder" care topics week to week. This week's topic was Woes of 'Continuing Care' Centers.

The article provides not so much a critique on CCRCs (continuing care residential community) but things to consider when researching them, determining if they are the right option for you (or your loved ones) and how to go about selecting one.

The same WSJ Sunday has another article (from their sister magazine SmartMoney) titled Picking a Nursing Home which gives some good advice on finding and evaluating nursing homes. 

We have many options on where to live as we age - right? (I'm not talking geography)

Well, sort of but not really. The big four include:

1. Stay in your house/condo/apartment and as your needs increase bring in hourly help for meal preparation, assistance with activities of daily living, companionship, etc.
2. CCRCs
3. Assisted Living
4. Nursing Homes

Other options include cohabitation (dad moves in with the kids) and the really interesting (and sometimes bizarre) trend of co-operative arrangements.

While I am a huge proponent of aging in place (at home) I am aware that this option may not be for everyone - by their choice or otherwise - e.g., it is not a realistic option when your caregiving needs become too much for one or even two people to manage (the final stages of Alzheimer's).

One problem I have with the senior care marketplace is how representatives from each housing option seem to market their products as if their option (i.e., assisted living) should be the ONLY option you consider. 

Selecting a "place" to age is complex. So many factors go into it - personalities, physical and mental health needs, family dynamics, money, etc.  And people usually transition from one option to another. They start out at home, move to assisted living and then maybe to a nursing home. Making these "where to live" choices requires a lot of thought, preparation and research and unfortunately a lot of families don't put enough effort into it - or are unable to.

This is why I see a growth in truly "independent" services that educate families and individuals on the various senior housing options and guide them through the evaluation and selection. A buyer broker if you will that has no ties to any particular option nor takes placement fees or commissions from chosen options.


The closest we have to this type of service today for the masses are employee benefits like work-life or EAPs but most individuals in the country do not have access to such services. Another option is geriatric care managers (probably the best option) but they are expensive (up to $100 an hour) and not everyone can afford them. Then you have the Administration on Aging which is wonderful but like many government agencies providing support to the public it is understaffed and quality of support is inconsistent.

Maybe a solution is a type of supplemental insurance product geared toward evaluating and selecting caregiving options as we age.

I don't know but I do know there is a huge business opportunity for anyone who can figure it out.

Now if we can just pay for it once we do make the decision - but that's another topic.

Gentiva buys Odyssey. Convergence and Consolidation in the Care for Aging Americans.

Last week Gentiva Health Services (GTIV) paid $1 billion to purchase Odyssey Healthcare (ODSY).

This Investors.com article gives an excellent analysis of what this may mean for the broader senior care marketplace.  In particular, the home health care, assisted living, long-term health care, nursing home care and hospice markets.

Read the article here.

Rating Nursing Homes and Senior Care Services. A Yelp for Elder Care is Needed.

An article from the Washington Post titled Nursing-Home Ratings Earn Mixed Reviews   discusses the debate about whether a new website run by the federal government to compare nursing homes is meeting the public's needs.

The online tool rates nursing homes on a scale of one to five stars for such measures as number of employees, state health inspection results and how many hours of licensed nursing care are provided each day.

The nursing homes industry is complaining that the grading system was started much too quickly and that the information, gleaned from homes as well as from state inspection reports, misleads families and patients because it doesn't give an accurate picture of the amount and kind of care in each facility. For example, nursing homes say simple counting of workers does not reflect the care patients actually receive, while consumer advocates complain that employee information that comes from homes is unchecked and may contain errors.

While I tend to agree that most any "rating" system (especially one that is run by the government that does not include actual customer feedback) has its limitations, these tools do offer consumers a starting point in which to begin their evaluation. 

But with the growing aging population and the increased demand for all types of elder care products and services I believe a Yelp type service is desperately needed in senior care. I know of a few companies working on this model (none have critical mass yet) and there will be some excellent business opportunities here. There is nothing like customer feedback to give an accurate assessment of a product or service.

"Searchable" Senior Care Directories. A Rapidly Growing Product Category.

Leena Rao at TechCrunch posted an excellent blog titled "OurParents Launches Free Customized Service To Find Senior Care Providers".  Techcrunch writing about the senior care space is a big deal given their enormous popularity and PR clout. So kudos to the marketing and PR team at OurParents for getting the visibility.   And based on a quick look around OurParents I was very impressed. They will be a fun company to watch.

This space (searchable provider directories of senior care companies) is exploding so I thought I'd share with readers of this blog my thoughts on the space.

Again, these are my opinions so if I mischaracterize anything PLEASE let me know. 

First of all, let me define what is meant by "searchable provider directories of senior care companies".  In a nutshell, these are online directories that allow people to search for various types of elder/senior care companies from residential care to medical products to handyman. However, most seem to focus on in-home care, assisted living and nursing homes (the most lucrative and widely requested type of senior care providers).

There appear to be THREE broad models although I realize there are many variations and hybrids of each.

MODEL ONE: LEAD REFERRAL
These are what I call pay-to-play models whereby the only companies who get listed or referred are those who pay to be in the search results. With some variations of this model, you don't actually get to view the search results. Instead, you are contacted by a sales rep or "care consultant" who helps connect you to a provider (and of course they get paid a commission if you choose that provider). While these models can be quite useful their downside is you may not be referred to the best provider if they have not paid to be in the directory. An example of this model is A Place for Mom, who I believe is the largest company of its kind oin this space.

MODEL TWO: USER-POPULATED
These directories include companies who have taken the time to create a listing - usually at no charge although they can get premier placement for a fee. The main downside to this model is again, you may not get a complete listing of providers in your area or the information may be out of date. The quality varies considerably amongst the various directories. An example of this model is The Senior List but there are hundreds of these sites. 

MODEL THREE: MAINTAINED DATABASES
I could not think of a better name for these directories so I use the word "maintained" because typically the company running these sites gets their information from their own internal researchers, state licensing or other agencies and/or databases. This insures (a) all providers in a particular zip code are listed and (b) the information is up-to-date. Needless to say, there are a lot fewer of these sites because they are very expensive to run - labor intensive.  As a result, many companies in this space are focusing on a specific category such as Assisted Living with hopes of expanding into other categories in the future. I believe SNAP for Seniors and OurParents (the site Techcrunch reviewed), are good examples of this model although their business models are quite different.

 Some of the best companies with maintained databases are not B2C but B2B companies like Employee Assistance (EAP) or work-life vendors who provide these services as an employee benefit by charging employers who in turn offer the online directories (and access to caregiving consultants) to employees as a benefit. Examples of these include LifeCare.com, Ceridian and CIGNA. 

PUBLIC SECTOR DIRECTORIES
Although these most closely resembles MODEL THREE, I broke it out because unlike other models, these directories have no "business model" and don't need to make money :-). Instead, our tax dollars support them. These are government sites that provide listings of various types of providers. As a result, they are bare-bones, often difficult or cumbersome to navigate and provide no enhanced listings or bells and whistles.

MAKING MONEY
Ahh, details, details, details. There is no question the demand for these types of sites is going to balloon. But what types, how many and who will survive remains a mystery because there is no clear winners in terms of business models. True, model 1 seems to make money today but there are a lot of unanswered questions about the growth potential of these types of services. 

With regard to model 2, the B2B EAP and work-life companies I mentioned will continue to do very well as they have for decades because they have a proven business model. But the B2C companies adopting model 2 currently don't have a sustainable revenue stream (no, advertising in my opinion is not sustainable in this sector - yet) and whether or not they can make money by up-selling other services like insurance and health related products is unknown. This may explain why the B2B companies like Lifecare.com and Ceridian have yet to penetrate this market. Why should they? Although you can bet they'll do it when they figure out how to go B2C without cannibalizing their profitable B2B business.

In the meantime, consumers have a lot more choices today than they did a year ago in terms of finding senior care resources. And that's a good thing.

Will The Changing Economy Bring Families Closer Together? What it Could Mean for Elder Care.

John Sumser is an expert when it comes to employment and recruiting topic. At our recent annual company meeting, John gave a superb keynote presentation where he touched upon how changing demographics and other societal trends are impacting everything from politics to marketing to recruiting - and the opportunities this is presenting. Fascinating stuff and I highly recommend John for any event you are planning. His presentation can be tailored to any company/industry. It's important stuff. 

Anyway, John's presentation got me thinking about elder care.

People say it takes a village to raise a child. This is debatable but when it comes to caring for elders, there is no question about it - it takes a village or at least a team of experienced and caring professionals. Especially when the elder has Alzheimer's.  But most of all, it takes a family. Unfortunately, within the last one hundred years of our society, increasing numbers of people have moved away from home. The number of long-distance caregivers in the U.S. who are caring for an older relative is about 7 million. Long-distance caregivers are generally defined as living more than one hour from the older adult needing assistance.

But a recent USA Today article titled For family, There's no Place Like Your Hometown  shows this trend is starting to reverse - and the economy is a major reasons why. In fact, geographic mobility is at the lowest levels since the government began keeping statistics in 1948 according to a recent study by Pew Research Center.

"People move for economic opportunity, and they stay put for family ties," says Paul Taylor, project director of Pew's Social & Demographic Trends Report. "But if you add it all up, you find ultimately family trumps money when people make decisions about where to live." 

Those who study migration trends say a combination of factors has led to the decrease in mobility, including an aging population (the prime ages for moving are 18-29); a rise in two-career couples, which complicates job moves; a murky employment outlook; fewer moves to traditionally high-growth areas; and the economic slump, whose roots began years before the word "recession" came into play.

My opinion is that this trend of decreased mobility will dramatically increase in the next 10 - 20 years - meaning I believe families will be brought closer together by either (1) children moving back to their parent's hometown or (2) parents moving to their child's hometown.  And the primary reason I believe this will happen is economics.

And the impacts this will have on companies providing products and services relating to the aging population is enormous.

According to Met Life,  the average cost of a private room at a nursing home in the USA is about $77,000. The average monthly "base" rate for an individual residing in an assisted living community is about $35,628 annually. If you have dementia and require additional support, this number can exceed $100,000 per year. And unless you have a long term insurance policy, this is all  private pay. What about in-home care? The average hourly rate for in-home care is about $20. If your needs increase to requiring a full-time live-in you can end up spending $200 per day or over $70,000 per year.

Now, how many families can afford these rates? 

Not many.

And even fewer with the recent real estate and stock market downturns.

As a result, children of aging parents requiring some level of care may be forced to live if not together, closer to their parents.

And this will impact how we market senior services.

Rating Nursing Homes - A New Tool

A USA Today article titled Feds Rate U.S. Nursing Homes  reveals that non-profit facilities fared better than for-profit ones, but that the overall quality of homes left a lot to be desired.

Nationally, 23 percent of the nursing homes rated achieved just a "one-star" ranking overall (out of five). The ratings site, Nursing Home Compare  is administered by the Centers for Medicare & Medicaid Services, part of the Department of Health and Human Services (HHS).  Nearly 16,000 nursing homes are included on the rankings site, which focuses on facilities that are certified to participate in Medicare or Medicaid. Both for-profit and non-profit homes are ranked.

The ratings are based on data from:   

- Health Inspections:  There are three types of inspections including (1) "Comprehensive" whereby the nursing home health inspection process looks at all major aspects of care in a nursing home (about 180 different items); (2) Onsite visits whereby trained inspectors visit each nursing home to check on the quality of care, inspect medical records, and talk with residents about their care; (3) Federal Quality Checks whereby federal surveyors check on the state surveyors’ work to make sure they are following the national process and that any differences between states stay within reasonable bounds. The limitations are that there are some differences in how different states carry out the inspection process and there are also differences in state licensing requirements.

- Staffing: The quality ratings look at the overall number of staff compared to the number of residents and how many of the staff are trained nurses. The limitations here are that staffing data is self-reported by the nursing home, not collected and reported by an independent agency. Also, staffing data are reported just once a year and reflect staffing over a 2 week period of time so it's a snapshot.

- Quality Measures: These measures show how well the nursing home helps people keep their ability to dress and eat, or how well the nursing home prevents and treats skin ulcers. Limitations are that again, the quality measures are self-reported by the nursing home. Also, the quality measures represent only a few of the many aspects of care that may be important to a family.  

When it comes to caregiving, it was not that surprising that non-profit facilities fared better than for-profit ones. We also see the same when it comes to for profit and not for profit hospice programs.  The theory is that for profit entities often times limit care in order to make a larger profit but this is not always  the case and believe me there are exceptions.

Anyway, in spite of the limitations of these rankings, they serve a very useful purpose as they give families and caregivers additional help in selecting appropriate nursing facilities for loved ones. I just wish there were more services like this for in-home care and assisted living which are much more popular today than nursing homes.

These ranking sites and the growing popularity of web 2.0 including blogs and social networking sites for caregivers and senior care suppliers are great for the industry because they can only raise the bar when it comes to care.

The Bias Against In-Home Care: Things Heating up in Florida.

Fact:  If you qualify for Medicaid (the state-federal partnership that provides health coverage and nursing home care to the poor) and get sick or disabled enough to require substantial care, you have little problem gaining admission to a nursing home. But obtaining Medicaid-supported services at home, such as visits from an aide, is substantially harder and often involves a long waiting list, even though it may cost the government less.  In fact, even if you do NOT qualify for medicaid there is a bias toward residential care versus in-home care. For example, long term care insurance policies often have a higher daily benefit for "confined care" (e.g., assisted living or nursing home) versus "non-confined care" (in-home care) meaning families pay more out of pocket for in-home care - again, even though this option often saves the Government (and family) money.

So it was with interest I read a news story about Florida Medicaid recipients want out of nursing homes.

The debate?

A group of residents on Medicaid in Florida are claiming the state is illegally forcing them to live in nursing homes when they should be able to live where they choose. They claim that nursing homes, afraid of losing money, have successfully pressured politicians to make qualifying for community care more difficult. They have filed a federal lawsuit seeking class-action status on behalf of nearly 8,500 institutionalized Floridians.

What one Medicaid resident said:

"I can't choose what meal I want, I can't have a visitor after 8 o'clock - it's just like a prison without bars," he said. "People are making decisions for and about me that don't even know me or even care about me. All they care about is the money they're getting for me."

And some very influential people are supporting them:

"There are very, very, very few people who cannot be cared for outside in the community," said Stephen Gold, a Philadelphia disability lawyer who, along with AARP attorneys and others, is representing the group. "Why should the state give a damn whether you put the money in the left pocket of the nursing home or the right pocket of the community?"

"There's a lot of concern that the nursing home industry is very powerful in many states and has made sure that a lot of Medicaid dollars go to institutional care as opposed to home and community-based care," said Toby Edelman, an attorney at the Center for Medicare Advocacy.

What does the State of Florida say?

The Florida Agency for Health Care Administration, the Florida Department of Elder Affairs and Gov. Charlie Crist's office - the three defendants - all declined to comment on the litigation. So did the attorney general's office, which is representing the defendants.  But In court filings, the defendants have claimed the plaintiffs lack standing because they haven't proven that treatment professionals deemed community-based care appropriate for each patient.

"Plaintiffs are not alleging that Florida's Medicaid program has failed to cover their medically necessary services," the defendants wrote. "Instead, plaintiffs want this court to second-guess the manner by which Florida's elected officials and policymakers have chosen to make those services available in light of the state's available resources."

Sadly, many nursing homes (and assisted living facilities) are excellent facilities and very well managed but a lot are not and they tend to be the ones getting media attention.

The message to the nursing homes and assisted living facilities? Do a much better job with your public and community relations, admit the shortcomings of the industry, pressure the poor performing institutions to get their act together and work with residents, their families, the government and other "patient" advocacy groups to improve the laws to better support the needs of families and the elderly/disabled.

Yes, a tall order but if the industry does not voluntarily change then it will be forced to change by legislation.

How do I know this?

Because the aging Baby Boomers will soon insist these changes take place and they have the numbers to make it happen.

Assisted Living for Individuals with Alzheimers. Do Your Homework. Manage Expectations.

My mom has advanced Alzheimer's disease (AD). In the early stages of her dementia we kept her in her home. Something I highly recommend for any senior who wants to remain at home, be safe and can still communicate this preference. Eventually, as my mom's needs increased, we hired a 'companion' from a local home care company. The one I used was Comforcare - excellent agency but it's a franchise business model so quality may vary by location.

Initially the companion visited my mom for a few hours each day (about $20 per hour and covered by most Long Term Care insurance policies) but as my mom's needs increased we increased the hours. Eventually, we hired a full-time live in from the agency for about $200 per day. Sounds like a lot and it is but quality residential care (e.g., assisted living) can be more than this in some locations.

Eventually, my mother's needs became more than what a single caregiver in the home could effectively manage. At this point we moved her to an assisted living facility. But wait, how can you place someone with AD into "assisted living" if they can't care for themselves?

As it turns out, most assisted living facilities have a dedicated floor for residents with AD. If a family can afford it, it's a better option than a nursing home (way better). If you do choose this option, in addition to the obvious questions to ask a facility , make sure the AD section is on a ground floor, residents can walk outside on their own (fenced in area of course), the staff is trained in AD, rooms have sensors to detect at-night wandering, there is plenty of stimulation, residents can get out once in a while (via a bus with a lift) and daily schedules are flexible.  One such facility that I am familiar with that meets all of these requirements is Aegis Senior Living - in particular, the Aptos, CA location. This is a very impressive facility. They "get it" when it comes to assisted living for AD.     

Now, here is where it gets interesting and why you need to do your homework when considering assisted living for people with AD.

Assisted living facilities do not typically provide one-on-one care. So if you need assistance getting dressed, going to the bathroom, getting to-and-from meals, etc. your going to have to pay extra for these services or hire an outside agency (like Comforcare) to provide "supplemental" care. And as your needs increase an assisted living facility may ask you to provide 24/7 supplemental care. So it is not uncommon to be paying close to or in excess of $100,000 a year for care in some areas.  In my experience the good assisted living facilities will be very clear about this but the not-so-good ones will be vague about it. Remember, when you take a tour of an assisted living facility the tour guide is a sales person. They get paid to place residents.

So what can a family do that can't afford this option? They typically end up spending all of the elder's money on care and then qualify for Medicaid. True, you can "spend down" or "gift" assets to other family members to qualify for medicaid faster but the laws make it very difficult to do this - and part of me understands and accepts the reasons why. 

Crazy isnt it? Yes it is. The sad truth is that families of AD patients get a double whammy because they need to spend so much more on supplemental care. And to make matters worse, the tax code and LTC insurance companies do not distinguish between elders with AD and those without so you are subject to the same daily maximums and restrictions.

I don't blame anyone for our imperfect system but as one Geriatric Care Manager recently told me "when congressional leaders have to begin caring for loved ones with AD I think the rules will be changed".

I hope you are right Nancy and I have a feeling changing this imperfect system is the final legacy the Baby Boomers will leave us with. They have the numbers and the influence to do so.

At least I hope so.

How to Manage, Operate and Market a Senior Housing Facility

Benjamin Pearce from Potomac Homes emailed me about his new book,  Senior Living Communities. It is a guide book on Operations Management for Assisted Living, Congregate, and Continuing Care retirement communities. It was just released in its second edition by Johns Hopkins University Press. 

Contemporary Gerontology describes the book as an " in-the-trenches approach to the administration and marketing of assisted living, congregate and continuing care facilities".

As the demand for senior residential communities continues to rise with the aging U.S. population, this is a great idea for a book and one that will prove useful to the many administrators and staff members who often are forced to learn by trial and error the complicated task of delivering high-quality and consistent services to elderly persons. It's also a must-read for the many facilities who have been plagued by a variety of administrative and financial difficulties.

Mr. Pearce offers a wealth of sound advice and practical solutions, discussing resident relations, operating methods, staffing ratios, department management, cost containment, sales and marketing strategies, techniques of financial analysis, budgeting, and human resources. New chapters address issues particular to dementia care and architecture, and the appendix contains a department-by-department audit of senior living operations.