Wednesday, September 29, 2010

Concerns Rise About Continuing-Care Enclaves

By ELIZABETH OLSON
Published: September 15, 2010
FOR middle- and upper-income retirees who had the money, it was almost a no-brainer in recent years to choose living in a continuing-care retirement community. They could move, as the need arose, from independent living to assisted care to skilled nursing care — all without leaving the community.
Well-off older people like Charles W. Prine Jr. of Pittsburgh, a former home building executive, plunked down six-figure entrance fees for a spot in a spacious, well-kept colony with amenities like organized outings, prepared meals and musical performances.
"We thought it would be a great place to be," said Mr. Prine, 84, who, along with his wife, Elizabeth, moved into an independent living unit in nearby Mount Lebanon, in southwest Pennsylvania, in 2002. "It was a kind of insurance so you could be taken care of, at the same price, when you or your spouse needed more care eventually."
The community, then called the Covenant at South Hills, was one of about 1,900 aging-in-place operations — many with waiting lists — that sprouted around the country, especially in California, Florida, the Midwest and the mid-Atlantic states, and provided homes for 900,000 people.
Few of the communities — about 80 percent of which are operated by nonprofit organizations — have closed or gone bankrupt. But concerns are rising about their financial stability, entrance fees and how the fees are used, and reduced services. Governmental inquiries at several levels have voiced concerns and called on the communities' operators to disclose more information about their finances to residents and prospective customers.
Choosing to enter a continuing-care retirement community "can be a difficult decision and is not without significant financial and other risks," said the Government Accountability Office, the investigative arm of Congress, in a report released in July.
Buyers should consult a lawyer before committing their savings to a promise of lifetime health care, said the G.A.O., which examined industry practices at the request of the Senate Special Committee on Aging. The committee produced a separate study of five communities.
Larry Minnix, president of the American Association of Homes and Services for the Aging, an industry group, said his group supported the G.A.O.'s recommendations because "putting up an entry fee is a risk, perhaps a little risk, but it is a risk."
According to the studies, the financial risk is that the operators could use the entrance fees, which this year averaged about $250,000, to cover operating costs or to pay debts from construction. The entrance fee is generally refundable to residents who move out or to their heirs.
Only 875, or fewer than half, of all such communities require entrance fees, said Robert G. Kramer, president of the National Investment Center for Services, Housing and Care, which provides financial data on housing for older residents.
In addition to the entrance fee, most residents pay a monthly bill of $2,000 or more that goes to pay for services and maintenance. Because the labor-intensive care for residents in poor health often costs more than the monthly fee, the money from new, healthier residents is sometimes used to help pay for the care of the less healthy.
But the flow of new customers has been endangered by the housing downturn, which has made it difficult for the elderly to sell homes or, at least, to sell them for the price they had anticipated. The communities are "particularly vulnerable during economic downturns, as stagnant real estate markets drive down occupancy levels in independent living units," the G.A.O. report found.
The communities' financial models have also come under scrutiny as some heirs and former residents have begun to ask legislators to look into lengthy delays in recouping entrance fees.
Recently, questions have also been raised over whether entrance fees are taxable. One operator, the Classic Residence by Hyatt, now renamed Vi, tangled with the Internal Revenue Service over whether entrance fees were prepaid rent, which is taxable income. Tax officials decided that in Hyatt's case, the refundable portion was a loan and not taxable. But the I.R.S. cautioned that in other situations such fees might be counted as income.
Shivers also went through the industry when Erickson Retirement Communities, one of the largest operators with 19 communities and more than 23,000 residents in a dozen states, filed for bankruptcy protection last year after it accumulated $3 billion in debt in a major expansion effort. It emerged from bankruptcy in April after being sold to an investment firm.
State insurance regulators need to keep better tabs on the finances of such communities, Alicia P. Cackley, the G.A.O.'s director for financial marketing and community investment, told the Senate Aging Committee at a hearing in July.
The government's report noted that 12 states and the District of Columbia do not have specific rules governing the communities. The report looked specifically at the practices of eight states: California, Florida, Illinois, New York, Ohio, Pennsylvania, Texas and Wisconsin.
Florida, which has 73 licensed continuing-care retirement communities with 30,000 residents, is stricter than most states and closely oversees the $1.4 billion industry there, the state insurance commissioner, Kevin M. McCarty, testified at the hearing.
After several prominent bankruptcies in Florida and nationally years ago, the regulatory climate for continuing-care retirement communities evolved, Mr. McCarty said. Florida's Legislature this year increased the amount of financial data that must be disclosed to prospective and current residents.
If that had been the case in Pennsylvania, Mr. Prine said, his community might have avoided bankruptcy last year. "That cost the residents the $26 million we paid in refundable deposits," he said. "We didn't get a penny back."
Concordia Lutheran Ministries, of Pittsburgh, bought the community, renamed it Concordia of the South Hills, and honored the residency agreements and the life-care contracts. But about 100 residents are suing the previous owner, B'nai B'rith Housing, a nonprofit affiliate of B'nai B'rith International, as well as the parent organization, to recoup their entrance fees.
Michael Plummer, a lawyer for Mr. Prine and other residents, said: "B'nai B'rith International set up an affiliate called Covenant at South Hills, and had its own directors and officers serving as the affiliate's directors and officers.
"B'nai B'rith International contracted with the affiliate to receive a $1 million licensing fee and half of the facility's net operating income in exchange for use of its name and logo in marketing. Seniors relied on B'nai B'rith's reputation when they decided to move into the facility and pay their entrance fees."
In effect, Mr. Plummer said, B'nai B'rith Housing and the Covenant at South Hills, "were shell organizations run by B'nai B'rith International."
B'nai B'rith Housing submitted written testimony to the Senate aging committee after its July hearing, explaining that "for a variety of reasons, including unfavorable economic conditions, the Covenant failed to meet all of its pro forma projections."
The project was weighed down by debt, the statement said, but the testimony — which did not list any names — insisted that B'nai B'rith executives had participated "in many personal visits, town-hall style meetings and teleconferences, all of which gave the residents a forum to share concerns."
Sharon Bender, spokeswoman for B'nai B'rith International and the housing affiliate, said the two groups were "affiliated nonprofit companies, neither of which has ownership interest in the other." The written statement to Congress, she said, "stands as what we have," adding, "We're not going beyond that testimony."
Mr. Minnix of the industry group said that a clear majority of such communities were nonprofits, adding: "This concept extends back 150 years or more. Masons, Catholics and others sponsored them to take care of the aging. Later they were called 'life care'; then about 40 years ago, the modern version, with comprehensive-care campuses, started. It was a form of insurance for prepaid care."
The Senate Aging Committee study, which did not identify the communities it had examined, found that "all five of the entities are either experiencing cash flow problems, struggling with debt or both."
Despite investing their life savings, residents and their concerns have often been ignored, and they have been excluded from their community's governing council, said Katherine C. Pearson, a Pennsylvania State University law professor who specializes in legal issues and aging.
"My sense is that facilities are moving in the direction of complexity" in their finances, she said, "sometimes driven by the need for more cash or resources to stay solvent."
Few residents complain, she said, because "they fear they will be shunned, encouraged to leave their homes or subjected to other negative response if they talk about what they perceive as problems."
Even so, residents' groups call her weekly, she said, to ask for advice.
"We have to see whether we're past the worst, or if we're at the start of a more difficult period for these facilities financially," said Professor Pearson. "They're not out the woods yet."

http://www.nytimes.com/2010/09/16/business/retirementspecial/16CARE.html?pagewanted=2&_r=1&ref=elderly

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Friday, September 24, 2010

Backup eldercare helps caregivers balance work and family responsibilities

By Lydell C. Bridgeford
June 1, 2008
When UPS employee Diane Davies needed help in taking care of her dad, who is in his 80s, a coworker told her to try Senior Helpers, a service provider that offers backup eldercare.

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"My mom had gone into the hospital to have an operation, and during the procedure she had a stroke," says Davies, who works at UPS's airline division in Louisville, Ky.
Her mother, also in her 80s, went into rehabilitation. "During that time, my dad really couldn't stay at home by himself, so my brother and I had to stay with him, but I also had to work," explains Davies, who didn't take the traditional route of contacting her employee assistance program for eldercare advice.
Davies' experience at UPS reflects how employers are recognizing that workers who are caring for an aging relative need an array of options to successfully manage professional and family responsibilities. Yet in offering eldercare programs and services, employers may sometimes struggle in communicating those efforts to their workforce.
Spreading the word
Even though companies have eldercare programs and services, employees do not always know about them, says Kathleen O'Brien, senior gerontologist with MetLife Mature Market Institute.
The Connecticut-based institute, which studies retirement and aging issues, conducted a survey of employees who were caregivers that worked at three Fortune 500 companies offering robust eldercare benefits.
"Two-thirds of the respondents did not know that the employer had those programs," says O'Brien.
"The company may announce the services, but people are not thinking about them when they are announced, and when they become a caregiver, it's not upfront anymore."
The implication for employers is to increase employees' knowledge about eldercare services. Citing research from the Society for Human Resource Management, O'Brien says about 11% of employers train their middle managers about caregiving programs and how to work with employees using those services.
Research from the institute also shows nearly 63% of all caregivers ages 51 to 64 work, with most employed full-time. About 75% of them are the primary caregiver. In addition, male and female children of aging parents alter their work schedules to accommodate caregiving responsibilities.
For instance, 54% of men and 56% of women have modified their work schedules, with 78% of men and 84% of women coming in late and/or leaving early. In addition, 38% of men and 27% of women have altered their work-related travel.
Bottom-line implications
More employers are starting to understand the financial toll eldercare may have on their bottom line, O'Brien confirms.
In 2006, the MetLife Mature Market Institute and the National Alliance for Caregiving reported that U.S. companies pay between $17.1 billion and $33.6 billion annually in lost productivity due to caregiving, depending on the level of caregiving involved. That equals $2,110 for every full-time worker who cares for an adult relative, notes AARP.
Historically, most eldercare services offered in the workplace resembled the childcare benefit model in terms of offering information and referrals to agencies that could help workers who were caregivers.
Some companies have moved to a more sophisticated model in which they provide a care management visit, where a long-term care specialist talks with the family to sort out the caregiving issues, explains O'Brien. What's more, some employers have onsite support groups, while others provide substantive resource materials written by caregiving experts.
"We don't really think of flextime as specifically for eldercare, but the ability [to take a] leave of absence without it impacting your job, and the ability to arrange your schedule in a different way, are benefits that help people deal with eldercare," she says.
Lending a helping hand
Maryland-based Senior Helpers provides in-home personal and companion care for seniors. This includes help with housework, meal preparation, errands, transportation, medicine reminders and Alzheimer's care.
UPS, which employs about 358,000 U.S. workers, offers an employee discount program where it collaborates with companies that provide group discounts on services and products, including Senior Helpers.
"Employees who may have the need to use Senior Helpers for services are offered a discount through Senior Helpers," says Jackie Blair, a UPS spokeswoman.
In Davies' case, it was a 10% discount on services rendered for a week. "It went smoothly, but more then anything, it took a lot of pressure off me in terms of work and taking care of my dad," says Davies, who has been with the package delivery company for 15 years. She is part of its administrative staff in the international support unit.
"I felt like he was being taken care of. He is at the point where, if something were to go wrong with the services, he would be able to tell me," Davies explains. "I never felt, as a caregiver, I was under a lot of pressure to retain my job." Management has been accommodating, she adds.
As the population ages, more people will start to have loved ones who are living longer. Consequently, they will need some extra help in taking care of those individuals, says Tony Bonacuse, president of Senior Helpers.
"We want to help employers understand the cost associated with eldercare crises and what workers who are caregivers are going through," he explains.
The idea for the company originated, in part, by watching his mother, who was working part-time, struggle to find professional help to assist her with taking care of one grandmother with a broken ankle and another one with a hip replacement. Both women were in their 80s.
"Unless you have had a need for homecare, you really do not realize our industry exists outside of the general health care industry," Bonacuse adds.
"In a lot of respects, senior care has been an underground issue," says Cindy Carrillo, president of Colorado-based Work Options Group, which offers backup care for infants, school-aged children and seniors.
"When someone has a baby, employers see the process unfold, and then the employee has the baby and pictures to show for it. You don't talk about mom falling and breaking a hip," she adds. "We're trying to help educate employers that senior care is a concern."

http://ebn.benefitnews.com/news/backup-eldercare-helps-caregivers-balance-work-586401-1.html

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Friday, September 17, 2010

A New Era in Nursing: Community Health and Aging Population Shift RN Employment

By Cathryn Domrose
Sunday September 12, 2010

The fastest-growing nursing jobs in coming years will require strong critical thinking skills, an ability to work independently and in cooperation with other providers, an understanding of how healthcare systems work, and familiarity with the needs of older adults. And they won’t necessarily be in hospitals.

“There will always be hospital jobs, but I think we should expect to see a lot more jobs in what we call community health,” says Linda Tieman, RN, MN, FACHE, executive director of the Washington Center for Nursing and board president of the Forum of State Nursing Workforce Centers.

The Statistics
Despite a slow period, due mostly to a sluggish economy, RN employment is expected to grow by 22% from 2008 to 2018, “much faster than the average for all occupations,” according to the 2010-11 edition of Bureau of Labor Statistics Occupational Outlook Handbook. But not all healthcare industries will be hiring nurses at the same rate. Though hospitals employ about 60% of all RNs, that share is expected to drop as healthcare reform, technological innovations and cost-cutting trends provide incentives to take care of more people in the community.

The fastest-growing RN jobs will be in physician offices (48% growth rate), home health (33% growth rate), and nursing care facilities (25% growth rate), according to federal projections. Hospital jobs will continue to increase as nurses get older and start to retire, but at a lower rate (17%) than other healthcare settings.

“While the intensity of nursing care is likely to increase, requiring more nurses per patient, the number of inpatients is not likely to grow by much,” the Labor Department report states, noting that earlier discharges and more outpatient procedures will keep hospital patient populations relatively stable.

Still, some nursing workforce researchers point out that an increasingly large aging population with multiple chronic conditions likely will mean an increase in hospital patients as well as patients in community care.

Healthcare Reform Effect
Healthcare reform, with its emphasis on prevention and coordinated care, also will help produce a shift from the hospital to the community, says Sheila A. Haas, RN, PhD, FAAN, a professor of the Niehoff School of Nursing at Loyola University Chicago and a past president of the American Academy of Ambulatory Care Nursing. “Much of the [newly passed Patient Protection and Affordable Care] Act isn’t about acute care, it’s about care in the community. The more I delve into the legislation, the more jobs I see.”

With a federal investment of $11 billion into community health centers — authorized by the healthcare reform legislation signed in May — the number of patients seen in the centers is expected to double in coming years, says Mary K. Wakefield, RN, PhD, FAAN, head of the Health Resources and Services Administration. Nurses make up the largest group of workers at the centers, and the need for primary care nurses at all educational levels will increase, she says.

Traditionally, nurses worked for at least a year or two in acute care before going into the community, say nurse leaders and educators, but the demand for nurses from all fields will mean new graduates should have expanding opportunities to go straight into community care areas such as ambulatory care, home health and public health. “The old bias was that you had to go to work in a hospital to be a real nurse,” says Geraldine Bednash, RN, PhD, FAAN, CEO and executive director of the American Association of Colleges of Nursing.

But new graduates can be hired directly into community care if they have the right education, training and support, say nurse leaders and educators. “I think it’s starting to change, but it just hasn’t changed enough yet,” says Beverly Malone, RN, PhD, CEO for the National League for Nursing. “I think it will continue to the point where you can graduate right into the community.”

To work in community health and hospitals, nurses need critical thinking skills and an ability to consider the needs of their patients in a variety of settings, not just when they are being seen in a clinic or hospital. For many nurse educators and nurse leaders, this means a bachelor’s degree or higher. “In baccalaureate programs, there’s more emphasis on leadership, care coordination and systems thinking,” Tieman says. “I think there’s a general agreement that nurses don’t need less education, they need more than they have. There’s more to understand with the complexity of the population.”

Physician Shortage Effect
Advanced degrees also will be in demand as a physician shortage is expected to produce more opportunities for nurses who can work in primary care, Bednash says. A federal plan to double the National Health Services Corps — which employs primary care practitioners in underserved areas — also will increase opportunities for nurse practitioners and nurse midwives, Wakefield says.

Most ambulatory care requires independence and the ability to know when and where to go for help, Haas says. “You may not see the patient for a couple of months, and if you’ve missed a chance for education or referral, you’ve missed it, and the patient doesn’t get the care,” she says.

Haas believes most nursing students are not exposed to ambulatory care as thoroughly as they should be. But many community health centers and long-term care facilities are working with nursing schools to provide places for new graduates to get clinical training. Federal funds for 10 nurse-run health centers have been allocated, with the intention that they serve as training grounds for students in nursing and other healthcare fields, in addition to providing care for underserved populations, Wakefield says.

New technology could allow instructors, using computers, phones and cameras, to monitor and support a number of students working in ambulatory or home care, Malone says.

Giving students a variety of experiences, perhaps through residency programs, would help reinforce the idea that care occurs in many places besides a hospital, Malone says. Patients and families need someone to help them navigate a network of providers, medications and information, whether they are in a hospital bed, a clinic, a long-term care facility or their homes. “That kind of systems thinking is what we really need nurses to have,” she says.

Aging Boomers Effect
Nursing students and new graduatesshould seek ways to work with elderly people, whether in long-term care, senior centers or home health, says Martha S. Anderson, DNP, CNS, FNGNA, associate professor at Jefferson College of Health Sciences in Roanoke, Va., and a National Gerontological Nursing Association board member. Once they begin to understand the needs of older adults, nursing students almost always enjoy working with them, she says. Though most nursing schools offer some instruction on older adults, many could expand in this area by offering specific education on aging and aging services taught by gerontological nurses or others who specialize in working with older adults, she says, and by working with skilled nursing facilities, home health agencies and other long-term care services to offer clinical experience.

“I think nurses have a huge responsibility and opportunity to become experts in geriatric care,” Anderson says. “That is the patient population, and it’s going to grow.”

Cathryn Domrose is a staff writer.

http://news.nurse.com/article/20100912/NATIONAL01/109130045/-1/frontpage

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Friday, September 10, 2010

Home-Based Intervention Seems to Provide Some Benefit to Dementia Patients, Caregivers

Home-Based Intervention Seems to Provide Some Benefit to Dementia Patients, Caregivers
But, did not find statistically significant differences for any outcome measure between COPE group and control group at 9 months
Aug. 31, 2010 – A program designed to improve the quality of life for home-bound dementia patients and their caregivers found some success, although caregivers perceived the greater benefits, according to a study in the September 1 issue of the Journal of the American Medical Association (JAMA).

Among the more than 5 million persons in the United States with dementia, most live at home, and are cared for by family members. With disease progression, families increasingly provide hands-on physical assistance with activities of daily living (ADL), with this often resulting in heightened caregiver distress.

"Trials of anti-dementia medications show few if any benefits for physical function or caregiver burden and have substantial adverse effects," the authors write. "Optimal treatment to postpone functional decline in patients with dementia is not established."
The Care of Persons with Dementia in their Environments (COPE) trial was designed by Laura N. Gitlin, Ph.D., of Thomas Jefferson University, Philadelphia, and colleagues to test a non-pharmacologic, bio-behavioral approach to support physical function and quality of life for patients with dementia and the well-being of their caregivers.

"The COPE program targeted modifiable environmental stressors to decrease sensorial, physical, and cognitive demands and align with patient capabilities and also ruled out underlying medical conditions that could lead to reduced patient functioning. The intervention sought to re-engage patients in daily activities and increase functionality, thereby alleviating caregiver burden," the researchers write.

The trial included patients with dementia and family caregivers (community-living dyads [two individuals regarded as a pair, such as a husband and wife]) who were recruited from March 2006 through June 2008. Of 284 couples screened, 270 (95 percent) were eligible and 237 (88 percent) randomized.

Data were collected from 209 couples (88 percent) at 4 months and 173 (73 percent) at 9 months.

The intervention consisted of up to 12 home or telephone contacts over 4 months by health professionals who assessed patient capabilities and deficits; obtained blood and urine samples; and trained families in home safety, simplifying tasks and stress reduction. Control group caregivers received 3 telephone calls and educational materials.

The researchers found that there were statistically significant improvements in functional dependence for COPE patients at 4 months compared with control group patients. Improvement occurred mostly for instrumental activities of daily living (IADLs), and COPE patients improved slightly more in ADL functioning than controls, but this was not statistically significant. There were also small but statistically significant improvements in engagement for COPE compared with control patients.

COPE caregivers, compared with control group caregivers, reported improvement in well-being and enhanced confidence using activities. Of 112 caregivers (53.8 percent) reporting 1 or more caregiver-identified problems eliminated by 4 months, 64 (62.7 percent) were COPE caregivers and 48 (44.9 percent) were control group caregivers.

The researchers did not find statistically significant differences between the COPE group and the control group participants at 9 months for any outcome measure.

"However, COPE compared with control caregivers reported a 'great deal' of improvement in their lives overall, disease understanding, confidence managing behaviors, made life easier, ability to care for patients, patients' quality of life, and ability to keep patients home."

"Because most patients live at home with functional decline, a nonpharmacologic, biopsychosocial-environmental intervention may positively contribute to disease management. Future research needs to examine effects of underlying medical conditions, ways to boost treatment effects, cost-effectiveness, COPE in combination with pharmacologic treatments, and translational potential," the authors conclude.

http://seniorjournal.com/NEWS/Eldercare/2010/20100831-Home-BasedIntervention.htm