Nursing Homes Are Changing Even Now

Vol. 18 •Issue 20 • Page 14
Nursing Homes Are Changing Even Now

That Trend Will Accelerate as Elderly Rates Soar

Near the end of a long conversation about baby boomers approaching geriatric status, Ed Howard, middle-aged director of a bipartisan think tank called the Alliance for Health Reform, had a confession to make.

“Somehow,” Howard told ADVANCE in an unguarded moment, “the idea of an 85-year-old named Tiffany being rolled around in a nursing home is anathema to me.”

He’s not alone. Perhaps even more than death itself, the prospect of entering what used to be termed a rest home, of growing too old to care for oneself, of losing one’s independence, of needing help bathing, preparing meals, even moving, seems unthinkable to those who formed that we-can-change-the-world youthquake of the 1960s and 1970s.

How many of them even now, all these years later, seriously entertain notions of living in bleak institutions with their frail, hobbled peers, sharing photos of their grandchildren, amusing each other with distant memories of Jimi Hendrix and free love, remembering what they used to do but can’t do anymore?

Baby boomers are “a transitional generation,” said Elizabeth deProspero, RN, a caregiver for the elderly in Philadelphia and a boomer herself. “We’re more health-focused, independent. We work out, floss our teeth.”

Flossing or no, long before the “tomb boom” enriches the nation’s funeral directors and cemetery owners, an awful lot of baby boomers will live for many years in nursing homes, assisted living facilities and other environments built to meet the needs of elderly people.

Nursing homes and baby boomers make a most unlikely pair. How will each react to the other?

Home-Like Environment

When considering any issue about baby boomers, it’s wise to recall that their numbers are legion and so are their preferences.

“Boomers really are a big group. They encompass two population cohorts, early and late boomers,” pointed out 55-year-old Robyn Stone, DrPH, executive director of the American Association of Homes and Services for the Aging. “We’re very diverse and come from many different socioeconomic levels.

“The real question is, where and how do we want to live?” Stone continued. “What is the range of options we need? I want a lot of activities. People need options.”

Diversity of views notwithstanding, it’s a good bet that Wendy Fox-Grage, MS, MPA, speaks for most when asked what kind of life she’d prefer if she became infirm in her elderly years.

“I would try to foresee if there were a way to stay in my own house,” answered Fox-Grage, senior policy advisor for the AARP’s Public Policy Institute.

“If I had to go into a nursing home,” she added, “I would want a home-like environment. That’s where I would feel most comfortable.”

Private Rooms

Stone agreed: No one wants to spend his or her remaining years in an institutional environment.

“There’s probably not a soul on this earth who would want to go into a nursing home with double-loaded corridors and nursing stations,” she said.

Expectations about comfortable environments may lose out to financial reality, however, given America’s strained resources and the sheer numbers of boomers.

“The notion is that everyone has to have a private room,” Stone said. “In Taiwan, they couldn’t even relate to that. More people live in the same space there.”

For Stone, the question is: Can we have a system both designed and financed to be flexible enough to meet the various needs of a very diverse group of people?

“In 20 years, we may see nursing homes only for people with very high acuity levels, to live there for a short period until they pass away,” she said. “And we may have options with telemedicine to keep people in smaller community settings.”

More Demanding

Even today’s elderly Americans of the World War II and Korean War generations are changing the geriatric landscape, according to Celia Strow, RN, MPS, the CEO of MyZiva®, a Web site for nursing home managers.

“There are so many different venues now,” said Strow, who established the first JCAHO-accredited dementia unit on Long Island, N.Y., among other accomplishments.

“People are healthier. Eighty-five year olds are not sitting in rocking chairs. They’re still playing golf, still working.”

Today’s nursing home patients are upping their demands to include private telephone service, access to computers, different kinds of food, longer visiting hours, greater insistence on privacy and rights. “It’s more individualization—what’s good for me and less for the good of the community,” Strow said.

Nursing homes are no longer “just a dumping ground for the elderly,” she continued. “The elderly today are coming in older and with more acuity, really compromised. They stay at home longer. So nursing homes will take on a much larger and more important role.”

Nursing homes must change their image, according to Strow. “People still think of nursing homes and say, ‘Oh, my god, I don’t want to go there.’

“I never really thought, overall, that nursing home care was bad,” she added, saying only negative incidents in nursing homes tend to get publicized in the media. “Technology has improved. New advances have come out to improve and speed up care.”

Assisted Living

For seniors blessed with financial assets, assisted living facilities, sometimes called residential care facilities, have become the preferred alternative to nursing homes. In fact, assisted living facilities are now the fastest growing form of senior housing.

In the past decade the number of elderly Americans in assisted living has tripled, to nearly one million, according to the Census Bureau.

In 2004, states reported 36,451 licensed residential care facilities with 937,601 beds, according to the U.S. Department of Health and Human Services (HHS).

Assisted living facilities are required by state laws and regulations to provide or coordinate these services at a minimum:

• 24-hour awake staff to provide oversight and meet scheduled and unscheduled needs,

• Provision and oversight of personal care and supportive services,

• Health related services (e.g., medication management services),

• Meals, housekeeping, and laundry,

• Recreational activities, and

• Transportation and social services.

In a 2000 survey, the National Center for Assisted Living (NCAL) found that assisted living facilities charge an average monthly fee of $1,873, which typically included rent and most additional fees.

NCAL also learned that half of all assisted living residents have some degree of cognitive impairment, three-quarters need help bathing, eight in 10 cannot administer their own medications and more than 90 percent can no longer cook or do housework.

Usually, residents leave assisted living facilities not because they die but because they run out of money and must go into nursing homes, where Medicaid can cover their expenses.

HHS Survey

In 2001, the Department of Health and Human Services undertook the first comprehensive national survey of assisted living facilities, including walk-on inspections.

HHS observers found the visited facilities to be largely well-maintained, clean, relatively homelike settings for frail elderly with a wide range of social and recreational resources. Most of the facilities were located in suburban areas.

The survey found that half of all residents were 85 or older. Nevertheless, on average, residents of assisted living facilities are less severely disabled than residents of nursing homes, HHS concluded.

Residents generally felt they were treated with respect, affection and dignity. However, many expressed concern about staffing levels and turnover. Moreover, a “significant number” of staff members were poorly informed about antipsychotic drugs and some issues related to the care of individuals with dementia, HHS found.

“The majority of staff members were almost completely unaware of what constitutes normal aging,” the survey notes. “Given the goal of enabling residents to age in place and the advanced age of current residents, these results are particularly disquietingÉ(since) many of the conditions staff identified as a ‘normal part of aging’ were potentially treatable and reversible.”

You can reach Michael Gibbons at [email protected].

Baby Boomers, Old Age Homes: An Unlikely Pair

“Ah, old age,” muses a character in the film Citizen Kane. “It’s the only disease you don’t look forward to being cured of.”

Sooner then they think, millions upon millions of baby boomers will find themselves in that exact predicament, living in the strange, alien land of old age.

During the next 20 years, the first wave of boomers, those born between 1946 and 1954, will hit their 70s, with younger boomers swiftly bringing up the rear. By 2020, one in six Americans will be 65 or older, the U.S. Census Bureau predicts.

Baby boomers will experience the joys and trials of advanced age far longer than previous generations. Life expectancy in this country reached a record high of 77.6 years in 2003, according to the Centers for Disease Control and Prevention.

Men who live to 65 today can expect to live to 83, women to 85.

“It used to be you planned to live to 85, but today you should plan for 95 and, as time goes by, see how the numbers look,” Neal Cutler, a financial gerontologist at Widener University, told the Philadelphia Inquirer.

How 70-plus million retired baby boomers will take to the inevitable physical breakdowns and cognitive impairments associated with old age is one thing.

How society will assimilate all these medically challenged retirees is quite another.

As of now, at least, plans to provide long-term medical care for such a vast swath of frail elderly aged 75, 85 and beyond are as weak and suspect as those levees guarding New Orleans.

“Where the financing of their health care is coming from is a big unanswered question that Congress hasn’t tackled yet,” long-term care expert Anne Montgomery told us. “How we end up financing long-term care will be the big, big question. I don’t know the answer.”

In this and the next two issues of ADVANCE, we will ask that question in a variety of ways. We will consider the defenses America must build to withstand this imminent, Katrina-like demographic event.

On Oct. 3, we will examine the nation’s growing shortage of geriatric providers as well as the burden on younger adults to care for their elderly parents while maintaining careers and raising their own families.

The Oct. 17 issue will ask: from where is the money coming to care for the elderly?

But we begin the series by looking at the future of long-term care from the eyes of now and future long-term care patients themselves.

What type of assisted living conditions do they want? And will the baby boomers, who comprise the most indulged of all American generations, get what they want?

Adult Day Centers Offer Alternative to Nursing Homes

PHILADELPHIA—It’s a large living space, homey by design, with upholstered chairs, couches, scattered bookshelves, a small TV. Commanding attention in room center is a baby grand piano, on which local musicians occasionally pound out tunes new and old for an always appreciative audience.

This morning, about 30 elderly, predominantly African-American “clients” sit in a large circle, some in wheelchairs, some dozing. Chatting is at low tide at the moment. Quiet prevails, broken only by some Motown and some Tommy James and the Shondells streaming faintly from a small radio.

Soon, though, social worker “Roz” Richardson leads the group in some chair-bound arm and leg raises. She gets some up on their feet for elementary dance steps to Gladys Knight’s version of “Grapevine.” A few folks here and there still doze.

“This is a good way for clients to interact,” Richardson explained.

Social interaction is much preferred over watching television. The TV here comes on only for major events, such as Ronald Reagan’s funeral, and for Oprah in the late afternoons, as clients prepare to return home. “We always want to keep our minds alert,” Richardson said.

Jerry Springer’s show is verboten, though one gentleman admitted to watching it at home on occasion and ventured an opinion that there’s too many female “man-haters” on the show who physically assault their straying boyfriends. That spurred two women nearby to good-naturedly accuse him of expecting women to bow down to men.

Meanwhile, over in the dining area, Activity Director Gladys Davis, who exudes a quiet calm and has perfect teeth, teaches a small group how to insert Spanish moss in plant soil to help the plant retain moisture.

Welcome to a day center, very likely the future of elderly care in America.

Growing Trend

Day centers are for-profit facilities in which elderly people who live at home come for hot meals and several hours of group activities that can include exercise, discussion groups, singing, arts and crafts, card games and line dancing.

This center, in the Chestnut Hill section of Philadelphia, is the largest in Pennsylvania. Licensed for 63 clients, the center sees an average of 50 per day. It’s open Monday through Friday, 7:30 a.m. to 6 p.m, with requests to open Sundays too. It has an RN on site plus a full-time activities director, a part-time social worker, a podiatrist, a rehab specialist and a hair dresser. There is one staff member for every six clients.

The center is operated by Senior Care Centers of America Inc., which has 20 such facilities in five states. The largest provider of day centers is Active Services Corp., in Alabama. Altogether, about 3,500 to 4,000 such centers serve more than 150,000 seniors around the nation.

Day centers are “absolutely a growing trend,” said Leslie Gilman, regional manager for all of Pennsylvania’s Senior Care Centers of America. “It is such a wonderful way to take care of people when they’re older and need supervision other than putting them in a nursing home. People are a bit disillusioned with nursing homes.”

People prefer keeping their aging parents at home as long as possible, and this type of facility enables family members “to be less than 24-hour caregivers,” she added. “It’s so much more cost-effective as well as offering a better quality of life.”

Not Child-Like

Senior Care’s referrals come from case managers, home care companies, physicians, visiting nurses and employee assistance programs.

Caring for non-independent elderly parents means many lost hours of work, “and we provide a solution to that,” said Gilman, adding that one Senior Care center in Horsham, Pa., sits within an industrial complex. “It’s wonderful for those employees to be able to drop mom or dad right there.”

That may sound synonymous with child care, but “we strive very hard to make our activities not child-like,” Gilman said. Clients are encouraged to exercise, learn crafts, bake, discuss current events and take once-weekly day trips to museums, restaurants, shopping malls and other senior centers.

Her clients include former artists, teachers, nurses, doctors and at one time included the first African American administrator of Temple University, since deceased. Although day centers are not medical facilities, “We’ve had people on O2, colostomies, feeding tubes, brain injuries, nebulizer treatments,” Gilman said.

If someone becomes ill, the family is notified to come for them, or a staff member calls 911. “Here, you have an RN looking at them every day,” she said. “They are able to pick up on things that a home care aide would not pick up on, such as pre-stroke symptoms or an infection brewing.”

As she spoke, one woman sat alone, her back to the room, rocking her body, her head slumped down. She will shortly enter the Alzheimer’s unit, a smaller room that affords clients with advanced dementia a quieter setting, away from the hustle and bustle of the main living room. “We tend to divide up clients by cognitive level” from highest functioning down to minimal function, Gilman said. “We see a lot of dementia.”

Because many clients are incontinent, the center has a laundry room on the premises. Clients bring an extra set of clothes with them in case of accidents.


Dementia patients usually adjust to the center in about two weeks if family members “hang in there” and patiently help their loved ones adjust, Gilman said. Inter-generational contact is encouraged. “Even a client with very advanced dementia, if you put a small child before them, they will have a conversation and not seem like they have dementia,” she said.

The center’s nurse, Elizabeth deProspero, RN, mainly sees cases of diabetes, hypertension and degenerative joint disease, but her expertise extends to geriatric psychiatry so she can also manage dementia and behavioral issues.

“Most of the dementia we’re seeing is in the African-American and Hispanic population, and this is expected to grow,” deProspero said. “Ninety-five percent of clients here have some dementia, most very mild memory lapses.”

She mentions “sun-downing,” that as-yet-unexplained but common phenomenon known by all geriatricians: the elderly tend to grow more confused and agitated in the late afternoon/early evening.

Fatigue and dehydration are likely culprits, but deProspero ventures her own guess: people who have worked for decades in 9-to-5 jobs just think they need to get home when the sun starts sinking. “We’re creatures of habit,” she said.

Waiting List

During breakfast, Davis walks from table to table, getting a client a napkin, patting another gently on the back and asking, “How ya doin’?”

Dietitian-approved meals are served restaurant style, with staff doubling as waitresses. On July 4, the center served up barbeque. “It’s good food, not baby food,” assured one satisfied customer, Debra, 80, pencil-thin, a former nurse. “I’ve been in other places, but not like this.”

Noticing Debra talking to a reporter, deProspero said later: “Debra brings that nurse persona to this center when she comes. If a client is having a medical crisis, she wants to become involved and gets agitated that she can’t. She’s a born caregiver.”

One female client had tears in her eyes the first time the center served dinner, according to Gilman. “She said, ‘This is the first time in ages I’ve gone out to dinner with my husband,’” she recalled.

For food and the other services, clients pay $58 per day, or $40 for the half-day program (four hours plus lunch). The center has a mix of funded and private-pay clients with long-term care insurance. “The general population doesn’t typically have long-term care insurance, but baby boomers are more aware of this insurance and more have it,” Gilman noted.

That could be a portent of a coming deluge of clients. When it first opened, the center had a waiting list but “it went away,” Gilman said. “Now we’re hearing rumblings that there may be waiting lists again.”

You can reach Michael Gibbons at [email protected].