When the time comes to move to an assisted living facility there are some questions you must ask. It is a difficult, traumatic and long term decision. You have to make sure that the move is pleasant and right. Below are a set of guidelines/questions that can help in making your decision.
- Is the residence licensed? Is it a good location to family/doctors? Is the entire facility wheel chair accessible? Is the décor attractive and home-like? Is there good natural and artificial lighting?
- do the residents socialize with each other? Do they appear happy and comfortable? Is the facility clean and odor-free?
- does the facility assist with self-administration of medications? What is their policy on medication storage? Do physicians visit patients on the premises?
- Is there 24-hour help available? Is the staff friendly & properly dressed? Does the staff know the residents by name?
- Are units private or shared? What safety features do they have in each apartment? Can residents bring their own furnishings? Is there a kitchen area in the unit?
- Is there an activities program? Is there a wheelchair-accessible van for transportation? Do residents have access to computers and the internet?
- Do they provide three meals daily? Do they provide snacks too? Are there set meal times? Are there special diets available?
- Are the rates all-inclusive or do you have to pay more for higher levels of care? Do they accept the Medicaid Waiver/Diversion programs? If so, is the family/resident expected to contribute financially to help cover the cost of care?
Asking the right questions will help ensure that the decision made is the right one.
The Deficit Reduction Act of 2005 was created to reduce barriers that allowed people to move from nursing homes back to the community. The biggest allocation of funds by Medicaid in 2007, The Money Follows the Person program, allocated $1.7 billion to 30 states with the goal of transitioning 38,000 individuals away from nursing homes. As of June 30, 2011 only 15,818 individuals had actually moved to community care despite the fact that the funding was increased to $4 billion in 2010 and 13 additional states were included in the program. With this additional funding, participating states have until 2019 to meet their targets and until 2020 to spend the funds. Florida was among the 13 states that were approved under the program but failed to secure the needed administrative funds for implementation of the program. In fact, states are given great flexibility by the federal government to use these funds to reduce waiting lists, conduct research and other activities that help rebalance their long-term program. Rebalancing means increasing the funding for community care and decreasing the amount spent on nursing home care.
With so many seniors currently living in nursing homes and wishing to go back to the community it’s a wonder why so little progress has been made. The numbers of transitions vary sharply by state. Some like Texas and Ohio have transitioned thousands back home or to assisted living facilities. Others like North Carolina, Missouri and Kentucky have moved fewer than 500. Our firm has worked in North Carolina and Kentucky and these states have very strong nursing home lobby’s preventing the increase in community care. Some states have found it hard to move the elderly with only 1/3 of transitioning individuals being 65 years and older. 900,000 individuals living in nursing homes are in fact eligible to be transferred. Barriers to transfers reported by the states are the lack of state funds (federal funds must be matched by state funds) and the absence of affordable housing and community care providers.
Our experience, having worked with the program, is that other barriers exist which include very strict requirements by the federal government as to eligibility of both the individuals and the place they are transitioning to. For example, in order for an assisted living facility to be eligible to take clients they must offer full apartments with kitchens, a separate bedroom and dining space. The client must have lived in the nursing home for 90 days. But more importantly is the reluctance of some states to stop relying on nursing home care for the growing number of seniors; a reason that is more political than financial.
This has been our battle cry for over twenty years. The benefits of keeping seniors at home with needed services has proven to be cost-effective, beneficial to the health of these clients and responsive to seniors’ desires. And yet, change has come slowly particularly in southern states. Under the pressure of skyrocketing Medicaid budgets fueled by the increasing numbers of low-income seniors our policymakers have had to shift toward funding more community instead of institutional care (nursing homes), what is called in the industry: “rebalancing long-term care.”
One state that has been successful in doing so is Oregon that rebalanced their budget back in the early 1980’s. Many other states have followed, including Washington and Colorado. The number of people receiving Medicaid-funded nursing facility care in these states grew at a much slower rate than in the rest of the nation from the inception of Medicaid home and community-based waiver programs in the early 19080s to 1994. The number of people in nursing homes as a proportion of the population age 75 and above in these states decreased faster than the average for the rest of the nation. Total annual Medicaid spending on nursing facilities also increased at a slower rate in the study states than nationally after controlling for growth of the age 75-and-older population.
Today only a handful of states remain committed to forcing seniors into nursing homes when no longer able to live independently – Kentucky, Virginia, Alabama and West Virginia do not pay for assisted living services. Although an increasing number of states have created Medicaid waivers to pay for assisted living services, the funding always falls short of the need which creates long waiting lists. clients in need of assisted living services cannot wait the two or three years it takes to receive an allocation. So seniors and disabled adults are still forced into nursing homes and we continue to pay for poor quality and undesirable care.
In 2003 our firm started the conversation with the Department of Housing and Urban Development urging them to join forces with the Department of Health and Human Services (federal Medicaid program) to properly fund community care at least for those living in public/subsidized housing. Seven years later, it happened and both departments partnered to create the Community Living Initiative that funds housing and services for low-income disabled adults. Seniors, however, have to wait longer and as of today no initiatives have been taken to address the issues of the seniors.
Apparently financial crisis alone will not prompt the federal government to act. I firmly believe the issue of low-income seniors ending up in nursing homes prematurely must arouse public opinion. Those most affected, the seniors, the families, the advocates, need to demand this change. Rather than being remembered as the “silent minority” we must be remembered as the generation that changed the way we care for seniors in this country.
America is a relatively young country as far as the percentage of individuals 65 years and older in the U.S. today. About 12% of the population in the U.S. is 65 years and older. However, that percentage is projected to increase to 20% within the next decade. Compare those numbers with that of other countries like Japan with the highest percentage of seniors currently at 21.5% of the population. Global aging affects all aspects of our society: work, health care, retirement, services and housing, among others. One of the major challenges is what we call the dependency ratio which means that for every person age 65 years and older there will be fewer than two persons in the workforce and available to care for the older generation. Exceptions are those countries with high birth rates (Mexico, Iceland and Turkey) or in countries like Australia, Canada and New Zealand with high immigration. However, in most countries the dependency ratio will sharply increase from 2020 to 2050. It is becoming more important that we create new ways to care for this aging population that is cost effective and dignified. The U.S. has the highest per capita health care expenditure in the world with a per capita cost per individual of $6,714. Japan, on the other hand, has the lowest health expenditure with a per capita expenditure of $2,581, half of that of the U.S. Most of the expenditure in Japan is paid by the government.
During the Ashoka Summit held this month we were able to discuss with other Fellows challenges facing their countries. Masue Katayama, a Fellow from Japan, has worked for the past twenty years in providing services to the older population in Japan. She came to learn how our firm has been able to change how we care for this older population. We believe that the global financial crisis is pushing us to make due with less and to learn how to use government funding more efficiently. Our firm has a proven track record of being able to service three times as many seniors with the funding the government spends on one. Japan, along with many European countries, has older people and lower health care spending than the U.S. They do this by fixing prices and manipulating prices to keep costs down. Every two years the price of each treatment, test and medication is examined to see if excess profits are leading to overuse and if so the price is cut. This is not done in the U.S. because those who profit from high prices are so powerful. This rationing and price cutting impacts the ability to control chronic illnesses at an early stage. Instead of rationing, Japan should look at ways to improve people’s lives by systematically changing lifestyles through better diets, exercise, medication management and supervision. This is something that Japan and other European countries can learn from the U.S.
Masue and I sat down to establish a collaborative effort that will enable us to learn from each other. She visited one of our affordable assisted living facilities and was impressed with the home atmosphere and the improvement in the physical and cognitive health of our residents. We agreed to formalize this collaboration by her sending a group of her operators to the U.S. for a month to live and learn at one of our facilities. Mia will do the same as we know that there are lessons to be learned from Japan as they tackle the common challenges of global aging.