'Aging in place' can be a marketing trap.

In the late 1980s and early 1990s, long-term care became preoccupied with "aging in place." Unfortunately, the profession took itself too seriously when it adopted the phrase without truly understanding its implications for facility operations (and the resulting legal and financial consequences).

And just what is aging in place? The concept certainly sounds nice. And for a time, in the late 1980s and early 1990s, it became a mantra for those who would argue for the overriding value of home- and community-based long-term care. Assisted living, in particular, used it extensively in its marketing broadsides against nursing homes. To age in place--what a wonderful concept! No need to be "institutionalized" (yet another ideologically charged word, designed less to educate than to proselytize). No need to suffer under the psychological burden of "transfer trauma." You needed simply to remain in your own home, your own "place," as it were, and support would be there.

The idea certainly resonated with the public at large (not to mention their elected officials). Let's face it, Americans are not enamored of the idea of leaving their homes. Admission to a nursing facility is perceived as a threat to personal independence, a limitation on one's right to choose how to lead one's life. Aging in place offers an attractive alternative, one that most Americans are only too ready to grasp. And politicians, as always, are more than ready to feed into the dream.

But, politicians notwithstanding, the issue cannot be painted in simple black and white. It carries its own complexities and contradictions. Nursing homes were among the first to express such concerns. Admittedly, many of their publicized fears reflected more a perceived loss of market share than a deep concern about quality care, but some were legitimate.

Let's look at aging in place. What does it really mean? Is it really achievable? Are there risks involved? Can those risks, if present, be ameliorated? Because, to be frank, there is the potential for harm here--and more than minimal harm, at that. Aging in place can become a quality-of-care problem; it can become a truth-in-marketing issue; it can occasion operational difficulties; and it can, ultimately, raise legal concerns.

Let's deal with that last issue first. Quite simply, providers who cannot offer the required care as a resident ages in place will end up in court. So will providers who promise their customers more than they can deliver. Indeed, providers who attempt to restructure their operations to fulfill their promise of aging in place may well end up in court, too (in this case, bankruptcy court).

What it comes down to is this: saying is easier than doing. We spend too much time grappling with labels rather than with underlying concepts. The issue is not adult day care versus nursing homes. It is not assisted living versus home care. Those are just words, definitions that take on meaning only when applied to the services offered. It is the services offered that, ultimately, underlie the ability of any long-term care provider to facilitate aging in place.

But here's where it gets tricky, because required services, in turn, are a function of need. And need, ultimately, is a function of condition. It is, in reality, the long-term care customer's condition that will determine need; need that will determine service; and service that will define setting. If a provider can accommodate any condition, adjust to any need occasioned by that condition, and provide all services responsive to that need, it makes little difference whether that provider is called home care, assisted living, adult day care, or skilled nursing.

But therein lies another dilemma: How many providers can really do that? Early on, many assisted living providers made such a promise to their customers--and then found that they had to break it. Indeed, average resident turnover in assisted living facilities is approximately 50% per year--and the setting in which most outgoing residents are placed is the nursing facility (which is not really the picture painted by some assisted living brochures). I remember one of those brochures so vividly that I can quote it by heart: "Whatever their requirements, now or in the future, we will offer our residents the necessary care and services.... As residents' needs or conditions change over time, their Care Plans change accordingly." Pretty direct--and unlikely to be fulfilled.

In many states, an organization's attempts to accommodate increasing care needs by "moving the resident up the acuity chain" might confront licensing issues. As one begins to provide services for medical conditions, not just ADLs, many state regulators might look for a provider's nursing home license. This varies by state, of course--in fact, my own mother, although appropriately receiving "assisted living" services in Minnesota, would be precluded from receiving that same care in neighboring Iowa, where she was born and raised.

Confronted with a change in condition that might precipitate needs and services more typically associated with a nursing facility, an assisted living community has only three options available: (1) do nothing, (2) attempt to provide the additional services, or (3) discharge the resident. Most facilities opt for number three, but a distressingly large number choose options one or two.

Option number one is an obvious recipe for disaster (a disaster that, in all likelihood, will entail tort litigation). Option number two would appear to be the most desirable, at least from the customer's point of view. But, as indicated, it is an option fraught with both regulatory and financial pitfalls. Jim Moore, one of assisted living's most respected consultants, refers to this approach as the "one-million-dollar wake-up call." He notes that by adding just 60 minutes of assistance per day for just 40% of the typical assisted living community's residents, costs will increase by $123,000 per month. If the facility is unable to cover those additional expenses with higher prices, traditional valuation methodologies will show the facility losing value to the tune of more than $1.4 million per year. This, unfortunately, is why some facilities choose option number one, its obvious dangers notwithstanding: Just keep the resident a little bit longer, because it's better to have an occupied unit in today's saturated and highly competitive market, even if the services provided are not commensurate with a resident's real needs.

Already, the mainstream press has picked up on this issue, focusing on the increasing numbers of assisted living customers who are left no choice but to supplement their care with private-duty nurses and personal-care aides. This is not good for the industry's public image; it's not good for customers, who thought they were buying "the complete package"; and it's definitely not good for facilities that catch the legal system's attention.

No less than nursing facilities, assisted living communities are stuck with the laws of economics. Goods and services cost money, and more desirable goods and services cost more money. So, let's not pretend that aging in place comes without financial or organizational implications. It is not a fiscal panacea, as so many in the political arena have suggested. It requires innovation and resources. But it can be done.

In fact, we have already seen major experiments oriented toward the practical application of aging-in-place principles. One that particularly appeals to me is the Program of All-inclusive Care for the Elderly (PACE). PACE recognizes and brings to bear all the service settings available for the delivery of long-term care, and does so in an integrated and multidisciplinary fashion. It precludes no setting. This approach works because it is person-centered, rather than site-centered. While the PACE model's preferred focus is the adult-day-care center, if a nursing or assisted living facility is in the best position to provide the service commensurate with the customer's condition and needs, so be it, says PACE.

The long-term care "campus" is a more traditional approach to facilitating aging in place. The service package offered by CCRCs is, perhaps, the best example of that particular model.

Both of these approaches recognize one basic fact: No one provider can easily or efficiently offer the entire continuum of long-term care without having numerous settings on board. In responding to the concept of aging in place, providers have not changed the definitions of the various locations in which care is provided, but rather, have changed the definition of "place." Place, in this sense, is a state of mind. It is a level of comfort. It need not be contained within the same building or even the same piece of ground. It is a sense of community well-being, not a physical location.

The wise provider knows when transitions have to be made. And the compassionate provider knows how to make those changes without damaging the sense of community. PACE, perhaps, does it best, but there are numerous innovators out there moving in the same direction.

In conclusion, aging in place is more than glossy marketing. And it is more than a political bromide. It reflects, when done right, a meaningful attempt to respond to our customers' most basic needs. While this may tax our capacity for innovation (not to mention our pocketbooks), a satisfied customer is well worth the effort.

To offer comments on Dr. Willging's views, as expressed here, please send e-mail to [e-mail].

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.