Assisted living meets "aging in place." (interview with Presbyterian SeniorCare Executive VP James Pieffer and Gerontological Services consultant Maria Dwight)(Interview)

Perhaps no issue creates more misunderstanding, confusion and general consternation in the field of assisted living than "aging in place." What services should be provided to residents in declining health? How should they be paid for? When does assisted living become de facto skilled nursing care, and what should happen when the line is crossed? Recently Nursing Homes asked for observations from two professionals who address these questions every day: James Pieffer, Executive Vice-President of Presbyterian SeniorCare, a 50-facility operation in southwest Pennsylvania that includes 12 assisted living and 12 skilled nursing facilities, and Maria Dwight, a consultant with Gerontological Services, Inc. of Santa Monica, CA.

Pieffer: "Our organization has been providing 'assisted living' for over 70 years, but over the past 10 years we have been redesigning our services and facilities to deal with the changing population and aging in place. During this time our average age of admission has risen from the mid-70s to the mid-80s. Our residents are entering more impaired and our length of stay is decreasing.

"In response we have developed many new programs. Our first new service was called 'Personal Care-Plus,' Which involved adding services and staffing to maintain and support the residents' independence and delay or eliminate a transfer to a nursing home. As this program has developed, we have also increased our collaboration with and use of outside agencies, such as home health care, geriatric assessment, hospice and other services to assist and complement our facility staff.

"Our organization has worked closely with regulatory agencies in Pennsylvania in maintaining our most frail residents, many of whom could be considered 'nursing home-eligible.' We had to reexamine our staffing levels and our facilities.

"To accommodate residents with more health-related needs and mobility problems, we have increased our staffing ratios, in some cases to near-nursing home levels, but focusing more on resident care staff than on professional nursing. We have also added to or enhanced many of our fire safety systems and improved the handicapped-accessibility at many of our facilities to support independence. The cost of renovation is a major financial issue for existing facilities, particularly those trying to serve low- and moderate-income residents.

"One of our major thrusts today is providing quality dementia care in assisted living. The vast majority of our residents with dementia do not need a skilled care facility. They require a safe, prosthetic environment that allows them to wander, has flexible and specialized programming and has specially trained staff to support their needs. We are providing this care at 75-80% of the cost of a typical nursing home.

"Presbyterian SeniorCare has learned a great deal about aging in place and dementia residents through research at its Woodside Place facility. Woodside Place is nationally known and recognized as one of the first residential dementia care facilities in the country.

"The bottom-line issue for most providers and residents concerning aging in place is reimbursement and cost. Only a few states have a reimbursement system for low- and moderate-income residents that supports aging in place. Placement and transfer decisions can be based more on finances than need or appropriateness. As a nonprofit, charitable organization, most of our charity care is focused on assisted living residents who have 'spent down' their funds or cannot afford to pay the full cost of their care.

"Pennsylvania is only beginning to develop home- and community-based waivers for low-income persons in assisted living. The waiver programs, combined with opportunities in managed care and capitated payment systems, may hold the key to aging in place.

"Nevertheless, it is becoming more difficult for assisted living sponsors to back away from the responsibility of providing increased health care support for their residents. We are driven by so many pressures in this industry - regulatory concerns, reimbursement problems, consumer choice, and fear of litigation. The Fair Housing Laws are also starting to have an impact. More and more elderly residents are asking, 'Why can't I stay here?'

"Our industry is becoming more consumer-driven and, just as residents are not accepting the double-occupancy rooms, the shared bathrooms and all those 'nursing home features' that are making nursing homes dinosaurs today, they will no longer accept our decisions for transfer without question.

"The market for assisted living facilities is increasing, but everyone seems to be competing for that top 20% of income in our market in the Pittsburgh area. There has been a sort of 'Field of Dreams' attitude - if you build it, they will come - and today we are seeing facilities with projected fill-ups of seven to eight months operating at less than targeted capacity two or three years later. And, once these developers have made their up-front fees, we will still be faced with the question of how to operate for the future. The industry needs to focus on ways to serve a broader range of incomes, particularly the low-income market.

"An interesting example of service to low-income seniors involves the residents of supportive housing, such as the HUD 202 program. By working with service coordinators and case managers and having access to excellent community-based services - which, in Pennsylvania, are partially supported by the state lottery - we have been able to provide service in these settings that actually parallels assisted living. Aging in place is an issue here, and we have been able to cope with it, particularly in serving the medically complex. People with dementia fall through the cracks in this setting, further reinforcing this niche for assisted living."

Dwight: "In my opinion, aging in place is not a problem for the assisted living industry, it is its purpose. All programming, design and operational planning should be focused on helping residents to age in place.

"In fact, I am seeing a lot more being done in the assisted living setting - more IVs, more TPN, more home health care-type service being billed for as an add-on, sometimes in time increments of as little as 15 minutes. I am also seeing development of multiple levels of health care assistance. The question is, who decides to move the resident from one level to another - and, for that matter, what happens if the resident doesn't want to be moved? I haven't seen any firm answers as yet.

"The problem in assisted living as currently practiced, though, is that this sort of intervention is typically not planned for or even thought of when residents are admitted. If ever there were a situation calling for team evaluation of prospective residents in their homes prior to admission, this is it. At least the facility would have some idea as to who really is coming in, what their service needs are and the prognosis for change. Instead, assisted living is being sold more as independent living with some services. As a result, we're seeing some very elderly, frail people being admitted and having either shorter lengths of stay than anyone imagined, or else being kept longer than perhaps they should be to maintain cash flow.

"I'm also seeing a lot of warehousing - that is, not much in the way of stimulating programming, very little understanding of or intervention with dementia, and quite a bit of putting people on a wandering alert system and letting them sit. Although I'm very much a proponent of assisted living as it could be - these settings are highly preferable to nursing homes for dementia residents without medical complications or psychotic behavior - I would rather be in a good nursing home than a bad assisted living facility.

"That is why I think the real estate developers who have led the way in much of this are in for a terrible shock. They will find that assisted living is probably the most difficult part of the health care continuum to administer. It is so emotionally, physically and psychologically demanding, and families are so involved, yet there is no reimbursement to meet many of these needs. I think even CCRCs are finding assisted living to be the most difficult part of their continuum.

"It is also interesting that, in some areas of the country, nursing homes are actually cheaper than assisted living. I have seen older, community-based nursing facilities coming in at $20 a day cheaper than new assisted living facilities in the same area because of all the debt that the newer facilities carry.

"In general, assisted living can and should manage aging in place successfully. And Medicaid waivers and managed care should open up the market more to elderly needing this service. There are concerns about what sort of regulation may follow and the quality of managed care gatekeeping, and these are questions that assisted living will confront in the future."

James Pieffer, Executive Vice-President of Presbyterian SeniorCare, Oakmont, PA, is at 412-826-6005. Maria Dwight, of Gerontological Services, Inc., Santa Monica, CA, is at 310-393-0332.