Futurescape: long-term care "without walls."(Not-for-Profit Report)

Senior citizens have two well-founded concerns: where they will turn if they become unable to care for themselves, and how they will pay for care if and when that day arrives. Friends Life Care at Home, an organization that serves a five-county Philadelphia region, combines home-based services with the basic concepts of long-term care insurance to address both those worries in a way that is less costly than residence in a retirement community.

Friends Life Care at Home was founded in 1985 by two Quaker-based organizations: Jeanes Hospital and Foulkeways, a pioneer continuing-care retirement community (CCRC) in the Philadelphia area. The idea sprang from research funded by grants from the Robert Wood Johnson Foundation and the Pew Charitable Trusts.

In this study, designed to test the concept of a "retirement community without walls," CCRC residents were surveyed, focus groups convened and a national telephone survey conducted. Researchers sought to find out why the elderly move into CCRCs and what services they would want if they could remain at home.

Three key findings that encouraged the founders to proceed with their plan were that: (1) seniors were highly interested in guaranteed lifetime health care; (2) social activities available in residential settings outside their own homes were not of particular interest (significant because of the founders' concern that lack of social interaction might be viewed negatively by prospective members); and (3) people with modest incomes who were living in CCRCs were interested in a plan that would allow them to live in their own homes.

In addressing these needs, Friends Life Care at Home does not employ its own home health aides or clinical staff. Rather, the organization contracts with a network of providers, including adult day care centers and, for future referral possibilities, assisted living residences and skilled nursing facilities. All the plan's revenue is derived from enrollment and monthly fees, and except for the research grants, it has received no public or private funding.

Members of Friends Life Care at Home pay a one-time enrollment fee, based on their age and the level of benefits they choose when they join. The fee ranges from $3,500, for a 60-year-old desiring the minimum available service level (home-based services only), to $40,000 for a 90-year-old who wants a plan that will pay 90% of all costs for future care. The enrollment fee increases in yearly increments for each benefit plan, in accord with the applicant's age; after joining, all members pay $280 per month, regardless of their age and which benefit plan they have chosen.

Three other available plans include one in which 70% of care costs are covered and 30% paid by the member; a 50-50 plan, in which the member equally shares in his/her cost of care; and a plan for individuals who have partial nursing home coverage through other sources, such as long-term care insurance, which pays for nursing home or assisted living services after a three-year deductible has been met. The home-care-only option is also suitable for individuals who have their own long-term care insurance and do not wish to drop it.

Home- and community-based services include home health care, homemaking assistance, skilled nursing, meal delivery, an emergency response system, adult day care, referral to home improvement/maintenance service vendors (many of whom give senior discounts) and more; service levels are based upon need and choice. If, at any time after joining, a member should need to move permanently into a skilled nursing facility or an assisted living residence, he or she continues to pay the monthly fee and a percentage of the cost of care, based on the benefit plan in which he or she enrolled.

The enrollment process begins with determining whether the applicant can function independently at home. The Admissions Committee looks at the individual's medical profile and determines whether he/she is living a healthy lifestyle. This is individualized for each applicant - for example, someone who smokes is not automatically excluded from membership, but if an applicant smokes and has a condition such as emphysema or heart disease that is exacerbated by smoking, membership is denied. Applicants also are excluded if they have been diagnosed with a terminal illness or neurological disorder.

Once new members are accepted, they are assigned to one of eight care coordinators, who arrange and monitor services. The care coordinators, seven of whom are social workers and one of whom is an RN, are divided into two teams, each with three coordinators and a team leader. The team approach is used so that someone on the team can always be on call to cover the caseloads; it also allows team members to provide support to each other. Each coordinator oversees services to 130 to 150 members; at any given time only 15 to 20% require intensive care coordination.

How much contact each member will require with a care coordinator is estimated at the time of enrollment, based on the member's wishes. When the coordinator discusses with members what they want, some say, "I hope I never need to see you again," equating contact with health crises, while others desire more regular contact. At minimum, the coordinator sees members yearly, to see how they are doing and to perform risk assessment.

Quality monitoring and improvement are concerns for any healthcare organization these days. In addition to CQI (continuous quality improvement) surveys - some conducted yearly and some continually, with responses compiled yearly - Friends Life Care at Home established a member advisory committee to assess and improve member satisfaction. This component, added last year, involves 15 members who volunteer to serve for one year. Members are selected in such a way that the committee's composition reflects the demographics of the overall membership.

The first issue the member advisory committee tackled was redesigning our CQI questionnaire. Their advice was sought on what questions should be asked, what terminology was unclear or included jargon, and how the questions could be better phrased. As a result of their input, the feedback from surveys has greatly improved.

Another issue this committee addressed was the yearly across-the-board increase in monthly fees. Their advice was sought regarding how to best present that information to members so that they would understand the need for the increases.

Friends Life Care at Home has grown continuously. From 78 members enrolled in 1990, the organization has grown to more than 900 members as of late 1997. Other indicators of success are the high level of member satisfaction, as shown by the CQI surveys and the program's low drop-out rate. (If members wish to end their membership, 2% of their entry fee for each month of enrollment is retained by Friends Life Care at Home, an arrangement typically used by CCRCs, as well. In addition, the cost of any services received is deducted from the amount refunded.)

Friends Life Care at Home is pleased with the success they have achieved in just seven years. By providing members with a means of remaining independent and at home for as long as possible and an assurance that they will be able to afford additional care down the road should they need it, Friends Life Care at Home offers them a sense of security and peace of mind.

Carol A. Barbour is president, Friends Life Care at Home, Blue Bell, PA.